1. A Close look at the MMC DKA Protocol “Clinician driven performance improvement”

2. Designing a hospital-wide clinical improvement project Identify the opportunity Identify the opportunity Establish the team Establish the team Set specific goals Set specific goals Literature review Literature review Develop local practice guidelines Develop local practice guidelines Define sources of data Develop quality measures Data reporting Implement changes Monitor results

3. Short Version Team of experts Team of experts Literature search Literature search Define current process Define current process Identify gaps Identify gaps Develop solutions Develop solutions Establish measures Establish measures Implement changes Implement changes Monitor results Monitor results

4. Identify the opportunity Clinical Pathways top 25 DRG’s Clinical Pathways top 25 DRG’s Facilitated Evidence Based care Required critical self assessment and analysis Reduced variations in practice Offered basic performance improvement

5. Establish the team Physician experts: Physician experts: Endocrinologist Endocrinologist Emergency medicine Emergency medicine Internal and Family Medicine Internal and Family Medicine Performance Improvement Performance Improvement Project Manager Project Manager Data Analyst Data Analyst Nursing experts: Diabetes Clinical Nurse Specialist Medical unit Special Care Unit Emergency department Nurse analyst Nutrition Services

6. Set specific goals Decrease LOS for patients with diabetes Decrease LOS for patients with diabetes Dr. Phil approach to problem solving: Dr. Phil approach to problem solving: “can’t fix what you don’t acknowledge” “can’t fix what you don’t acknowledge” We did not know what we were trying to fix We did not know what we were trying to fix

7. Goal Setting “don’t wait for the home run, just get to first base” Literature review Literature review Evidence based guidelines Evidence based guidelines Standards of care Standards of care Define current processes Define current processes Identify gaps Identify gaps Identifies opportunities for improvements Identifies opportunities for improvements Go after low hanging fruit Go after low hanging fruit

8. Literature review “Hyperglycemic crisis in patients with diabetes mellitus” “Hyperglycemic crisis in patients with diabetes mellitus” “ Effect of Physician specialty on outcomes in diabetic ketoacidosis” “ Effect of Physician specialty on outcomes in diabetic ketoacidosis” “Using a severity of illness scoring system to access intensive care unit admissions for diabetic ketoacidosis” “Using a severity of illness scoring system to access intensive care unit admissions for diabetic ketoacidosis” Venous vs. arterial blood gas in assessing pH Venous vs. arterial blood gas in assessing pH

9. Summary of findings ADA published clinical practice guidelines ADA published clinical practice guidelines pH is an important diagnostic tool pH is an important diagnostic tool Potassium should be assessed prior to insulin Potassium should be assessed prior to insulin Endocrinologists are valuable in complex DKA Endocrinologists are valuable in complex DKA Severity of illness score improves resource utilization Severity of illness score improves resource utilization Nutritional consults are a JCAHO standard Nutritional consults are a JCAHO standard

10. Develop local practice guidelines Identify variations / gaps in current processes Identify variations / gaps in current processes Flowchart reality Flowchart reality Flowchart “best practice” – 80% rule Flowchart “best practice” – 80% rule Brainstorm opportunities for improvement Brainstorm opportunities for improvement Let go of sacred cows Let go of sacred cows Ask why do we do it this way Ask why do we do it this way Involve other experts to help identify solutions Involve other experts to help identify solutions Ask “what would it look like if…..” Ask “what would it look like if…..”

11. EBM Insulin dosing protocol Insulin dosing protocol pH is important diagnostic tool pH is important diagnostic tool Obtain potassium results before insulin Obtain potassium results before insulin Consult endocrinologist for complex cases Consult endocrinologist for complex cases Calculations for a Severity of Illness Score Calculations for a Severity of Illness Score Nutritional consult is a standard Nutritional consult is a standard

12. Gaps Our process Our process Arterial blood gases not standard Arterial blood gases not standard WHY? WHY? difficult to draw difficult to draw patient dissatisfier - painful patient dissatisfier - painful time consuming to obtain – requires RRT time consuming to obtain – requires RRT Insulin dosing before serum K+ results Insulin dosing before serum K+ results WHY? WHY? knee jerk response: knee jerk response: lab takes too long to turn around results – 1 hour lab takes too long to turn around results – 1 hour lab expert: time limitations inherent in running serum-based labs lab expert: time limitations inherent in running serum-based labs time to draw (tube does not always get to lab quickly) time to draw (tube does not always get to lab quickly) time to clot time to clot time to spin time to spin

13. Brainstorming Venous blood gas is an acceptable alternative to ABG for the majority of DKA patients Venous blood gas is an acceptable alternative to ABG for the majority of DKA patients Point of care testing Point of care testing Venous pH, Glucose, Electrolytes Venous pH, Glucose, Electrolytes iSTAT – analyzer used in NICU for rapid results iSTAT – analyzer used in NICU for rapid results “Standby” machine for neonatal transports “Standby” machine for neonatal transports could we move it to the emergency room? could we move it to the emergency room?

14. Solutions Identified “Chiron” analyzer in lab for whole blood Identified “Chiron” analyzer in lab for whole blood Venous pH Venous pH Electrolytes Electrolytes Glucose Glucose Hct Hct Ionized calcium Ionized calcium Developed new lab item: Developed new lab item: DKA panel DKA panel Whole blood sample – routine phlebotomy Whole blood sample – routine phlebotomy no time to clot no time to clot no time to spin no time to spin 5 min turn around time after arrival in lab 5 min turn around time after arrival in lab Developed DKA Calculator Developed DKA Calculator

15. Define sources of data Chart audit Chart audit Data collection forms Data collection forms ADT data ADT data Electronic order entry data Electronic order entry data

16. Develop quality measures Total admits Total admits SCU admits SCU admits ED treat and DC ED treat and DC Utilization of rescue drugs Utilization of rescue drugs Mannitol Mannitol Glucagon Glucagon D50 D50 NaHCo3 NaHCo3

17. Data Reporting Select a sample of cases for review Select a sample of cases for review Develop practice and outcomes reports Develop practice and outcomes reports Develop ongoing monitoring program Develop ongoing monitoring program

18. Implement changes in clinical practices Use of venous sample for pH Use of venous sample for pH Obtain potassium results before insulin Obtain potassium results before insulin DKA panel – whole blood testing for pH, K+, and glucose DKA panel – whole blood testing for pH, K+, and glucose Insulin dosing and weaning protocol Insulin dosing and weaning protocol Consult endocrinologist for complex cases Consult endocrinologist for complex cases Calculations for a Severity of Illness Score Calculations for a Severity of Illness Score Nutritional consult is a standard Nutritional consult is a standard

19. Monitor Results Develop ongoing monitoring program Develop ongoing monitoring program Team responsible to analyze data Team responsible to analyze data Revise plan as data indicates Revise plan as data indicates

20. Clinical performance improvement is a continuous process that does not have an end point Clinical performance improvement is a continuous process that does not have an end point