Multidisciplinary Diabetes Team Activities in a 196 Bed

Community HospitalRobin Southwood, Pharm.D, CDE and

Beth Melvin, RD, MS, CDE

Purpose•Describe the development of a multidisciplinary diabetes care team in a non-academic community hospital

•Report the activities and impact of the multidisciplinary care team.

•Describe contributions of students

Mission

We, St. Mary’s Health Care System and CHE Trinity Health, serve together in the spirit of

the Gospel as a compassionate and transforming healing presence within our

communities.

St. Mary’s Health System, Inc Services

• 196 acute care beds • Center for Rehabilitative Medicine• Home Health Care/Hospice• The Exchange/Wellness Center• Industrial Medicine• Highland Hills• Hospice House • Alzheimer Dementia Center

Creation of St. Mary’s Diabetes Care Team

• Identification of needs• Program chair• Physician champion• Nursing representation• Pharmacy representation

• Identification of available resources• Program chair – Director of Diabetes Education• Physician champion- Hospitalist service• Nursing- Administrative and Bedside• Pharmacy- Quality assessment and clinical• Other- Ad hoc laboratory, dietary

Inpatient Diabetes Support Team

Core Team

Dietetics

Students / Interns

Quality

NursingMedical Staff

Laboratory

Pharmacy

Inpatient Diabetes Core Team

• Program Chair – Beth Melvin, RD, CDE• Physician Champion – Robert Meyer, MD• Mira Brown, RN, CDE• Robin Southwood, PharmD, CDE• Karen Turner, RN

Inpatient Diabetes Support Team

• UGA Doctor of Pharmacy students – • 2 students for 5 weeks- total of 45 weeks per year

• UGA Public Health intern• 1 intern for 400 hours

• UGA College of Dietetics intern• 1 intern for 120 hours

Diabetes Patient – From Admission to Discharge

• Supplement knowledge

• Identify barriers• Optimize therapy

• Offer outpatient education

• Physician appointments

• Prescriptions

• Knowledge evaluation

• Optimize therapy via standardized processes

• Screen for diabetes• A1c to assess

control• Hypoglycemia

Protocol

Admission Inpatient

Prepare for

DischargeDischarge

Physician Champion Roles

• Liaison with medical staff– Committee – Surgeon

• Provision of Education

Team Activities

• Education – Patient– Care providers

• Standardization of care– Develop processes

• Participation in care– Focus on patients with suboptimal care

Participation in Care

• Identification of Uncontrolled Diabetes– A1C > 8%, BG > 200 x2, BG <100

• Knowledge and needs assessment• Communication of concerns and

recommendations to medical and nursing staff• Weekly Multidisciplinary Patient at Risk Meeting• Ensuring continuum of care

Performance Measures S – Shoot for 15 Minute Hypo Recheck

H – Hypoglycemia Treatment Documentation

O – Outpatient DM Follow-Up Appointment

T – Teaching Booklet Given and Documented

Jan-

12

Feb-

12

Mar

-12

Apr-

12

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adherence to Hypoglycemia Treatment Pro-tocol 2012 - 2014

Hypoglycemia Treatment Documentation

Nov-14 Dec-14 Jan-15 Feb-150

102030405060708090

100

82.5 78.9 79.9 81

15 Minute Hypoglycemia Recheck

Nov-14 Dec-14 Jan-15 Feb-150

102030405060708090

100

72.264 62 60

Discharge Follow-up Appointment

Jan Jun-14 Sep-14 Nov-14 Dec-15 Jan-15 Feb-150

102030405060708090

100

Percent of Follow-up

Documentation of Teaching Booklet

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

0%

20%

40%

60%

80%

100%

Additional Performance Improvement

• Additional Hypoglycemia Measures– Cause Identification– Prevention– HEN – BG < 50 mg/dl

• Patient Satisfaction• Glucometrics

Amount of Time Spentin Patient Interactions

Jan-08

Mar-

08

May

-08Ju

l-08

Sep-08

Nov-08

Jan-09

Mar-

09

May

-09Ju

l-09

Sep-09

Nov-09

Jan-10

Mar-

10

May

-10Ju

l-10

Sep-10

Nov-10

Jan-11

Mar-

11

May

-11Ju

l-11

Sep-11

Nov-11

Jan-12

Mar-

12

May

-12Ju

l-12

Sep-12

Nov-12

Jan-13

Mar-

13

May

-13Ju

l-13

Sep-13

Nov-13

Jan-14

Mar-

14

May

-14Ju

l-14

Sep-14

Nov-14

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00Hours

• Monthly time spent in direct patient interactions (January 2008 vs July 2014)• Increased from 7.7 hours to 66.2 hours spent interacting with patients• 740% increase in patient interactions

Average Glucose Value

Sep-0

7

Nov-07

Jan-0

8

Mar-

08

May

-08

Jul-0

8

Sep-0

8

Nov-08

Jan-0

9

Mar-

09

May

-09

Jul-0

9

Sep-0

9

Nov-09

Jan-1

0

Mar-

10

May

-10

Jul-1

0

Sep-1

0

Nov-10

Jan-1

1

Mar-

11

May

-11

Jul-1

1

Sep-1

1

Nov-11

Jan-1

2

Mar-

12

May

-12

Jul-1

2

Sep-1

2

Nov-12

Jan-1

3

Mar-

13

May

-13

Jul-1

3

Sep-1

3

Nov-13

Jan-1

4

Mar-

14

May

-14

Jul-1

4

Sep-1

4

Nov-14

120

130

140

150

160

170

180

190

200

BG Average (mg/dl)Linear (BG Average (mg/dl))Lower TargetUpper Target

Hypoglycemic Events

20082010

201241306

4136541426

4148741548

4160941671

4173041791

4185241913

419740

0.51

1.52

2.53

3.54

Hypoglycemia (%)Linear (Hypoglycemia (%))Critical Hypoglycemia (%) Linear (Critical Hypoglycemia (%) )

Drug Therapy Recommendations

•July 1, 2013 to June 30, 2014 – 897 documented recommendations•746 (83%) of 897 documented recommendations were accepted•239 (59%) involved Doctor of Pharmacy students

•Recommendations include:•Hypoglycemia protocol order / A1C lab order 377 (28%) •Insulin therapy – 412 (48%) of which 301 (73%) were accepted•Oral Medication Therapy- 84 (9.4%) of which 54 (64%) were accepted

•Insulin Pump Assessment- 13 (1.4%) •Recommendation of Hospitalist consultation for diabetes management- 6 (0.7%)

Assessment of Team Performance

•Creation of a multidisciplinary team resulted in a 760% increase in time devoted to patient education.

•With a multidisciplinary team, the wide variety of interventions have helped improve patient quality care.

•Diabetes medication safety • Implementation of computer based algorithm to facilitate management of continuous insulin infusion therapy

•Streamlining hospital diabetes medication formulary resulting in estimated savings of $20,000 annually

•7 Posters presented at National Meetings since 2012

Team Achievements

• Joint Commission Disease Specific Certification in Advanced Inpatient Diabetes Management.– Original 2012 (2nd hospital in Georgia)– Recertification 2013 and 2014

• Formulary management has reduced costs approximately $33,432 annually

• Collaboration with UGA College of Pharmacy

Doctor of Pharmacy Student Participation

• Standardization in student orientation– Assigned pre-APPE readings

• Active engagement in patient evaluation starting day 1

• Skill check off for patient education / device instruction

• Skill check off for documentation in electronic medical record

Doctor of Pharmacy Student Participation

• Daily assessment of diabetes pharmacotherapy and presentation to Core Team

• Development of recommendations for changes in pharmacotherapy

• Participation in patient education • Participation in Quality Assessment Projects

Future Growth Opportunities

• Recruitment of New Endocrinologist• Residency Program begins 2015• Medical College of Georgia / UGA partnership

Questions