Multidisciplinary Diabetes
Team Activities in a 196 Bed
Community Hospital
Robin 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
Dietetics
Pharmacy
Students /
Interns
Core
Team
Laboratory
Medical
Staff
Quality
Nursing
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
• Screen for diabetes
• A1c to assess
control
• Hypoglycemia
Protocol
• Offer outpatient
education
• Physician
appointments
• Prescriptions
• Knowledge
evaluation
• Optimize therapy
via standardized
processes
Admission
Inpatient
Discharge
Prepare
for
Discharge
• Supplement
knowledge
• Identify barriers
• Optimize therapy
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
0%
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Adherence to Hypoglycemia Treatment
Protocol 2012 - 2014
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Hypoglycemia Treatment
Documentation
100
82.5
78.9
79.9
81
Nov-14
Dec-14
Jan-15
Feb-15
80
60
40
20
0
15 Minute Hypoglycemia Recheck
100
80
72.2
64
62
60
Dec-14
Jan-15
Feb-15
60
40
20
0
Nov-14
Discharge Follow-up Appointment
Percent of Follow-up
100
90
80
70
60
50
40
30
20
10
0
Jan
Jun-14
Sep-14
Nov-14
Dec-15
Jan-15
Feb-15
Documentation of Teaching Booklet
100%
80%
60%
40%
20%
0%
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Additional Performance
Improvement
• Additional Hypoglycemia Measures
– Cause Identification
– Prevention
– HEN – BG < 50 mg/dl
• Patient Satisfaction
• Glucometrics
Amount of Time Spent
in Patient Interactions
Hours
100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
• 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
Nov-14
Jul-14
Sep-14
May-14
Jan-14
Mar-14
Sep-13
Nov-13
Jul-13
May-13
Jan-13
Mar-13
Sep-12
Nov-12
Jul-12
May-12
Jan-12
Mar-12
Sep-11
Nov-11
Jul-11
May-11
Jan-11
Mar-11
Sep-10
Nov-10
Jul-10
May-10
Jan-10
Mar-10
Sep-09
Nov-09
Jul-09
May-09
Jan-09
Mar-09
Sep-08
Nov-08
Jul-08
May-08
Jan-08
Mar-08
0.00
Average Glucose Value
200
190
180
170
160
150
140
130
120
BG Average (mg/dl)
Lower Target
Upper Target
Linear (BG Average (mg/dl))
4
3.5
3
2.5
2
1.5
1
0.5
0
2008
2009
2010
2011
2012
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Hypoglycemic Events
Hypoglycemia (%)
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