1. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Management of Hyperglycemia in the Adult Hospitalized Patient: Admission to Discharge TEAM MEMBERS: Physicians: Maryann Emanuele, William Barron, Fadi Nabhan Nurses: Rita Vercruysse MPH, Terese Bertucci APN/CNP,CDE Donna Murphy APN/CNS,CDE, Theresa Pavone MSN, Barb Rumick CCRN, Rose Lach PhD, Camille Robinson (EPIC), Diabetes Liaisons Pharmacists: Barb Murphy and Alison Schriever Dietician: Jill Whitney RD/LDN, CNSD,BS Center for Clinical Effectiveness: Barb Pudelek, RN-CS, MSN, ACNP, Clinical Quality Improvement Specialist and Michael Wall PharmD, Sr. Clinical Quality Improvement Analyst Multidisciplinary ICU Committee

2. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Project Aim Statement: Traditional methods to manage hyperglycemia fall short of standards critical to reduce mortality and morbidity in adult hospitalized patients. - Diabetic inpatients at Loyola experience less than 60% of days with a glucose measurement > 180mg/dL. Measurement Goal and Target: Achieve euglycemia (glucose 80-120mg/dL) in all diabetic inpatients, without increasing the rate of hypoglycemia. PLAN

3. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Solutions Implemented: Created evidenced-based guidelines and protocols, based on basal bolus approach, to standardize management of hyperglycemia in hospitalized adult diabetics in ICU and non-ICU settings. Maintained quarterly Diabetes Quality and Safety Committee meetings. Reviewed and revised tube feed guidelines. Revised tube feed protocols in EPIC and developed them in the EMR. Add Glycosylated Hemoglobin (HgbA1c) lab order to all insulin protocols to better manage patient’s medication upon discharge. DO

4. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Solutions Implemented: Reviewed and revised insulin protocols to include a discharge regimen appropriate for Type 1, Type 2, renal impaired and body sizes. Developed a High Dose Insulin Infusion for Patients Refractory to Algorithm 1-5 Developed Correction Factor Algorithm 4-6 for patients receiving more than 120 units of insulin a day. Added TID dosing of Glargine when dose exceeds 200 units. Developed guidelines for severity of hypoglycemia and treatment. Ongoing hospital-wide, nursing, physician and pharmacist education. DO

5. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Presentation and Publication: Storyboard Presentation on insulin protocol data outcome and experience at: -University Health System Consortium (UHC) Quality and Safety Fall, Oct. 2006 in Baltimore, MD -Institute for Healthcare Improvement (IHI) 18 th Annual National Forum on Quality Improvement in Health Care, Dec. 2006 in Orlando Fla. -Storyboard published on IHI website Presented a half day seminar at Stritch School of Medicine for outside and Loyola audience titled: Glycemic Management in the Hospital; Admission to Discharge, Dec. 2006.

6. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Analysis: Graph 1: The median inpatient glucose value, continues to decrease with the implementation of inpatient insulin protocols and has been below 142mg/dL since August 2005. In Nov. and Jan., 2007 the median glucose was below 135mg/dL. Graph 2: The control chart indicates a significant improvement change in blood glucose levels below 60% since August 2005. January, 2007 marks the first month with a result below 50% Graph 3: The percent of inpatient with diabetes that experienced a day of hypoglycemia is consistently at 12% STUDY

7. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Definition: Median inpatient glucose levels in patients with diabetes. Glucose readings below 40mg/dL and above 400mg/dL and patients under 18 years were excluded. Data Sources: Clarity database, FORCE database. Analysis: The median inpatient glucose value has decreased with the implementation of inpatient insulin protocols and has been below 142mg/dL since August 2005. Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Continuous Tube Feed

8. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Definition: Number of diabetic inpatients who experience a day with a glucose measurement above 180mg/dL / Number of diabetic inpatient days with any glucose measurement. Glucose readings below 40mg/dL and above 400mg/dL and patients under 18 years were excluded. Data Sources: Clarity database, FORCE database. Analysis: The percent of inpatients with diabetes who experience a day with a glucose measurement above 180mg/dL has decreased significantly, has been below 60% since August 2005. January 2007 marks the first month with a result below 50%. Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Continuous Tube Feed

9. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Definition: Number of diabetic inpatients who experience a day with a glucose measurement below 70mg/dL / Number of diabetic inpatient days with any glucose measurement. Glucose readings below 40mg/dL and above 400mg/dL and patients under 18 years were excluded. Data Sources: Clarity database, FORCE database. Analysis: The percent of inpatients with diabetes who experience a day with a glucose measurement below 70mg/dL is consistently 12%. Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI Non-ICU hyperglycemia management protocol released into LUCI EPIC Inpatient Go-live Continuous Tube Feed

10. 4-07 CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT Next Steps: Develop guidelines for steroid use and intermittent tube feeds. Continue presentations and publications of outcome data and experiences. Publish tube feed protocols and results. Explore software program for Tight Glycemic Control Modules and insulin dosing. Monitor protocol effectiveness, staff compliance and protocol violations. Look at Length of Stay of diabetic patients on insulin protocols Incorporate inpatient discharge medication regimen guidelines to the outpatient. Establish a Glycemic Team to manage and control patients’ daily blood glucose. Continue physician and nursing education through inservices, fact sheets, e-mail announcements and unit based nurse Liaisons. ACT