Clinical Impact of An Inpatient Diabetes Care Model Beth Pfeffer MSN, RN CDE June 4, 2014 Objectives 1. Examine the development of the role of the diabetes case manager model in the inpatient setting 2. Describe the development of the Diabetes Resource Nurse Program for acute care hospitals 3. Review outcome measures aimed at improving quality of care and reducing readmissions for patients with diabetes 1
The Nebraska Medical Center 624 bed not for profit academic medical center 5,758 employees 1,082 medical staff 450 medical residents National reputation in Cancer Care Transplantation Neurosciences 3 Impact of Diabetes on Hospitals The total estimated cost of diabetes in 2012 was $245 billion, with $176 billion attributed to excess medical expenditures 1 Diabetes ranked #2, after circulatory diseases, as a hospital discharge diagnosis in 2005 2 The absolute cost of hospital inpatient care for people with diabetes has risen from $58 billion in 2007 to $76 billion in 2012. However, hospital inpatient care costs have fallen from 50 percent to 43 percent of total direct medical costs 1 1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012 2. http://www.cdc.gov/diabetes/statistics/hosp/adulttable1.htm Accessed January 21, 2008 2
The Nebraska Medical Center Stats 25 32% of inpatients have diagnosis of diabetes (100 140 patients daily) Additional 10 15% have hyperglycemia requiring treatment Insulin prescribed in 50% of patients Readmission Rates Higher for Patients with Diabetes Among 48,612 patients with congestive heart failure from 259 hospitals, 42% had diabetes All cause rehospitalization was significantly greater for patients with diabetes than for patients without diabetes (31.5% vs 28.2%; P =.006) 32% 31% 30% 29% 28% 27% 26% Rehospitalization Rates 28.2% 31.5% No Diabetes Diabetes Greenberg BH, et al. Am Heart J. 2007;154:277.e1-8. 3
Current Best Practices for Diabetes Care at Hospital Certification for Advanced Inpatient Diabetes Care from JC since 2010 Standardized order sets that help guide practice Policies and Procedures Hypoglycemia Identification of Hyperglycemia IV insulin Subq insulin pump Carb counting Current Best Practices for Diabetes Care at Hospital (cont.) Resources: Medical Director Diabetes Services Director 3.0FTE dedicated inpatient CDEs Identified blood glucose target range of 70 180mg/dl Glucose management metrics Average daily glucose available at unit and patient level Hypoglycemia rate for organization and unit level Hypoglycemia audit process for severe lows, recurrent or prolonged hypoglycemia Subscribe to SHM Glycemic Control Program for comprehensive glucose metric outcomes 4
Importance of Nursing Care for Improving Glycemic Control Nursing is at the front line and present 24 hr/day Nursing coordinates, and is aware of, the multiple services required by patient Appropriate timing of POC glucose / Insulin administration and meal delivery / Amount of carbohydrate eaten Critical Thinking: POC glucose results & coordination of glycemic orders Recognition of hyper/hypoglycemia and appropriate management What to do when TPN or tube feeding is interrupted Appropriate patient hand off Patient self-management education Transition to Discharge Factors Affecting Blood Glucose Levels in the Hospital Setting Increased counter regulatory hormones Changing IV glucose rates TPN and enteral feedings Lack of physical activity Unusual timing of insulin injections Use of glucocorticoids Unpredictable or inconsistent food intake Fear of hypoglycemia Cultural acceptance of hyperglycemia Nursing role is critical throughout hospitalization 5
Goals of Inpatient Diabetes Model Change 1. Quality Initiative Improve the care of the patient with diabetes or hyperglycemia during hospital stay. 2. Improve transition of care for patient with diabetes/ hyperglycemia to outpatient setting 3. Empower the nurse to be able to make educated decisions for patients with diabetes or hyperglycemia at the bedside. 4. Reduce the risk of adverse events 5. Reduce the risk for readmission to ER or hospital post discharge. Inpatient Diabetes Management Program Glucose Management Team Diabetes Services Director Diabetes Medical Director Diabetes Case Managers Diabetes Unit Resource Nurses 6
Diabetes Case Managers (DCM) Assigned to med/surg units with highest population of patients with diabetes/hyperglycemia Case manage defined high risk diabetes population for discharge planning and transition of care Adequate supplies Self management skills Post hospital follow up (Provider for diabetes management, Education, Home Health) Use daily interactions and collaborations with medical and nursing team to improve glycemic management through ongoing education and increasing awareness of hypoglycemia and hyperglycemia Uncover opportunities in glycemic management and encourage medical team to make treatment changes in collaboration with physician Partner with Inpatient Case Managers, Social Work, Pharmacy, to meet needs of pt population Diabetes/Hyperglycemia High Risk Patients Self pay patient with diabetes diagnosis New diagnosis type 1 or 2 DM, transplant related diabetes, CF related DM, steroid induced DM New to insulin DKA admission Hypoglycemia admission Readmission due to diabetes hypoglycemia or hyperglycemia 7
Diabetes Resource Nurses (DRN) Staff Nurses on units who receive comprehensive inpatient glycemic management education and act as resource/advocate for championing Best Practice bedside practices Role Pay it Forward Educate other staff Disseminate information to Unit Based Council of education or initiatives Participate in review of policies, procedures, tools, education for inpatient diabetes care Participate in ongoing education updates Work in collaboration with Diabetes Case Manager in providing diabetes specific patient education Staff RN Role in Diabetes Management Perform learning needs assessment, health literacy, setting and prioritization of goals Evaluate and update diabetes self management skills assessment Partner with Diabetes Case Manager and Diabetes Resource Nurse in coordinating diabetes/glycemia needs Provide patient education for diabetes self management skills to include Medication (insulin administration and oral medication) Blood glucose monitoring Hypoglycemia recognition and treatment Utilize standardized diabetes patient education handouts 8
Diabetes Resource Nurse Curriculum Interactive Hands on instruction Applicable to nursing at the bedside Focus on organization policies, procedures for glycemic management OBJECTIVES CONTENT State importance of nursing care in Impact of diabetes in the hospital setting improving inpatient diabetes care. Role of nursing in the management of glycemic control Measures of glycemic control Describe the role of nursing in the Base plan of care for type of diabetes admission of the patient with diabetes or Diabetes knowledge deficit assessment hyperglycemia. Collaboration with diabetes case manager Discuss common medications for patients Insulin vocabulary with diabetes or hyperglycemia. Indications of use for Basal, Bolus and Correction Scale Insulin order sets Use of oral anti-diabetic agents in the inpatient setting Discuss nursing s role in the monitoring of Glycemic goals of therapy the patient with diabetes or hyperglycemia. Hypoglycemia Policy and Protocol Diabetes Order sets Recognizing when and how to communicate with provider Review the nutritional needs of the patient Medical Nutrition Therapy goals with diabetes or hyperglycemia. Meal planning Medication timing and food intake Enteral nutrition Altered intake Discuss the educational needs of the patient Assessment with diabetes or hyperglycemia. Glucometer Insulin Administration Collaboration Discuss the role of nursing in the discharge Diabetes Discharge Instruction Form of the patient with diabetes or Assessment of need for home health care hyperglycemia. Collaboration with pharmacy in medication reconciliation and post discharge plan Follow up plan and provider appointments Diabetes Supplies plan Skills Training Insulin Administration Home Glucose Monitoring Carbohydrate counting Nursing Diabetes Education Model 9
DRN Recognition and Incentives DRN Pin presented by Diabetes Services Medical Director Piece of the Puzzle Unit specific bulletin board with pictures DRN representation on Glucose Management Team Complimentary registration to annual Diabetes Update Symposium OUTCOMES 10
Daily Hypoglycemia Report Sent daily to Unit Managers, Leads, Quality Champions and Diabetes Case Managers DCM audits results <50mg/dl recurrent hypoglycemia Prolonged hypoglycemia Allows method to evaluate adherence to hypoglycemia policy Recheck BG 15min after treatment Hypoglycemia Management 11
Daily Blood Glucose Report Can evaluate BG control at a glance Sent daily to Unit Managers, Leads, Quality Champions and Diabetes Case Managers Hyperglycemia Management 12
Length of Stay Readmission Rates by Fiscal Year FY Readmission Rate Overall Readmission Rate for DM Patients 2011 14.6% 20.1% 36.8% % DM Readmission of All readmissions 2012 14.1% 19% 39.6% 2013 12.8% 17.6% 39.9% 13
DRN Intervention Readmission Rates 18 month Pre intervention 18 month Post intervention All Discharged Patients N=34,472 All Discharged Patients N=32,046 All Patients with DM N=9520 (27.6%) All Patients with DM N=9391 (29.3%) All readmitted patients with DM N=1918 (20.1%) All readmitted patients with DM N=1653 (17.6%) *p<.0001 14
Prevalence of Diabetes to Readmissions 18 month Pre intervention 18 month Post intervention All Patients readmitted N=5030 (14.6%) All Patients readmitted N=4202 (13.1%) All readmitted patients with DM N=1918 (38.1%) All readmitted patients without DM N=3112 (61.9%) All readmitted patients with DM N=1653 (39.3%) All readmitted patients without DM N=2549 (60.7%) Diabetes Rates of Readmission 18 month Pre intervention 18 month Post intervention All Patients with DM N=9520 (27.6%) All Patients with DM N=9391 (29.3%) Readmitted patients with DM seen by DCM N=275 (15.1%) Readmitted patients with DM not seen by DCM N=1643 (21.3%) Readmitted patients with DM seen by DCM N=271 (15.7%) Readmitted patients with DM not seen by DCM N=1382 (18.0%) 15
Readmission Rates of Patients seen by CDE vs. DCM Readmission Rates of Patients receiving Usual Care vs. DRN Abbreviations: DM=Diabetes mellitus, CDE= Certified Diabetes educator, DCM=Diabetes Case Manager, DRN=Diabetes Resource Nurse 16
Limitations During the analysis period all hospital readmission rates decreased significantly from 14.6% to 13.1% (p <.0001) Accuracy of readmission data dependent on physician documentation Excludes patients with hyperglycemia Readmissions are tracked for all causes and not necessarily related directly to diabetes Financial analysis of program was not completed Implications The Diabetes Resource Nurse program can be easily replicated in other organizations and developed under the direction of Diabetes specialists Nurses should be involved in all stages of improving diabetes care, because they will be doing the majority of the implementation of processes, and are central to any efforts for improvement (Haas, 2006) Nursing role is critical throughout hospitalization 17
Next Steps Current DRN program continues to be offered 6 times per year to increase participation Using DRNs to help evaluate and implement other initiatives to improve diabetes care Monitoring/Meal/Insulin delivery timing Improvement in hypo/hyper glycemia rates Pay it forward Educating others bpfeffer@nebraskamed.com 18