As we are entering another exciting season of football, I started thinking about how the elements of a football game are a lot like solving any major problem. The players need to generate positive forward movement to continue to move the chains to get to score. In most situations other than football, we refer to this as “moving the needle,” a term often used in conjunction with making progress on a big goal or a big problem.
Inpatient glycemic management is certainly a big problem, and given the growing diabetes epidemic, it is likely to become an even bigger problem. It is estimated that 28-40% of patients in the hospital have diabetes and that number is growing. Also, hyperglycemia can impact patients that do not have diabetes due to the stress of hospitalization.
Hospitals, their providers, nurses and patients across the country are still being impacted by substandard glycemic management. Hospitals experience increased medication errors, longer lengths of stay, readmissions that impact their bottom line. Physician and nurses experience dealing with time consuming episodes of hypoglycemia that require intervention and treatment. Finally and most importantly, patients are affected. They may experience scary symptoms of hypoglycemia, poor wound healing, increased hospital acquired infections from high blood glucoses, and ultimately more time away from their loved ones at home.
Why is this happening?
Well, we know that the average hospital in the US is still using sliding scale insulin as the therapy of choice even though the major diabetes organizations recommend basal, bolus and correction insulin. We know that patient’s blood glucose levels are kept higher than national recommended standards because of the fear of hypoglycemia even though there are technologies that can assist with keeping patients in range while still preventing hypoglycemia. We also know that given the changes in glycemic management over the years, it is difficult for most nurses and physicians to stay abreast of new standards of care, yet rarely are they offered and required to participate in educational programs that focus on these advances and treatment standards. And lastly, we know that moving to new standards of care is a major change management challenge and change is hard.
So, yes, we have a big problem in our hospitals across the country. However, trying to tackle all these issues at one time can seem overwhelming and often prevent one from even beginning. That is often referred to as clinical inertia. How realistic is it to think that we are going to change the behaviors of every single nurse and physician that cares for patients in our hospitals overnight? Perhaps it is more realistic to focus instead on moving the needle.
What does it take to begin to move the needle?
The ADA and AACE all have standards and guidelines of what should be happening to improve inpatient glycemic care, but there are many elements to accomplishing those.
Listed below is what I perceive as the Top Six Glycemic Optimization Moving the Needle Elements:
- Recognize and understand the extent of your glycemic management problem. Gather baseline data and compare it to best practice standards: What is your average blood glucose? range of blood glucose during inpatient stay? percent of patient days in ADA recommended range? percent rate of hypoglycemia below 70mg/dl? percent rate of hypoglycemia below 54 mg/dl? percent of patients on sliding scale insulin vs. basal-bolus insulin? time to control? nursing and physician level of knowledge and understanding of best practice care for hyperglycemia? Understanding baseline data will help you be able to set moving the needle benchmarks and track progress towards meeting those benchmarks.
- Communicate about the problem, the data and set a vision for tomorrow. Once the data is available, it is important to communicate and share it with key stakeholders. Share with your patient safety committee, medical staff committees, nursing leadership and hospital administration. It is also important to begin to vision what it could be like in the future. What if we had zero insulin medication errors? What if we achieved almost zero hypoglycemia while keeping patients in ADA recommended target range? Often times, just understanding the problem and the data and visioning the future will drive small incremental improvements. People pay more attention to what is measured.
- Secure executive leadership support for moving the needle. As with any initiative for change, having the active support of senior leadership helps drive success. It is particularly important if you anticipate that there will be an associated cost of time, resources or money to accomplish it. For most hospital administrators, providing information about the costs and quality care issues surrounding the problem, potential solution, and return on investment in terms of both quality of care improvement and savings will go a long way in securing that support upfront.
- Select glycemic management optimization champion(s) to drive the change. We know from change management theory, that the most successful changes had individuals who were relentless in championing the effort, in soliciting others to help, and in assuming ownership of its success. This is particularly true in moving the needle on glycemic optimization. Designating and supporting clinical champion(s) is critical no matter how small or large an effort.
- Determine priority gaps and set moving the needle milestones and benchmarks. Generally, one will find many practice gaps when analyzing benchmark data. Many hospitals choose to focus on priority areas such as insulin medication errors, insulin dosing ,and decision support since it is such a high profile and dangerous drug. Others choose to begin to move the needle on moving from the use of sliding scale insulin to basal-bolus and correction while others choose to focus on education of medical and nursing staff. Regardless, it is important to set priorities and establish milestones and benchmarks against them. Otherwise, the inertia sets in again and movement towards the problem is stagnant.
- Explore, research, and select available best practice tools, technologies, and change management techniques that will assist with meeting milestones. There are a plethora of resources and tools available to hospitals today that have been proven to help them move the needle on the problem. It behooves anyone taking on the important journey of glycemic optimization to research and explore those solutions and to consider how any given solution will help with multiple elements of the problem. For example, some hospitals have decided that they can move the needle faster, more efficiently, and accomplish more by incorporating modern technologies, like EndoTool for insulin dosing, because it not only assists with insulin error reduction and meeting the standards, but it also comes with wrap around services that assist with elements of change management. Hospitals that have implemented EndoTool have moved the needle more significantly. They have moved hypoglycemia rates to statistically zero and they have made the crucial switch from sliding scale insulin to basal-bolus and correction.
By completing any one of the elements in the Top Six list, you are already “moving the needle” and hence getting closer to solving the problem or achieving the goal! You don’t have to know the end game, but moving the needle (or chains) gets you closer to the goal line and perhaps will even result in the big win. Regardless, it gives you the traction you need to move forward and is always worth the effort, especially when it comes to patient care.
For more information on “Moving the Needle,” join us at Monarch’s EndoTool User Group Meeting in Charlotte NC on October 18th as users from across the country gather to discuss their efforts in glycemic optimization challenges and opportunities.