Secrets to Successful Inpatient Glycemic Management Programs

Secrets to Successful inpatient Glycemic Management Programs.

0:04

Hello! Welcome to today's webinar, Secrets To Successful Inpatient Glycemic Management Programs.

0:10

Thank you for joining.

0:12

Inpatient glycemic management can be challenging for the Health Care team.

0:15

Patients' insulin needs vary widely. Internal resources are increasingly stretched and achieving consistent good outcomes can feel unattainable.

0:24

Today, our panelists will share their knowledge and experience on ways they and their organizations successfully manage this challenge.

0:36

My name is Spring Moore, and I will be the moderator of today's discussion. My background is ICU nursing, and I spent over a decade at the bedside before moving to a clinical liaison role for glycemic management software.

0:49

It's a pleasure to work as a Clinical Services Specialist for Monarch Medical Technologies, the provider of EndoTool.

0:55

And EndoTool is an FDA cleared clinical decision support software application used in the inpatient settings to achieve and maintain glucose control.

1:05

Our co-hosts today is doctor Paul ..., Monarch's Chief Medical Officer, Pauls, Medical Training, and Background as a nephrologist provide invaluable oversight and guidance for our team.

1:17

His prior experience includes a leadership role at a large healthcare organization where incidentally he had the unique opportunity to spearhead the successful implementation of a glucose management program across several facilities.

1:33

Before we get started, there are just a few housekeeping items to cover.

1:38

All participants will have audio muted during the panelists discussion as we want them to share without interruption.

1:44

We would welcome the opportunity to answer your questions. Please drop those in the comments section, and we will answer as many as possible during the Q&A.

1:53

As a reminder, a recording will be made available to everyone who has registered for this webinar.

2:01

On our agenda today, we will talk about building the Glycemic A Team, Tips for Implementing: an Effective Glycemic Management Program, and Education Strategies for Success.

2:15

Our panelists are an amazing group of individuals, with a wealth of knowledge to share.

2:19

Each one will introduce themselves, and for context to our discussion, share their organization's journey with Glycemic Management, and when a glycemic management software program was introduced, Jennifer, do you mind to begin?

2:34

I don't mind, thank you so much, Spring. My name is Jennifer ..., I'm a pharmacist, and a pharmacy manager for Atrium Health, which is now a part of the health system advocate health. My role as pharmacy manager is in medication safety and quality for the south-east region of Atrium. I work alongside teammates in North Carolina and Georgia at Atrium Sites to improve med safety. Although I've been in a regional role for about 18 months, I spent my entire career prior to that at Atrium Health, Wake Forest, Baptist. An important part of my work has been as Pharmacy Chair, Ethically Case Management Subcommittee, which this and work alongside this section head for endocrinology. There's always been a presence of glucose management practices at atrium health. But that subcommittee has been in place for over 10 years now and works with our Pharmacy and Therapeutics Committee on all things glucose management. Tool has been in place at Atrium Health, Wake Forest Baptist since March of 2022.

3:35

Thank you.

3:38

Thank you, Jennifer. Megan, do you mind to go next?

3:42

I'm Megan Hopkins', I am the nurse practitioner, one of the nurse practitioners at Centennial Medical Center in Nashville, Tennessee, with a BA.

3:53

We started the glucose management team in 20 15.

3:58

There was always the presence of endocrinologists, and, but most of diabetes with manner.

4:05

By our hospital group, this was a big push to improve glycemic care inpatient.

4:11

Part of that was using IBM ...

4:14

software to improve our patient care in the ICU and length of stay, So we implemented in the fall and spring of 2017.

4:28

Thank you, Megan, Christie.

4:31

Sure.

4:33

Hi, I'm Christine user, I'm the DCI or the Director of Clinical and Clinical and Operational Informatics. For UPMC. I support seven hospitals in Central Pennsylvania. In this role, I liaison between nursing operations and our IT and technology team, to manage and monitor ongoing projects, where, anyway, when nursing, practice, and technology intersect.

4:59

As for glucose management programs, they've been in place for quite some time in all of our hospitals. We have a very active Diabetes Committee that looks at various performance measures across our seven campuses. We went live on EndoTool in August of 2022.

5:19

Thank you, and I'll turn it over to Paul for the next two sites.

5:22

So, why should our hospital organization focused on inpatient glycemic management? It's a, it's a key part of many patients that enter the hospital, and the management of diabetes is one in three. patients that are hospitalized are likely on insulin or other forms of diabetes management. And if this is not managed well, there's a real potential for patient harm back in the day, when I was in hospital leadership, we had several patients die Because they were managed poorly with their insulin, and if they're not managed properly, in addition to harm, there's an increased cost of care. There's been one study that's shown if the patient has an episode of Hypoglycemia Before, they're ready to be discharged. They're going to be in the hospital for another day, and we have data, with a number of our clients. That show with improved glycemic Management.

6:11

The length is, say is lower, and there's less time in the ICU, there's increased visibility on glycemic outcomes. There's now reporting to CMS with electronic clinical quality measure. The rates of hypoglycemia and hyperglycemia. So that's just another area where potential patients can judge the hospital's performance and make a decision. That's where they want to receive their care. And then there's a lot of variation in the, in the delivery of care for patients with diabetes multiple order sets that often exists within a hospital.

6:47

And there's often sub standard types of care utilize such a sliding scale insulin. So the development of a glycemic steering committee can really address all of those issues, and we use, when you look back at how diabetes is managing the hospital, there really is no one owner of how diabetes should be managed. So that's where it's very important to have a glycemic steering committee. That's, that committee can look at how, well, what education is really needed for nurses to better care for patients.

7:17

That committee can monitor outcomes, to see where there needs to be extra focus placed, and that committee can, can look at available technology to help enhance the care.

7:27

Shown on this slide here are the results of our institutions for the, from the three panelists, as well, for all of our industrial customers that have made a decision with their glycemic management committee to leverage technology. And that technology is a tool insulin dosing software. And you can see that all of these institutions have very exceptional outcomes. Most hospitals will have a hypoglycemia rate less than 70 without using this technology. Greater than 2%. And all of these sites actually did have race greater than 2% prior to launching into tool. And you can see that the rates of severe hypoglycemia, which is one of the measures to CMS, is now tracking, are almost non-existent. And you can, a real shock goes to ACA Tristar, with has, has, said, no. Hypoglycemic episode is less than 40 in the last 18 months, and then also as CMS is striking is tracking hyperglycemia. You can see very, very low rates with the use of the tool.

8:25

Spring, I'll turn it over to you.

8:29

Thank you, doctor Paul.

8:30

Our first topic is building the team. In this section, our panelists are going to discuss the pre implementation phase and share who they would choose for their glycemic 18. Our first question is, Can you share the journey of why you decided to implement a Clinical Decision Support tool for glucose management? And, I will ask Kristi to begin.

8:51

Sure. In Central Pennsylvania, we really wanted to take better care of our patients and decrease the cognitive and task saturation for our nursing team.

9:03

As it relates to insulin drip, we looked insulin drifts. We looked at both are recorded and are anecdotal medication management opportunities.

9:12

While we reviewed these, we recognized that the cognitive burden that our traditional dosing model placed on nursing, know, made patients on insulin drips. Very, you know, complicated to manage. And what we heard from our nursing team.

9:25

Is that the way that we dosed and used a linear dosing regimen with very specific administration instructions, but really open to interpretation and lead to variability in care.

9:38

So, know, we saw this when, when we learn about EndoTool, as an opportunity to mitigate that cognitive burden, that we place on nursing, and decrease that variability.

9:50

And we were hopeful that, along with that, we would see decreased hypoglycemic rates decrease time to goal and decreased length of stay in the hospital, all of which we have been able to realize since our implementation.

10:03

So that was, that was really our driving force behind the transition to the glucose management tool.

10:14

I love that you have such a awareness of your nurses, pain points, and vision to help them Jennifer, what was the journey like at Wake Forest?

10:26

Well, we had some great systems already in place are endocrine physicians and glucose management team, which is comprised of ... that work with that section on Endocrine. Of course, we're already taking care of patients. We already had our glucose management subcommittee that I already talked about in place, and that committee had been monitoring metrics and employ improve classroom management processes over several years. That even with that work and improvements to order sets and other workflows, the data were still suggesting that there were improvements needed. Looking at hypoglycemia right rates, looking at length of stay, especially for patients with ..., looking at the adverse events that were being recorded in our electronic system. They were not where we want them to be. The section head for ..., even for a few years prior to our ...

11:21

implementation, And then, working to help our leaders understand the value of an Employee Patient E glycemic Management tool. He had experience with a tool in a different health system, so we knew the value, and had pushed to implement it, and said, Section, Head along with his business administrator, within intercurrent, created the business plan, and we use the metrics that were previously mentioned to help justify the tool.

11:50

Love it that you guys were relying heavily on that data.

11:53

And then the experience of another that there was a Better Opportunity, or Option, Megan, what was the journey like for HCA?

12:03

We similarly had some opportunity to improve our quality of care in the ICU with a paper protocol that had a lot of variability.

12:15

We actually did a study, or med safety committee to study with, I think it was like 30 nurses to do the same in 400, And there was just wildly variability up to 15 units at one point, if you got all of the model.

12:31

And so we had faith to improve our care and wanted to implement the tool to not only, you know, reduce that variability, but also give our nurses and some competence and decrease their workload with using the tool, and also help reduce length of stay. Because, with very high variability, comes longer times on OneDrive.

13:01

It's really amazing how the data really played into that. But then, looking at the nurses burden. cognitive burden, as you mentioned there, at UPMC how all of that came together, to start this. Our next question is, If you had the freedom to assemble your dream team for glycemic initiatives, would you bring together and why? And for this one, Jennifer, if you don't mind, to respond first?

13:27

I think to have a Dream Team, you definitely have to have an interdisciplinary team. It's critical because all of us bring something different to the table, Physician Champion from 4 and 4 from Endocrine is a must, I believe, along with ..., that work alongside of that section to take care of patients. Pharmacists and nurses are, who are well versed in case management challenges are also important, along with nursing, educators and nursing leaders. It is extremely important with an implementation like EndoTool to have strong nursing champions because it does have a heavy nursing component. It can also be helpful to add teammates from the laboratory as well due to the heavy need for point of care testing devices and other lab values.

14:20

Teammates from your EHR, build teams, a great addition, especially teammates, that work within the pharmacy and inpatient operations team. I know at our institution we have Epic and so we had multiple teams within the Epic system at the table with us.

14:38

Anyone who is on the financial side like that Business Administrator in Endocrine can help with your budget needs. And, I think it's important not to forget about our pediatric colleagues, consideration for pediatric endocrinologist in AP piece along with Pete's Pharmacy and Nursing. They can have an important seat at the table as well.

15:02

Is amazing! I want to say there may not have been anyone you forgot in that group for the inter disciplinary approach. Megan, what would your deep dream team look like?

15:15

Well, I think, Jennifer, Jennifer nailed it, but, you know, for us, I feel like we did have that physician champion who really wanted to, you know, improve care across the hospital.

15:31

And, you know, using my team of ..., being patient, managing, you know, the end for an inpatient, utilizing in their tool in our youth, our diabetes educator, play a heavy role, getting those patients home and making sure we're setting them up for success at discharge.

15:53

As she mentioned, you know, pharmacy and our EHR, colleagues were huge in making sure that, you know, the order sets and things we were implementing were clear and concise.

16:05

You know, very direct at what we want it, and not too much, where, you know, nurses could get law, and in the order it and what they're supposed to be doing. And then, you know, as you said, nursing is the biggest component. They're the ones that have to execute all of our ideas. So, having them on board and engaged, in improving glycemic management made us successful.

16:34

That's amazing. Crissy, what would your dream team look like?

16:39

Well, it's very difficult to add anything. I really think that two other panelists covered this in detail.

16:45

But the one thing that I think that I would add to that, that we've learned, especially through this project, is that data analysts are so important.

16:53

As we're looking at these initiatives, because we need to measure these outcomes, monitor the success, and eight and decision making. If we're going to modify any parameters, you know, really digging into those details, I have found to be really helpful, especially in our post implementation phase, so that we can then take those, you know, results back to the nursing team, the clinical team taking care of the patient, and show the successes.

17:20

This is amazing, thing to hear each of you share.

17:25

It's definitely an interdisciplinary approach, but mentioning even down to the lab, the EHR and then the data analysts, That's amazing, I think we sometimes forget those when we're focused on physicians, nurses, and those inquiries of the team. Now, we're going to look a little bit at implementation, discuss the implementation phase, our panelists will share what the onboarding of new application and the change process looked like at their organization. Our first question is, what was your rollout strategy and some of the hurdles you had to overcome. Kristie, I'll ask you to go first. UPMC.

18:03

OK, our rollout strategy was Big Bang. So we went all sites, all adult unit, that basically had the ability to care for a patient, on an insulin trip across press, R seven campuses went live at the same time.

18:17

And that was a really big undertaking.

18:19

There was a lot of end users, a lot of patient populations and, you know, as I've said, a lot of stakeholders that we needed to get buy in and, you know, shared decision making and to agree on things. So one of those hurdles was looking at our order sets, Our order sets needed changed across the board.

18:41

And really, we made a decision to make it impossible to order an adult insulin drip in these areas without using Ando tool. But that, that required a lot of discussion with a lot of stakeholders, like ours, are specialties between, you know, spanning adult women's and cardiac surgery. So I think that was probably one of the biggest hurdles to get over and work through those details for a smooth, smooth rollout.

19:11

That knowing how large your facility is, that thing took a lot of effort, and just concerted, diligent approach from you all to make that successful. Megan, what was the rollout strategy at HCA?

19:27

ACA we started with one hospital, which was here at Centennial and so we wanted to trial it, per se, hearing, kind of per factor rapport or not perfect it, but try to make improvements before we went anywhere else that we went live in all adult ICU, medical, surgical, neuro, our cardiac ICU, but not in our cardiovascular surgery unit. So that one actually did not go live until about a year ago.

19:55

They, you've learned more than any unit in the hospital, so they were actually more well versed on the old system we had, and felt comfortable doing what they were doing.

20:06

And, you know, we did, we had some pushback initially on implementing that in that patient population, and so we went live and all other youth had good data, And we're able to show that to them and, you know, now, or live across the board here at ..., and then have expanded over to one of our other, sister, hospitals and tristar. So, some of the hurdles we went through, like that work.

20:34

Yeah. As I mentioned, some physician buy in and trusting software and that sort of thing.

20:42

And then also just nursing, you know, with what to expect.

20:48

And the timeliness of it, you know, we obviously want timely, actually tracked, but that can vary a little bit when it's on paper.

20:57

And so when it's coming at you, through technology, you know, that's something that, you know, they were, they were having to work through of how they would stay on time. And it helped improve our quality, for sure.

21:10

So, as mentioned, by Christie, you know, changing our protocols and that sort of thing.

21:17

Something we had to do, and we also tried to make it difficult to order it outside.

21:23

And so we had a lot of success with that glucose management team being here and able to help us with that.

21:32

You, Megan, It's interesting to hear that you no rolled it out in a stage sort of approach, and then you have the data to help support those other units and sites coming on board.

21:44

Jennifer, how did it look at Wake Forest?

21:48

Is the approach at Atrium Health? Wake Forest Baptist is definitely more along. The lines of what Megan said with HCA and they approach was to start small to adult patient care areas at the Academic Medical Center were selected Cardiovascular Intensive Care Unit, and an Intermediate Care Unit, which is like a step down unit from the ICU. These units were selected based on metrics regarding glycemic Management, as well as they had a high utilization of insulin drafts. Intermediate care was also selected because most patients with ... were added on that unit. We continue to devise a plan for where to implement the tool next. Once again, using data as well as expressed interests from leaders in those patient care areas. And, to be very honest, the success we were having with patients on ... was assisting in the request, her roles, the tool out to other areas.

22:47

I just recently added another campus, and I see used in that setting as well. So really glad to keep rolling it out. We did have a few hurdles that our health system had to overcome prior to implementation. one such hurdle was the need to ensure that, just like everyone else has said so far, to align protocols, especially around Hypoglycemia, I and insulin management. one particular thing that was interesting for our health system we had preferentially use Dextrous Dextrous 10% for hypoglycemia because it just some ongoing shortages, was being able to get D 50. And EndoTool for adults does preferentially use D 50 for hypoglycemic management. And so we had to also make that change ahead of the EndoTool, implementation, working with our pharmacy team, to adjust inventories, and to ensure their automated dispensing cabinets were set up correctly.

23:45

So that was just another change that we need to make that industrial helped us make it, as well. Another hurdle was the completion of nursing education, prior to go live. Our implementation was in early 2022, which was still a very challenging time related to kind of event, and taking care of patients. So, it was challenging for nurses to be able to get away from their patient assignments to complete online learning, but we knew that it was instrumental in order to be able to go live. So, our nurse leaders were very helpful in working with nurses to ensure that their education was completed. Also, prescriber education and awareness was a hurdle that we continue to work through even today as we continue to roll out in the tool.

24:33

Spring, I would add, I've heard all of the panelists mentioned, the use of data. And there's often a lot of skepticism amongst physicians to use this software, such as this. They feel that the current protocols are sufficient and doing a great job. Why should we do something different? But when you can look at your own hospitals hypoglycemia rate and compare that to what?

24:55

in the two offers, that tends to give a lot more reassurance to the providers and allow them to be accepting of it. So, there is often a lot of skepticism amongst physicians in the beginning.

25:06

Thank you, doctor Paul. And thank you all for sharing. It's really cool to hear how very different approach can be from that big bang, all the way to just one pilot unit and then slowly moving out, and yes, data plays a big part. I also heard a lot of hurdles about standardizing how even within the same healthcare system there is a lot of variables Then have to come together into a more standardized approach. So, the question, we would all love to know next is looking back, what would you pivot, or changing your approach, and why? And making, I'll have you go first.

25:44

I think, you know, our system with a little bit different in that we did already have our glucose management team established, And so, I think having nurse practitioners really just available and made a successful, we also are the ones ordering the endpoint drip.

26:02

And so we were already well versed in what the patient needed, and how to order it, and that sort of thing.

26:10

And so I think, you know, from our standpoint, it went really well because we had a lot of control over it.

26:19

But just really standing by our ICU teams and, you know, we're obviously not here 24 hours a day, So really getting them comfortable with ordering and even nursing what to expect. There.

26:34

A lot of that in the algorithm of managing a patient on IV insulin, and so I think trying to make them successful as possible with leading them with ways to come really helped make us successful in the beginning.

26:55

That's good to hear. Jennifer.

26:57

You have that pilot approach at your organization. What would you pivot and why?

27:05

We are looking back on it. We allowed for insulin to be ordered without EndoTool.

27:12

And so, on droughts, we kept off two different processes in place and that did lead to issues. And I think we might want to do that differently if we had it to do over again. If we did have some instances where prescribers were challenged to find the order set that they needed. And so, we've since remedy that. But that was an issue that we worked through. We would have also been more deliberate, I believe, with prescriber education for ... tool, although we had a training module available, how Swag Communications Grand Rounds presentation. It's still a challenge to get to everyone, especially when you have a mix of residents and interns, fellows, attendings, and they're all rotating through these places on a monthly basis.

28:01

It did make it challenging to ensure that our aware of in the tool and the value of that, And so, I think we, we probably could have spent more time on that early on, and maybe even work with our interns and some of those, you know, just boots on the ground teammates to get their ideas on how best to reach the masses.

28:24

Very insightful, Christy, UPMC, had that big bang approach, what would you pivot or change and why?

28:31

Yeah.

28:32

Just really taking the baton from, from Jennifer.

28:36

I think that, looking back, our opportunity was probably some more focused provider education, especially on the transition tools, to get more buy in and adoption of the recommendation. So, one of the things we found was, I think our providers were unprepared for how quickly EndoTool would say, hey, the patient, you know, ready to come off, and they'd be getting that kind of messaging and communication from our nursing team. I think we were used to having patients on insulin drips much longer.

29:02

So I think showing some of that data and getting, getting more buy in. And again, because it was Big Bang and we have a lot of residents and different, you know, physician groups. I think we had some opportunities there for some more robust physician education or maybe use of champions within the groups rather than just relying on our endocrinology team. And then for nursing, I think that we did a better job with education.

29:30

But the one thing that, now, kind of that we know, is that I think our nurses were somewhat unprepared for how EndoTool would recommend supplemental carbs. It's something that they just weren't used to. They were used to treating when someone's blood sugar dropped. They weren't used to, you know, real proactive, treating. And then recheck. So I think, emphasizing that in the training and helping to connect to the why, with the hypoglycemic rates before and after.

29:57

No, it would be something that that definitely, I think, that our nursing team would put more of an emphasis on, to help them understand that, as well.

30:06

Thank you.

30:07

It's actually amazing to see, with the very varied approaches to how you rolled out that there's not a shift in how you would do it, but primarily in education, into some of those preparation pieces. So we all recognize education is key when attempting to soften the impact of the change and make it successful in this section, our panelists will share strategies they used, as well as how they assess the effectiveness of their programs.

30:34

Our first question is, Share one strategy that you used to prepare for the adoption of the glycemic management software, and Jennifer, if you could begin.

30:45

I think, when you are preparing for adoption of any sort of software like this, the identification of the key stakeholders from multiple disciplines early in the process is critical. For the individual implementation of monarch does a great job with helping your team understand what has worked best with past implementations. And we tried to mimic those success stories. We said a clinical trial partnership between a medical staff, nursing, and pharmacy leader to help drive the implementation plan. And with the vendors assistants, we had a routine implementation team meeting with report outs from subgroups regarding the technical and clinical build, as well as continue planning for education. We tried to.

31:34

Time to digest those issues were identified, and I think it's important. I've said it before, but I have to say it again, to have that strong information technology, engagement from several teammates, due to the importance of how the order sets and nursing documentation are implemented. The team, we met more frequently as we move toward go live and spent quite a bit of time in the final stages, of ensuring that that education for nursing and providers and communications were complete. With an ... implementation. Nursing education had to be completed at a high compliance rate, and so, that was a lot of the focus as go live approach. So, we just said, we tried to prepare with that team, and just make sure that we have that team in place that could push all the initiatives as quickly as possible.

32:26

It's amazing. It's definitely a team approach, and not any one person that is going to make this successful. Megan, how did What strategies did you use at HCA?

32:39

I think as doctor Paul, you mentioned earlier, it's just getting nursing and physician, know, to buy in for the Why. Why are we doing this? Why is this going to be a better process and what we are already doing? Any change is difficult at Bill burdensome, you know.

33:00

We've done it for years and years and years, and that doesn't mean it's always best.

33:04

So, really trying to explain, you know, to the nurses as why we're doing this, why we're changing. And have them buy into how this is going to not only make their lives easier, but also give better patient care.

33:21

As well as the physician and a colleague, as do, you know, how this is going to help our patients get them home faster?

33:32

Get them better, faster, and just being present, and answering those questions, you know, in real time.

33:42

I have found over the process of implementing the theme 10 years ago, that, no, just, the questions don't come up until it happens, right?

33:52

And so, there, you're never going to be able to prepare at the beginning, as Jennifer said, you know, trying to get compliance and education is huge.

34:02

But until they actually have to do it with their first patient, you know, there, there's gonna be things that come up that they never thought of, that really just trying to walk right beside the nurses and our provider colleagues to make that successful, I think was a strategy we tried to lean into.

34:22

Your team clearly has a high level of engagement and ownership as you work to make this successful.

34:29

Kristi, What would you share about a strategy used for UPMC?

34:36

As I mentioned before, I think it's what we've had an opportunity to do better with physicians.

34:40

But for nursing, we used a super user strategy, where we really had each unit identify two day shift and two night shifts super users. So for nurses per unit, which ended up to be about 300 super users across the system.

34:56

And then those super users got a higher level of education beyond just the self paced modules that all nursing staff got.

35:05

And our hope was that they got a little more comfortable with the with the product through some interactive webinars and then could provide that at the elbow support on their units to the team.

35:16

So, I think the super user approach was our, our best strategy at Go Live, and we also relied heavily on our nurse educators, too, you know, be part of that Super User team, in addition to the bedside nurses from the unit.

35:31

So, super users, and, and leveraging the nurse educators to be, we'll call them super, super users, per train the trainer.

35:41

That provided that extra support on the unit.

35:45

You guys have such a recognition. And it plays such a value on supporting your nurses, at UPMC. It's very cool.

35:53

Final question, How do you evaluate the effectiveness of your glycemic Management Program? And, Megan, I'll ask you to start.

36:03

So I think one of the things that is also great about the tool is that, they provide to analytics that are real time and can be run independently without a data analyst.

36:14

So I know previously data, um, on a paper protocol. It's such as hard to get your hands on and so, you know Endo told does have analytics that we monitor closely, quarterly, even no individual patients that we come across, that we have concerns about.

36:34

And so, you know, we really tried to watch those metrics and then also keep up with our nurses, as we're rounding on a unit, as we're, you know, going into different unit. How's it going? I still app might be the ICU even a year later. How's it going? And, you know, as I have mentioned, this team earlier, there are still things that they nursing report back on, that we try to work closely.

37:03

I'm with the vendor, try to make their life easier as much as possible.

37:09

And then, you know, also, one of the things that we really monitored closely at the beginning of our implementation with our length of stay, and so does our team, the glycemic management team, you know, are we helpful in getting patrons factor?

37:24

And, you know, the data was able to show that, yes, we were able to get patient home about a half a day sooner.

37:32

And, with the help of IBM time, you know, to goal and on influenza, it's really help aid in making, making that an effective process.

37:44

So, no, the data drives a lot, but also just, how can we continue to help our provider crawly with using the tool, but also nursing to make it better for them?

38:01

That's amazing.

38:02

A half a day decrease in length of stays truly stunning. Cristi. How do you evaluate the effectiveness? At UPMC?

38:12

So, in addition to using the fantastic data analytics that monarch does provide wood, which is fun, fun to dig into, we round on our nursing team.

38:23

So between our EHR team and myself, we round and, you know, survey them on their pain points. Ask them what it's like. Taking care of a patient on an insulin drip.

38:33

Get some feedback. Is it better than it was before? Which, you know, we have gotten in surveys that, they much prefer using EndoTool than the way we used to do it. And then providing some of that bidirectional data, with the nurses, as you round. one of the things that we find is that nurses just don't like taking care of patients on insulin drip. So we were getting some anecdotal feedback from our provider colleagues that nurses didn't like EndoTool. So we dug into that data a little bit more and what we found truly was that nurses don't like taking care of patients on insulin drips.

39:06

However, if given the choice between the way we used to do it or the way we do it now on Android Tool, they prefer the EndoTool method.

39:16

We do get, you know, ask them. What are the pain points. We've, we've gotten rounding details like from our cardiovascular ICU, that they were surprised that they weren't seeing as many to our rejects on patients that they thought, and very stable blood sugars. And we were able to work with the monarch team, and look at our data, and realized that we were able to make a parameter change, to get those patients out, to more to our rejects and decrease some of that nursing burden. And the nurses definitely felt that install that. The next time we rounded on them, they noticed that different.

39:45

So we do, I think, rely a lot on, you know, the data analytics that we're getting from monarch.

39:53

The feedback that we're getting from the end users and then being able to communicate that to them to make changes and to show them, you know, where, where we really are.

40:03

I mean, it's nice to be able to be on a nursing unit and that be able to tell them that, you know, we have almost a 50% decrease in blood glucose checks on patients on insulin drips than we did before.

40:13

We went live because of, you know, our decreased length of time on Drip because they're only seeing things shift to shift. Like they take care of a patient on an insulin drip on a ship. They're not necessarily seeing the bigger picture.

40:24

So it's nice to be able to provide them with that data and, and show them the difference that this tool is making.

40:33

That's really wonderful.

40:34

Data is powerful and lead, do you recognize having a patient on an insulin drip is time consuming?

40:40

So being able to share that with the nurses and help them see the value and what they're doing is awesome.

40:47

We're going to move to our Q&A section. And I'm so glad for all of you that have place comments in the chat. We'll go through and answer as many as we can in these last few minutes. The first one is, how is EndoTool integrated into the EMR? Is it utilized in Epic? Is it available to outpatient use?

41:08

Um, I'll go ahead and answer that in this current environment for our panelists today. They use it in the inpatient areas. But, Cristi, do you mind to discuss a little bit how it's integrated into the EMR?

41:25

Sure, so we, we use Epic in our inpatient areas, so when a patient has ordered an insulin drip, there is an icon in the fast toolbar buttons. If you're familiar with Epic.

41:38

And the nurse simply clicks on that button. It's a blood draw, to be honest and they, it launches them out to EndoTool. We have interfaced, demographic ADT data that crosses on the patient. It goes directly into the patient record with an EndoTool, pulls in the most recent CGM, or BG reading, and then makes the recommendation.

41:59

And that's where within Android, toll, nursing will get scripting messages that, you know, based on potassium levels or blood glucose levels, that they may want to, that they should initiate. ..., standing order fluids with electrolyte. So there's all sorts of messaging that we incorporate in there, too, to help guide the nurse, in caring for the patient on the insulin drip. But it's, they only go into Epic.

42:25

You hit a button, it takes them out to EndoTool and then then that information feeds one another.

42:32

We have ... reports that pull into epics summaries that you can look at in Shift Handoff, and that providers can see as well.

42:39

Or providers primarily just work within Epic, not within EndoTooll.

42:43

Our nursing staff is really the only ones launching out to Epic launching out to EndoTool to get that dosing recommendations during the drip management.

42:55

You mentioned Christie. When a provider orders and a tool, they select all the aspects of the care, the motor therapy, goal range, within an Epic and then moves right in.

43:07

Yep all of that crosses over so it's there, when the nurse launches into two EndoTool, for the first dosing recommendations, a lot easier for the nurse in that regard.

43:17

Sure.

43:20

Our next question is, What is nurses opinion about utilizing the software for glucose management? And, Kristie, I feel you actually addressed this one a little bit in the final question at UPMC sharing that they did not like the insulin trip, but they preferred EndoTool over the previous protocol.

43:38

Megan, what would you share, or could you give nurses opinions at HCA with utilizing it?

43:47

So, I think that tends to be kind of the common denominator across the board is that, you know, insulin drifts are or heavy workloads and it doesn't matter how you slice it, but with ..., we've had a lot of feedback that, there, we've taken a lot of that, no cognitive burden away from them, not having to calculate and follow, you know, the graph or the chart. And really just reducing their worry of making a med error.

44:23

And so, being able to put in the glucose and get a drip rate back and knowing that you have an algorithm behind the scenes that working towards managing the patient, it not, or no variability or error based on an individual. They also like that.

44:44

So for that instance, they like the easiness of it, log right, and get a glucose.

44:49

Get a drip rate, change it, Move on.

44:52

Do they like that easy enough of the workflow, and not having to, you know, calculated themselves, but also, they liked that they can cover for each other?

45:00

And so that was one of the things that we found, that if you have a nurse off the unit for, you know, procedure with a patient, or you have a nurse at lunch, and you're trying to cover knowing where they started and where you were supposed to go with really, really difficult.

45:16

And, you know, was going to be a high, no risk for an error at that point.

45:23

And so they it it doesn't care what nurses logging in and what nurses making the hydration. It's going to keep the course, regardless. So they are able to help each other a lot more, which, which has been great.

45:40

Thank you for answering that one. Our next question, Jennifer, I'll give this one to you. What areas of the hospital do you use and do tool?

45:50

Right now, at Atrium Health Wake Forest Baptist, we are still within critical care units, and then that intermediate Care unit. And that's also where we have taken it to another.

46:05

one of the other hospitals in the atrium, health white far assist. Over in high point, Still sticking to those, there's a lot of interest on potentially rolling out eventually to the sub Q version of ... tool that we are not there yet. And have to hold on that because of that, already. I think, we've, we are trying, in the process of merging two epic systems across the R, N or our region, which is a challenge. So, of course, some other projects have to go on hall because of that, We have started there, and of course, that's where the insulin droughts are mostly utilized and hopeful to move into the emergency department. After that EHR harmonization happens next year, we can't roll out as fast as we would like, to be honest.

47:01

And just to for our audience, are there any areas that Jennifer has not mentioned at either HCA or UPMC? that are also they are all that? Kristi go first.

47:16

So, areas that are not that are excluded for us right now, or alias that Jennifer had Jennifer's, it's in within critical care at wake forest atrium health. Are there any other unit areas that are in utilizing EndoTool you can see.

47:34

So we utilize it in all of our inpatient adult units.

47:37

We do not do it in pediatrics and we do not do it intra operative li. So when a patient goes to the OR, they become out of scope and that's managed by anesthesia until they go back to an inpatient unit, however, there is interest.

47:53

From initially, our OR chose to be out of scope for pre-op post-op and intra op, However, there is some recent interest from our teams to add post-op, so that it eases that transition from a patient out of surgery to the inpatient unit, so that's probably our next area of expansion.

48:17

Just something with that, when you spoke with Christy, there's interest as well, from a labor and delivery perspective, and that that's somewhere, like I said, previously, we don't have it currently, but there is interest in trying to roll out there, eventually.

48:35

Yes.

48:35

And I should mention, we do use it in our women's areas, so we use it in labor and delivery and a part, um, post-partum for those patients that it's applicable to and have worked with.

48:47

You know, obviously, our physician champions are physician leaders in those areas to, you know, develop that, the algorithm that's used for that specific population.

48:57

It's a little bit different obviously than our, our adult inpatients.

49:02

We have it in our OB, and our ER, as well Kristie: I echo your interests and particularly the ..., that's where the insulin drifts are getting started on all patients And so really, to adjust have continuity of care. We also would love to move there, and then we don't use it on any of our adult unit. So, a lot of that was driven by nursing ratios and that sort of thing.

49:34

We use it in our ICU, and are only ICU stepped down, we do unit and that unit, because ration nursing ratios are smaller.

49:43

But I do think that there is, know, an opportunity to use it in some of our other like PSU areas and also knowing that you can utilize attack or a nurse extern or something like that, the pain, the blood glucose, and then the nurse would actually be trading the trip.

50:02

So, that's something that, you know, we haven't seen a high need for that, but, you know, there are definitely some patients that could benefit from the Drip and those units that we don't currently use.

50:17

Thank you all for sharing. It is very cool that it is available in a lot of different use areas and units. I do want to just state that Ando tool is also available for use in pediatrics down to two years old and 12 kilograms.

50:34

But it is, again, very neat to see that it's in use throughout your different units and that there's areas for expansion as well.

50:44

I see some typing, so I'm not certain if another question is coming in or not. But I would like to give you all the opportunity, if there was just any final thoughts she wanted to share, or something you wanted to add for the topics that we have covered. This is a great time to do that.

51:03

If you have anything, you want to add an addition.

51:11

I'll mention that.

51:14

I do think it is a valuable partnership with Monarch I I appreciate the, the at the elbow support that was given with those first patients because I think I think Christy talked about, you know, you're doing an education module. It's just not the same as when you have a patient there in front of you. And so, that was a little nervous with that first patient, that trying to work through it. And just appreciate. monarchs, continued help when we need to troubleshoot, you know, a particular issue. And I know something that we talked about recently, as well, is, like, with downtime procedures, just with your EHR or things like that, which, they help with that as well. So, just, it's, it's, it's been great, and we, just, like, I said, we, we want to be able to roll it out to other areas, and, it's just, it's, it's a slow process in a large system. So, appreciate, the patients that are, our physicians have, is, we're trying to roll it out as quickly as we can.

52:24

You definitely have multiple competing things going on, just internally, but we definitely pride ourselves and aim to offer excellence.

52:36

I think I'll also add that, you know, it feels like a heavy lift at the beginning to get something like this off the ground.

52:44

But, I will say, you know, after having it and doing, and I can't imagine going back.

52:50

And so, I also think that as nursing shortages continue to be an issue around and we have a lot of travel nurses and that sort of thing.

53:01

It is a process and a system that is able to be utilized and done effectively with someone that's not even familiar with it.

53:12

So, you know, we obviously try to make, everyone is familiar as possible. But teaching the old paper system was difficult due to a nurse who was new to our system. And so EndoTool is very user friendly. And so it's something that we have found that nurses really pick up on quickly.

53:31

And I know with, you know how nursing bed by nursing has been over the last few years and will likely continue to go.

53:41

There will be a lot of movement around, and so, really, having a tool that, you know, you can still give great patient care with safety is important.

53:54

We got another question in, You mentioned travel nurses. Is it difficult to educate them?

54:02

Christy, do you mind to take that one?

54:04

How would you approach educating a travel nurse at UPMC?

54:08

So, at UPMC we actually have our own travel agency, UPMC travel staffing. So we do get a lot of travel nurses within 2 R 7 hospitals that maybe work in our other facilities outside of central PA that don't have EndoTool.

54:25

And they do fine. We've developed two things.

54:27

one is A, what they do, the online module for, or EndoTool. We included it, in our traveler education since we do it everywhere throughout the system. So, we included it, we do like a two hour epic refresh for patients coming into our system with workflows, even if they've had a bad experience. We talk about no pump inter-op and this and some specific workflows within our system. And then, we have a one page tip sheet that's included in their unit orientation from the nurse educator. So, it has been an area that that we've recognized and need for. But, in our rounding, we haven't we've gotten positive feedback from the travelers that they really like it. They wish, you know, other sites that they were at added and managed it. So, no problem, so to speak.

55:17

But that I can, that I can speak to, except for the fact that we did, you know, find definitely the need to develop traveler education for it. And since we have our own Travel Agency within UPMC. So, that's a pretty frequent occurrence for us.

55:34

Anything that she would add for either HCR or a weak force that you guys do for travelers.

55:44

I guess I just will say, that when we finally went live with all IP, that was helpful. Right?

55:50

So your, if you have a Trello nurses bouncing between ICU, we found it was difficult for them or even our shared staffing nurses, It was difficult for them, you know, and they often wanted and they're told that, you know, they didn't have to try to do those manual calculations. And so really consistency across the board I think make you more successful.

56:17

I think at wake Forest, we use utilize similar approaches to Megan and Christie said.

56:28

Thank you all very much worthy of note. That standardization does take some of that burden off the nurses and just the healthcare team in general.

56:37

And I think at times, certainly across different facilities within an organization, but even across different units within an organization, it comes to the surface, how different sites are handling things when you bring a program like this in and standardization's almost required. It's some areas.

57:01

OK, Kristie, we didn't give you a chance to share any final thoughts.

57:06

Was there anything else you wanted to add, Um, just at a high level, I wanted to share. We just had our, you know, one-year anniversary on Android tools. So, we had a chance to do some data analysis and share that as a win with our nursing teams.

57:22

And just as, you know, data talks, right? Like people really do like seeing, you know, how this is working. So, we've had 3100 patient runs in a year at UPMC Central PA hospitals. And we compared those to, you know, our averages, for our patients that are on insulin drips prior and how to, I think, I mentioned it was before a 46% decrease in BG checks. So we used to check on an average person's, check their blood glucose, 67 times on insulin Drip run, and now that's down to 25.4.

57:56

And on average, our patients are on insulin drips for 17 hours, less than they used to be.

58:01

So when you talk about that burden of care and that cognitive burden, that's huge for nursing, to have a patient on it for 17 hours, less than I bring that up because, you know, our nurses work 12 hour shifts.

58:11

So I think that was really powerful data for them to hear, because they take care of a patient on insulin drip for 12 hours, but don't necessarily know, know that that patient comes off a few hours later, et cetera. So, I mean, cutting, cutting that time, so significantly. Definitely. We're definitely seeing that decrease burden for our nursing staff. And we have four times less hypoglycemic events than we had, prior to going on into tools.

58:35

So, that's the other thing with nursing burden that we try to share with our teams, is that, that work that they're doing proactively, giving the supplemental carbs and, you know, staying on top of the insulin drips, decreasing, that work from complications, from patients, becoming hypoglycemic, having to the treatment, Having, to do additional lab work, or, you know, things That the patient needs, and keeping them, you know, on the drip Longer in the hospital longer, So I think the data has been really powerful. And our nursing team was excited to see that.

59:05

Thank you so much for sharing that Data really does speak, and that is just wonderful to hear. And then some of the data you shared making about that decrease in length of stay at HCA. That is just really powerful.

59:18

I want to encourage everyone, if you have any other questions or want any additional information, please go to WW dot monarch med tech dot com. There's some information there. You can also reach out directly to doctor Paul.

59:34

He is a wealth of experience, insight and is always available to answer any questions and help with understanding how you and your organization might move forward are options that you can pursue. Thank you all for your attendance today. Thank you to our panelists for sharing, and very much appreciate your time and attendance.