Why Every Health System Should Use Patient-Specific Insulin Dosing Software

Why Patient-Specific Insulin Dosing Matters | Setting the Stage & Introduction | Part 1

0:08
Hello everyone, and welcome to today’s webinar, Why Every Health System Should Use Patient Specific Insulin Dosing Software.

0:16
I’m Paul Chidester, the Chief Medical Officer of Monarch Medical Technologies where we make EndoTool, the patient-specific insulin dosing software.

0:24
I’ll be your moderator for this session and I’m excited to guide you through our discussion today.

0:30
Patient-specific insulin dosing software is transforming how we manage glycemic control with significant implications for both patient safety and quality metrics in healthcare.

0:41
Improved glycemic control is crucial not only for enhancing patient outcomes, but also for meeting the upcoming quality metrics required by the Centers for Medicare and Medicaid Services.

0:51
Beginning in fiscal year 2026, CMS will require reporting of episodes of severe hypoglycemia and hyperglycemia.

1:00
It’s also important that over a third of the patients admitted to the hospital any one time are on insulin therapy.

1:06
And by focusing on effective management of blood glucose levels, healthcare providers can significantly reduce complications related to diabetes, improve overall health and align with CMS standards.

1:18
There’s also the availability to reduce the cost of caring for diabetic using the insulin dosing software.

1:26
On our agenda today, we’ll explore the role of patient specific insulin dosing software on clinical outcomes.

1:32
The financial benefits are ROI of using it, its role in treating complex patients populations, why academic medical centers are adopting its use system-wide, and hear from a health system that has used insulin dosing software for almost 2 decades.

1:47
We have an esteemed panel of experts from top health systems who will share their insights on the importance of insulin dosing software to improving glycemic control and enhance patient outcomes.

1:58
This is a critical topic for healthcare professionals, hospital administrators, endocrinologist and decision makers in health systems.

2:06
Before I introduce our panel, I want to go over just a few housekeeping items.

2:11
All of your microphones have been muted during the presentation to minimize background noise.

2:16
We encourage you to use the chat function for any questions or comments, and we’ll address those in the question and answer session at the end of the webinar.

2:23
And also, this webinar is being recorded for those who registered and will not be able to attend, we will be emailing a recording to them after the webinar is complete.

2:33
With that information, let’s meet our panelists.

2:35
1st, we have Doctor Joe Aloi, who is the current chief of Endocrinology at Atrium Wake Health Forest Baptist Medical Center.

2:43
He’s also the enterprise leader for research and academics for Atrium Health.

2:48
He trained at the University of Virginia and then moved on to pursue research to improve glucose management through the use of technology at Eastern Virginia Medical School.

2:57
From there, he moved to Wake Forest School of Medicine.

3:00
His professional goal was to leverage technology to improve the care of persons with diabetes.

3:05
Doctor Dorothy Kodzwa is a Diabetes and Metabolism endocrinologist in Gastonia, NC and has over 16 years of experience in the medical field.

3:15
Dr. Kodzwa has extensive experience in osteoporosis and screening, thyroid disorders and diabetes and glucose monitoring.

3:23
She graduated from Wake Forest University in 2007 and completed her residency in Carolina’s Medical Center.

3:29
While she was there, she used EndoTool in its infancy while it was under development by Doctor Patrick Burgess.

3:35
Her fellowship training occurred at the Medical University of South Carolina, and she is affiliated with CaraMont Regional Medical Center.

3:42
And finally, Tracey Melhuish, RN, is a clinical practice specialist and critical care and sepsis coordinator at Holy Cross Hospital with Trinity Health.

3:52
There she leverages her extensive experience in critical care, nursing education and healthcare consulting to enhance patient outcomes.

4:00
She has a Master of Science in nursing from University of Phoenix. She’s dedicated to both patient care and education of future nursing professionals.

4:08
Her background includes proficiency and post-anesthesia care, medical nursing and advanced life techniques.

4:15
And then Doctor David Fleece is with us today as well. He’s the chief medical information officer at Temple Health and a professor of clinical Pediatrics.

4:25
He graduated from Tufts University Medical School in Boston and completed his residency at Saint Christopher’s Hospital for Children in Philadelphia.

4:33
He has been responsible for the implementation of both EndoTool intravenous and subcutaneous products at Temple Health.

Why Patient-Specific Insulin Dosing Matters | Implementing Glycemic Management Software | Part 2

0:07
So for our first panelist, let’s turn to Doctor Aloi.

0:11
Doctor Aloi, you’re going to be discussing for us the financial benefits of implementing glycemic management software.

0:18
Joe, could you start by sharing what outcomes have been most significant since implementing glycemic management software in your health system?

0:25
Yeah. Thanks, Paul, and thanks for the invitation to be here.

0:29
What I’m outlining for you was one of the first quality improvement projects I started when I came to Wake Forest a few years ago.

0:39
If you look at the bullet points, just to walk you through a little brief background, hospital missions for DKA and hyperglycemic emergencies have just been increasing over the last decade and how best to treat them. It’s still a little bit of an argument.

0:55
A recent consensus guideline came out a few months ago, and I left the reference there for the interested reader, but it goes through everything from appropriate fluids to blood glucose targets to measuring ketones.

1:10
We were interested in tackling our length of stay, which was hovering around 4 to 5 days, which historically you think you’re doing good as a hospital system if you’re closer to about 3 1/2 days.

1:26
So we thought there was an opportunity there.

1:28
This is one of the first things we looked at with EndoTool IV and our units predominantly where DKA is treated.

1:36
That was in three specific units.

1:38
The information I’m showing you is for about a year.

1:43
And you can see with the Endotool IV, we had about 190 patients. Standard treatment was a modified Yale protocol based in Epic.

1:51
We didn’t require at that point for all providers to use EndoTool. This was during the initial implementation. And our informatics team looked at two things.

2:02
One was just the total cost of care for patients who started with EndoTool IV or those who are treated with standard treatment.

2:11
And you can see that the length of stay was decreased by about half a day, which is pretty significant when you’re looking at length of stay changes.

2:20
If you look at total cost of care between the two, it was about $12 million and that’s really circling around just two hospitals in our larger system.

2:34
The other thing I’d point out and you’re going to hear more about CMS and metrics about avoiding hypoglycemia,

2:39
We looked back at a three-month study period of this group again able to look at EndoTool  versus non EndoTool

2:47
And over that period we had 55 events and the standard treatment that’s not 55 patients but 55 events. But a slightly smaller group of patients. I think the patient group was closer to about 30 versus 1 and in that one patient if the EndoTool protocol was followed completely, I think we would have avoided that.

3:08
So what we concluded from this is that you can both enhance patient safety and you can save money.

3:16
Particularly in our institution, these patients are housed in an ICU or a step-down unit and there’s always pressure to free up ICU beds and space.

3:26
And it’s obviously much more costly to care for patients in that space. And that’s part of the driving of the cost savings.

3:32
And I listed the reference for the abstract that is this was all presented the American Association Clinical Endocrinology in May. So you’ve had some some outstanding benefits and a fantastic cost savings.

3:45
I’m curious, any other impact on cost savings with improved glycemic control? I remember reading an article way back that if a patient has an episode of severe hypoglycemia, that’s likely that they’re not going to go home that day, but have to stay in the hospital another day.

4:03
And there’s also the cost of an episode of severe hypoglycemia. Any comments on that?

4:11
Yeah, both of those are important factors. You know, when you look at a lot of big EMR data it’s sometimes hard to flesh out exactly what’s driving what.

4:21
But I will tell you we did have the opportunity, not in this study group, but in another look at the results of hypoglycemia and somebody in the unit and clinicians tend to want to watch that person if they have a severe hypoglycemia.

4:37
So it delays discharge from the unit. And we think part of this is getting to control closer, quicker.

4:46
And you’re going to see some data about that using EndoTool, getting patients to blood glucose goal much quicker than standard infusion rates. But part of it too is not having any hypoglycemia. There’s not this leaving the patient on the drip longer or in the ICU longer.

5:02
We had calculated using our informatics group again, the total cost of care, and we estimated that an episode of severe hypoglycemia cost the patient about $12,000.

5:15
That takes into account additional hospital time, the additional blood testing and again looking at sort of just total cost of care between those groups.

5:24
And we saw an incremental change, in other words, higher cost of care for more episodes of hypoglycemia.

5:32
We tried, but we’re, we have not been able to publish that because again, when you’re looking at these big data sets, the data’s not, it’s squishy.

5:40
There’s clearly a relationship between hypoglycemia, other things that people think about that’s sort of on our radar, particularly in the heart patient, is wound infection and also any in need for dialysis because if you can avoid these glucose excursions, those tend to track pretty closely with improving those outcomes.

6:03
Excellent. Any other thoughts from the panel on outcomes or observations that you’d like to share particularly Tracey, you’ve had some great outcomes at Holy Cross with the implementation of EndoTool. Any insights you could share?

6:18
I’m just going to echo what he’s already said, especially in our CV population, we saw a significant decrease in adverse events related to diabetes and renal failure and the ability to get them off insulin faster, get them out of drips and out of the unit even faster.

6:37
You know, our wound healing has certainly not been impacted at all and overall and to stay in our CABG population is down.

6:47
Now as regards to other platforms and methods, DKA was a significant cost savings for us. Just the fact that we were able to get a DKA patient controlled in under 10 hour or 10 hours and get them out of the ICU faster.

7:02
Our ICU utilization and length of stay is the best that it’s been in a long time.

7:07
We’re able to shave off our length of stays, the average length of stays down to 3.2 days. So we, I just, you know, we see the same outcomes. We’ve used for 18 years now.

7:21
Excellent, excellent.

7:23
The other comment I would make is that a lot of times patients must stay in the ICU when they’re on an insulin infusion.

7:35
And the ease of using an insulin infusion with EndoTool allows some institutions to actually treat their patients needing an insulin infusion in the step-down unit rather than the ICU.

7:47
Any of the panelists have that experience? Were able to actually treat your patients outside the ICU on an insulin infusion?

7:53
I would start by saying that’s a study ongoing with the emergency room to keep these patients in an Obs, unit clinical decision unit, partly because of expanding EndoTool use down into the emergency room and the overall experience we’ve had. So we’re looking at that literally as we speak. Our Ed just went live mid-october.

8:16
Yeah, there are some of our customers that actually will use insulin infusions on the step-down unit now or they use it anywhere in the hospital.

8:25
Yeah, I will echo that, that we use it anywhere in the hospital. We use ours in the ER, we use ours in the birthplace. We use it in step-down units, we use it on Med surg floors. Everywhere pretty much.

8:33
Does that less than the need for an ICU stay for these patients? For a DKA patient, for instance?

8:34
I think it does. In terms of, we have to transfer them out means if you’re severe DKA patients, bicarbs of like 2, and we’re surprised they’re still awake. They tend to be in the ICU, but your relatively stable DKA patients, whatever that may look like at your facility.

8:59
Excellent.

Why Patient-Specific Insulin Dosing Matters | Insulin Dosing for Complex Patients | Part 3

0:07
Doctor Dorothy, I’d like to sort of talk about your experience at your institution.

0:11
You have mentioned to me before you have some a really tough patient population with very, very high hemoglobin A1Cs, yet you’re able to be successful in using EndoTool to manage those patients. Can you comment on your experience?

0:25
We tend to have A1C in our community, A1Cs of about 9.8 on average. We have some of the highest rates of U 500 insulin usage in the Southeast in terms of our prescription. Well, we tend to see a lot of within our facility, are mixed DKA/HHS patients.

0:45
So you will see those high glucoses over you know 1400 and you’ll see them also have low bicarb gaps. And so we tend to see a lot of that. I think in terms of the changes that it has helped us a lot is our rates of hypoglycemia especially since we have removed the bolus feature from our non DKA order set.

1:03
We have seen a significant drop in hypos, severe or just hypos less than 70.

1:10
In terms of as you look at those numbers, our percentage of patients that are over the Max meter reading about 17.8% and your customer average is about 7.4.

1:19
So our patients tend to roll in with blood sugar over the 600 on average.

1:23
And in terms of those that come in with their severe hypoglycemic, hyperglycemic range, that is the majority of our patients.

1:29
We have frequent fliers that come in regularly that stabilize over a matter of like 12:00 or so hours because the program knows them and we’ve gotten to know them over their multiple trips.

1:40
So yes, our patient population is fairly challenging and EndoTool has made a very big difference in how we manage them and the rate of hypos that we see.

1:48
Yeah, it’s interesting that you have so many patients that show up with the blood glucose greater than 600, more than twice as many as our customer average and yet you still manage to have phenomenal results with very low rates of hypoglycemia and rates of hyperglycemia.

2:06
So it’s, it’s definitely excellent outcomes that you’re seeing despite a rough group you’re managing.

2:13
It is. Lots of COPD and lots of smokers, lots of steroids, lots and lots.

2:20
Lots of unhealthy people. You know, as I mentioned in the introduction, you used EndoTool as a resident at Carolina’s Medical Center when it was really early on, in the early years of EndoTool. How did that impact your ability to care for patients as you were a trainee?

2:38
It helps of actually getting a little bit more confident with insulin drips. So at the time, at CMC, they were doing a lot of liver transplants. They still do, but they were doing a lot more starting then.

2:48
And with liver transplants, you have to maintain a fairly tight glycemic range. And I remember up until we started using EndoTool this beta infancy, we were having to do the math to figure out what their drift rates were.

2:59
And so we had a lot more hypoglycemia. And obviously hypoglycemia can be just as detrimental as hyperglycemia, obviously.

3:06
And I remember when we were around with patients that were on EndoTool, seeing how much less their hypos were in terms of rate and how quickly they were able to recover and actually come off with drips and go home in terms of their length of stay, it made a very, very large difference.

3:21
And I think especially as a young resident who was already really nervous about insulin and the training that I received, although we did diabetes, we didn’t do diabetes at our fellowship training by any settings.

3:34
And so by the time I got the fellowship, I was still nervous about insulin, but a lot less because I got to use EndoTool.

3:40
I was very comfortable by the time I got to my program where they were using other drips, I was very comfortable with navigating that, and I think I made a big difference there.

3:49
Well, one comment I often hear from clients is that if they’re using something like EndoToolor other insulin dosing software in a training institution, the trainees are not going to have the opportunity to really learn how to manage patients with a hyperglycemia crisis, for instance.

4:08
Doctor Fleece, you’re an academic institution. What are your thoughts on that? And has there been any pushback from your faculty to use such a tool for the residents?

4:20
I think early on when we were moving in this direction, this is around 2019, yeah, there were the comments like, you know, residents aren’t going to know how to dose insulin, but in reality, the residents don’t really know how to dose insulin that well anyway.

4:35
And so when you have a tool that does it better than the resident, it seems that you really should, you know, in the effort of good patient care, it only makes sense to use the best tool at your disposal.

4:46
So I think the argument that, you know, residents need to know how to accurately dose insulin.

4:52
I mean, of course, when the EMR is down and all that, sure, you know that then it comes up.

4:57
But for the great majority of time where we have all these tools at our disposal, you really should use the tool that gives you the best patient outcomes.

5:04
So I think that’s the argument, I would say against the sort of concern about how good our residents going to be at tweaking insulin drips.

5:13
You know, we’re never that good at it and this is better for the patient. I’ve got stas. That’s how I see it.

5:19
How about doctor Aloi, Tracey, any comments along that line?

5:24
I can start by saying I agree completely that insulin dosing is complex and I’m going to date myself,

5:34
but as a resident, part of my training including doing sigmoidoscopies, floating Swans, and doing other complex medical procedures that we no longer even train people to do because we feel they’re specialized.

5:49
I mean, I was the only person in the ICU at night changing vent settings.

5:53
It’s not exactly the same comparison, but in a way, if you look at complex high-risk medication, I think people need to know the basics and I think they do learn by following what EndoTool is doing.

6:09
Depending how you configure it, they have to make a decision to accept what EndoTool is advising and certainly when they’re transitioning off IV insulin.

6:18
So we as an academic Medical Center had a little bit of concern about that.

6:23
But now a couple years into it, the residents actually like it. They enjoy learning from it.

6:30
And our endocrine consult service is getting consulted mainly for very complex patients instead of every DKA because the tools managing it that well.

6:41
And I guess that’s my indirect way of saying I think this is the future. We don’t go get maps from McDonald’s to figure out how to get to the next city. We just tell Siri to take us where we want to go.

6:55
Oh, excellent, excellent analogy for sure. ‘sTracey, anything you could add?

6:59
Only that we had a resident that went on to become an endocrinologist who;s subsequently now practicing here as an endocrinologist.

7:07
And one of the drawbacks was because he got to use EndoTool here and he was very frustrated as a fellow that he didn’t have access to it.

7:16
But we don’t, you know, endocrinology does not come into the hospital anymore. Very rarely do they come in. Everything’s managed outpatient now.

7:25
And I think that’s where, you know, the endocrinologists are their best and they prefer to stay out there. And so I know from that perspective, you know, the residents love it.

7:37
They do get to teach and learn about it. And, you know, decisions are made jointly. If it makes suggestions, they’re in collaboration with the attending.

7:47
So and nursing will always go with EndoTool. No matter what a medical resident says, a nurse will say I think I trust EndoTool. So, and it is a great tool though to teach on. I do agree.

8:01
Well, thank you for that.

Why Patient-Specific Insulin Dosing Matters | System-Wide Patient-Specific Insulin Dosing | Part 4

0:07
Well, let’s switch gears a little bit and I’m going to move on to you Doctor Fleece.

0:12
Could you share with us what motivated your organization to invest in this software and what made you actually select EndoTool versus other products that are out there?

0:22
Sure. So again, back in around 2019, you know, our chief of officers and our quality people were realizing that we probably weren’t doing as well in our issues with glycemic control as we could be and started wondering if we should do something.

0:41
And I still remember this, the nursing director for the medical ICU said, hey, when are we going to implement that Epic module EndoTool?

0:48
And I’m like, I don’t know of any Epic module called EndoTool. Let me figure this out.

0:54
And honestly starting with Google and came across Endotool and saw what it was, but then also realized pretty quickly there were other products out there. And so went to Medline and went to, I mean PubMed, like I’m getting dated.

1:08
Went to PubMed and what not, I guess. And found out there were some other products out there and was able to find, I think this article that you have on the slide, which actually is the only article I could find at the time that actually looked at outcomes between the products that were in the market at that time.

1:26
And, EndoTool was outperforming the other, its competitors, you know, by a factor of 10 or more, as you can see on the slide, on these bar graphs.

1:35
So at that point, you know, why would I choose to use a product that was, you know, not nearly as good?

1:42
So I started talking to the company, sent to the health system CEO who immediately endorsed it because he actually has the wisdom to realize he can do a lot of cardiac surgery and whatnot, that the better we would manage these patients in the post-op period, the better our outcome is going to be and all that.

2:01
So really didn’t have to make much of a case because leadership was already looking for some kind of solution to improve it.

2:09
So we implemented at the end of 2019 in our ICU’s at our ORs and again have had good success in our patient population.

2:18
I don’t think we have the depth and breadth of usage that you know, Tracey and maybe Joe have in their places, but we’ve certainly been pleased with the IV product.

2:30
And so decided really a couple of years ago, probably two years ago, we wanted to implement the SubQ product as well.

2:38
And we finally got to the point of starting our EndoTool SubQ implementation with one of our community hospitals at the end of June.

2:48
We are planning to roll it out to the mothership in late January, which is where the brunt of our, you know, residents and fellows and surgeries are happening.

2:57
And then we have a few other hospitals in the health system that will then follow suit.

3:01
You’re in the process of rolling out the SubQ across your system. What have your learnings been with that?

3:10
Well, we did a lot. So the SubQ is, I mean, both IV and SubQ, really the work of using these platforms is on nursing.

3:20
You know, they’re the ones checking the sugars, they’re the ones getting the recommendations, tweaking the doses.

3:24
So we really knew that for SubQ, we had to do a lot of preparation with our nursing staff.
We had to start sending up meal trays with carbohydrate counts on them or at least total carbs. And because that’s one of the inputs for SubQ.

3:40
And of course then we had to have our nursing staff start to assess carbohydrates.

3:44
Now it’s not fine. Perfectly accurate carb counting of everything the patient takes in, but they had to start estimating and generally 50% of the trade, 25% of the trade, things like that.

3:57
So that was, we had a lot of preparation on that, which of course then gets you to your orchestration of checking sugars, delivering trays, giving insulin around the meal times.

4:07
So a lot of work on that and then went live with the dosing algorithm itself.

4:12
And as you can see from this table, so if you look at the greenish column, those are EndoTool SubQ hypoglycemia rates.

4:22
Then you see in the next one to the right are EndoTool SubQ for July through September and you see the pretty significant decline in those rates of hypoglycemia.

4:33
And yet we still have about 1/4 of our patients on SubQ insulin who are not on the actual algorithm.

4:40
And you can see here how the EndoTool algorithm is doing a better job at avoiding hypoglycemia than the sliding scale patients.

4:49
But what I will note is that even the slightest scale patients July onward, you see their numbers are better than they had been, you know, in the green run up period.

4:58
But I think that’s a reflection of all the nursing education and nursing preparation and operational preparation that you need to have in order before, because just changing your dosing algorithm is only one piece of this picture.

5:11
I think we also learned it was a big lift. It was a big change management lift. It was a big education lift, not just for nursing, but for providers.

5:20
And EndoTool can be a little more aggressive than what they’re used to in a good way. And in the sense of getting these hyperglycemic patients down into their target range faster.

5:31
But that initially can worry on the part of nursing, nursing calls to doctors.

5:37
Should I really give this much insulin?

5:39
The doctors who aren’t used to it yet may be a little bit hesitant.

5:42
So I think I would emphasize for those contemplating going to improve their SubQ glycemic management that you have to take a look at your processes and then you need to educate and build confidence.

5:57
And then you will then see the full benefits of the EndoTool algorithm and how can deliver.

6:04
So for the others on the panel, you’re not using EndoTool SubQ at your institutions currently. Have you thought about moving forward with that implementation at your institution? And what do you think is essential for a successful implementation?

6:18
I’ll start with you, Joe, any thoughts on that? Because I know we’ve discussed, possibly, implementation at your facility in the near future?

6:26
Well, I’ll start by maybe stating the obvious that each hospitals has its different needs. So there’s clearly almost to what Tracey was talking about. We have a lot of community hospitals. We have hospitals out of the region that there’s no endocrine coverage.

6:42
And so for our main hospital, yes, we’d like to bring it in. We’d like to, but I think we want to start with the places that have a bigger need.

6:53
What the system is planning to do is try to get us to do virtual management in those hospitals with our glucose management team.

7:02
So I think big picture I don’t want to grow the glucose management team to be an algorithm that’s already there.

7:10
In other words, you know, having a person that I’d rather teach again, as was mentioned, you know, the nurses learn from this, the staff learn from this, the residents, but it’s the nurse at the bedside that’s in with the backup of a very good algorithm can then dose this very safely once whether it’s the hospitalist, whoever is the admitting provider says use EndoTool SubQ.

7:36
So our plans are to start with a couple of the sort of, they just happen to all be more rural, but a few of the outlying hospitals, that would be a place to start because it might mean the glucose management team wouldn’t have anything to do. So I have to have because that’s largely what they’re doing.

7:54
So I have to have a plan to sort of decrease their presence there and build up the SubQ there, make sure it’s in the system working well with our EMR and then expand it.

8:07
Interesting Tracey, Dorothy, any thoughts about subcutaneous implementation within it or at your sites?

8:14
So for us, it’s, we’ve become one under a system.

8:18
So we would love to go to the SubQ platform, but we’re within Trinity Health now and it’s 100 and something odd hospitals and all decisions now have to go out to corporate and back.

8:32
So not for the lack of trying, it’s just we’re a lot of decisions are made outside of local control anymore.

8:41
Yeah, I’d say that goes the way of big health systems for sure. Dorothy, anything to add before we move on?

8:48
I am of the inpatient variety. So we do inpatient and outpatient. So we’re the ones that do all of that.

8:54
We are working on training the nurses because there is a, as I’m sure everyone also experiences a staffing issue and with staffing issues comes knowledge gaps.

9:06
And so trying to retain staff, trying to train staff, trying to train those nurses, that’s something that we’re actually working on.

9:13
So as of right now within the main hospital, we are not having that conversation.

9:18
We probably will have those conversations later at the new hospital that they’re opening down the street because that’s going to be remote versus us physically being there. So there’ll be that kind of conversation.

Why Patient-Specific Insulin Dosing Matters | EndoTool®: Lessons and Lasting Benefits | Part 5

0:07
All right. Tracey, I want to turn to you and actually it’s interesting you mentioned that now you’re being part of such a big system, all decisions come from the top.

0:14
But I understand almost 20 years ago you were instrumental in implementing EndoTool in your institution.

0:24
Can you share that story with us a bit?

0:27
So in 2005, end of 2005, one of our CV surgeons approached us about high glycemic control and the CABG population, lower incidence of hypoglycemia.

0:39
The literature had been published.

0:41
He had heard of various platforms and kind of tasked us with coming up with a proposal on how we were going to address it and we had heard of the different platforms that were available through our professional organizations.

0:55
So we met with all the vendors that were possibly around at the time.

1:00
And you know the decision I think was unanimous in the fact that EndoTool, not only with the support and the implementation, but the ongoing review and analytics of EndoTool was one of the biggest deciding factors on adopting EndoTool.

1:18
Initially, we only rolled it out for CVICU and the OR, but we quickly realized nurses obviously need a lot of resistance.

1:27
Why do I need something to tell me when to do an Accu-Chek?

1:31
But we could demonstrate quite clearly with EndoTool after implementation that we truly weren’t getting to an Accu-chek or a glucose within 30 minutes or 60 minutes as suggested. That we could go possibly 2 hours before we even checked it and hence why we weren’t getting control quick enough.

1:50
So they learned that if you did them timely with the prompt of software telling you when to do it, that you could go from your 60 minute glucoses to your two hour glucoses and meet medical stability and transition off.

2:04
But you know, just the adoption piece of it is that EndoTool had full support for implementation and then ongoing support.

2:12
So if we had any concerns troubleshooting, there was clinical 24 hours-7 support and IT support, which for us at the time before we merged with other system, was one of the deciding factors that we needed.

2:28
And then as we continue to use a linear platform on the rest of our ICU and have this great tool in our CVICU, we  got a lot of resistance from the medical intensivist. Like hello

2:40
Why can’t we have access to the same platform? So we then went live on all ICUs and a couple of years after that we went into the emergency department.

2:51
So it’s, you know, it’s great benefits. It’s easy to train on.

2:56
There are health stream modules that you can put agency nurses, per diem nurses, float pool nurses, everyone can go through the same training.

3:06
They can do it on an e-learning platform.

3:09
It’s easy to sign off on, it’s easy software to use.

3:13
Over the years we’ve provided and worked closely with, back then Doctor Burgess and now with Monarch Medica,l and just a lot of the updates that have occurred to the software over the last 18 years has been based on feedback that we’ve provided.

3:29
We’ve been, you know, asked to give input into different things that we see opportunities with.

3:34
And I think we appreciate that.

3:38
My staff certainly asks for it.

3:40
Now it’s the emergency department had implemented it.

3:43
Then the new director said, we’re not doing that. It’s too much work to get people onboarded.

3:48
And then they realized, the physicians realized, well, wait a minute, we’re not managing DKA effectively down here. And we saw a lot of drift in the length of stay again.

3:57
So the medical director firmly said: Nope, we will be using EndoTool100% in the ER.

4:03
So it’s great because they start down there and any DKA they come right up and within 10 hours you could have a DKA out of the unit.

4:11
We are looking at what one of the physicians said at a clinical decision unit,

4:16
we do have a CDU and a 23 hour Obs unit that we could possibly put the DKA patients on with a three to one ratio.

4:24
So that is something that we’re actively talking about now.

4:28
But in the meantime they do come to critical care, but we’re able to get them out.

4:33

Your phenomenal results that you’ve had. Are any other hospitals in your system aware of these results and consider adopting it as well? Or is that still more of a top-down strategy that it’s hard to migrate?

4:45
When we went live with Epic, there were this, there’s a few of us that are on EndoTool and since we’ve consolidated we all presented and sharing our data and Epic has a two bag dosing method that majority of the system have transitioned to.

5:02
But we try to standardize it and approach the computer based module and go to EndoTool.

5:08
There’s Saint Mary’s which showed all our data and you know, they didn’t want it to be forced on an individual hospital.

5:17
They wanted the hospitals to at least have some local control and decision making.

5:21
So the option is there if they want a computer-based platform, that EndoTool would be the preferred method.

5:29
But they weren’t going to ask all physicians, hospitals to transition to this.

5:35
You know, what’s the other thing about EndoTool that’s amazing is the safety features.

5:40
The ability to scan a patient from registration database. There is not manual entry of anything.

5:46
There’s an inflow and an outflow of, you know, glucose, chemistry’s coming in, potassium’s coming into EndoTool platform likewise information flowing out plus the ability to scan.

5:58
So you scan the patient that you know, it’s the right patient for the right dose and the right dose change.

6:04
And so the whole safety feature that has now come about with EndoTool is even more reason to use it.

6:12
You know, the other feature that’s relatively new for our product is that there’s order entry as well.

6:17
So when a physician orders EndoTool through the Epic or Cerner platforms, those specific orders for the patient are rolled over in the EndoTool.

6:26
So there’s no need for a nurse transcription of anything.

6:29
So for the panel, I mean you’ve all seen success with glycemic management software and you likely have colleagues at other institutions that haven’t adopted any insulin dosing software.

6:38
They’re still on a paper protocol or a protocol embedded into Epic.

6:42
What advice might you give them so they might consider the adoption of insulin dosing software at their institution?

6:48
I’ll start with you, Dorothy, thoughts on that?

6:51
Someone that’s had that, I mean, I’ve used other platforms.

6:55
I think the one of the things I would say is less hypoglycemia is key, decreased length of stay for patients.

7:03
The program gets to know your patients.

7:05
So for your frequent fliers, if you really want the most efficient way to reduce your length of stay with them, this is one way to do that effectively.

7:16
And in terms of better outcomes, I mean, you without hypos, I think that’s the main thing because, you know, with the ADA and looking at those guidelines, one of the things they always talk about is, yes, hyperglycemic excursion, but hypos are also critical to avoid.

7:31
And that’s why the guidelines talk about, you know, blood sugar between 140 and 180 in terms of cut offs.

7:35
And it’s very easy if you’re kind of doing it by yourself outside of a platform to get those hypos pretty often.

7:43
And here you have a program that allows for you to avoid that pretty effectively.

7:49
So Joe, David, anything else you want to add to that? So I recommend

7:54
I’d say that I was really surprised at how little education I ever had as a Med student and resident around glycemic control.

8:03
And I guess, you know, I’m a pediatrician in a mainly adult health system.

8:07
I kind of figured all the adult treating doctors really were way more on top of this.

8:12
But it turns out that well, not all are.

8:17
And so I was just sort of surprised at, again, honestly, how little people really care about glycemic control because the patient’s sugar is 70 or it’s 300.

8:27
They’re still sitting in bed watching, you know, more coverage or whatever.

8:31
So, and they’re not bothered to.

8:34
But I, I will say, like again, our CEO, he knew about the importance of it and he kind of drove us to do better.

8:41
The other big surprise for us when we rolled out SubQ a few months ago was patients pushing back on their insulin dosing, which nothing we anticipated happening.

8:51
So that I think speaks to the need for, you know, diabetes educators room in the floors in the hospital and helping the patients who don’t, you know, patients coming in who are normally on that form or maybe they’re on, you know, one dose of Lantus a day or whatever.

9:06
And all of a sudden we’re given them meal time insulin.

9:08
Yeah, they’re like, no, I don’t take insulin in my meals.

9:10
I don’t want that.

9:10
And so again, it’s a lot of change management, nurses, doctors and patients.

9:15
So I think I’ve learned a lot in the past couple years about what we do and don’t do.

9:20
Well, it’s glycemic management and why we should be doing better than we used to.

9:26
Yeah, it’s interesting.

9:27
I mean, so many patients come in needing glycemic control, but they have many other acute medical problems that tend to dwarf that.

9:34
And it also almost becomes sort of white noise in the background and almost ignored.

9:40
Joe, anything else you want to add?

9:42
No, I echo what David said on a couple points.

9:45
1 is when I was making the value proposition here when I came to Wake Forest 10 years ago.

9:55
When I tell the story, it took me about a year and a half to convince people that this was important.

10:01
When said that we’ve talked about, you know, complex high risk medicine, but CMS is going to be highlighting they want to eliminate avoidable hypoglycemia, severe hypoglycemia.

10:15
And ultimately clearly when it comes to penalty, I think all the administrators will be on board to how do we fix this problem.

10:24
And the last thing I’ll say is generally when I’ve gotten pushed back, the answer is like many things, well, we don’t have a problem, but nobody’s looking, you know, they don’t have a dashboard.

10:38
And if for the audience, if you’ve been looking across the board different hospital systems, you use a tool like EndoTool, we all kind of land, you know, in the same place.

10:49
And if you look at the before and afters, I think the best a hospital system can do from my experience without an insulin dosing application like EndoTool is an overall hypoglycemia rate around 2 1/2 to three.

11:04
I mean time and time again that’s we see you implement EndoTool and then you get your hypoglycemia rate less than half a percent.

11:11
And I think that’s very impactful.

11:13
And so once people make the patient safety, the value proposition becomes an easier float.

11:20
But again, as Doctor Fleece and Tracey and Dorothy mentioned, the tool’s important, but it can’t sit there without knowledge or that change process like trade delivery, like, I mean, you have the best system in the world.

11:33
There’s always somebody who can work around it if they don’t understand, you know, the reason why we’re doing things.

11:38
So it has to be partnered with education, but that’s right, that’s what we expect.

11:44
So I think this is a very important tool to use.

11:48
And obviously, yeah, one last thing I’ll say, when I had to really make the proposition for this at one point for a project we’re doing, the then CMO asked me why did my project cost $3,000,000?

12:02
And somebody who’s ahead of me with asthma or something was only, well, it was actually about the same or more.

12:08
And her perspective was there’s more asthma in the hospital than hyperglycemia in general.

12:13
You know, half the patients in the hospital, it’s like 40% have hyperglycemia issues.

12:19
So this is everybody should be paying attention to it.

12:22
And in essence, certainly for the hospitalized patient, that is my last thing.

12:27
I’ll say, actually, if there were more patients in the hospital with asthma than with diabetes or with be a mess, they you’d have respiratory therapists just on their gap.

12:38
And it was real.

12:38
I mean, she didn’t push back once we kind of pointed that out to her, but it was like, OK, and maybe I was presenting the information wrong, but that was my answer.

12:47
It’s like, well, I’m taking care of half the hospital at some level, not the entire care, but important part of their care.

12:53
And they gave us the money.

12:54
So it must have been a compelling argument.

12:58
Well done.

Why Patient-Specific Insulin Dosing Matters | Wrap-Up: Closing Reflections and Questions | Part 6

0:07
That is wrapped up the formal part of our discussion today.

0:11
We do have a few questions that I can go to. For the first one is, is this tool available only for hospitals or could private practices have it implemented? No this is just for hospitals right now.

0:24
It would be hopeful in the future that we could have an application that can be used in the outpatient setting for SubQ insulin, but currently this is just used in the hospital.

0:34
However, with the SubQ application when the patient is discharged, we do give an outpatient plan based on how the patient responded to the insulin therapy in the hospital.

0:44
So there is that start.

0:45
Then the next question is, has EndoTool been trialed or used in the operating room?

0:51
I know we have a number of clients that do use EndoTool in the operating room. For our panelists or any of your hospitals using it in the operating room?

0:58

Plan to but not currently.

1:02
And Paul, you know when I was used to Virginia medical school, we used it in the operating room there or an insulin dosing application there.

1:09
We use it in the OR

1:11
Okay. Excellent.

1:12
Yeah, we do too.

1:14
OK. Dorothy, are you the outlier?

1:19
Well, I use it in, I mean I used it in L&D for C-section in fellowship and we are talking about potentially using it here for our surgery.

1:31
We have it everywhere else.

1:34
Apparently the benefit is they, they come out of the OR in better control and they they’re on the same system when they’re in the ICU being managed in the post operative state.

1:44
And it’s a big difference from what I remember our anesthesiologist describing their management of glucose in the operating room.

1:52
Another question we have is it now that you’re using EndoTool, what is your confidence level that you’ll be successful with the new CMS reporting requirements?

2:03
I would say right now we don’t know the actual metric they’re going to use.

2:08
But looking at my own data, I would anticipate if we didn’t have any at all.

2:16
If you remember that slide in three months we had 55 episodes of severe hypoglycemia.

2:21
And I didn’t actually sort that out whether that would have most many of that would have met CMS criteria.

2:28
But are they going to penalize it, You know, 1% rate, a 2% rate.

2:34
I don’t think anybody knows that answer.

2:36
But real quick to that, you know, before we used to just compare ourselves to ourselves.

2:41
You know, we look at our data last year compared to our data this year.

2:44
And so if it wasn’t any worse, we were happy.

2:46
But about two years ago we started participating with the Society of Hospital Medicine and you know, CQM on glycemic control.

2:54
And we learned that for IV, we’re kind of in the middle of the pack and for SubQ, we’re at the bottom of the pile.

3:00
So we finally learned that other places were doing better than we were.

3:04
Now, a lot of these metrics, all these five metrics, they tend to have a tight range of best to worst.

3:09
You know, sometimes like, you know, one quality throws you from top 10 percentile down into the middle of the pack again.

3:15
But still, we didn’t really know where we stood compared to at least a cohort and this cohort at 86 hospitals.

3:23
So I think back to what Joe was saying, probably there will be when right now we’re all starting this data collection phase and we’re all seeing how we’re doing.

3:32
And I think once that’s spread and that deviation is defined, we’ll see what CMS wants to do with it.

3:38
But I think again, if you don’t compare yourselves to the rest of your peers, then you don’t really know where you stand.

3:45
And that was a big eye opener for us.

3:46
Yeah, great.

3:48
Thank you.

3:48
I have a question specifically for Doctor Kodzwa.

3:52
How does your institution handle patient to nurse ratio  with frequent point of care testing in non critical care areas with IV insulin use?

4:01
I think when it comes to a lot like a lot of other facilities, as I mentioned, we do have some staffing stuff.

4:05
So we usually have 3.

4:10
So a nurse will usually carry anywhere from 3-ish to 4 maybe, but they try to keep it at 3 patients on EndoTool to one nurse.

4:18
So it’s usually about 3 to 1, that’s probably kind of handle that.

4:23
Now in the ICU because they have more nurses, it’s usually anywhere from 1 to 1 or 2 to 1.

4:29
So in the ICU and the higher step care areas, they have less patients that have EndoTool.

4:34
And then our final question I believe is, which is pretty similar to what we’ve been discussing all along.

4:40
What other algorithms protocols have you used and how does EndoTool compared to them?

4:44
Well, when I was in Norfolk, we had Gluommander, I would say for that length of state data looks similar between these two tools.

4:53
But I think the hypoglycemia rates are different.

4:58
And I think 1 distinguishing thing with EndoTool and we, the big we. just presented some of the data about using EndoTool and renal failure patients and not having a lot of hypoglycemia.

5:13
It looks at how much insulin is estimated still to be in the patient, the estimated residual insulin calculation.

5:22
And I think that’s a discriminator between really all the other insulin dosing applications that I’m aware of.

5:29
And I think that helps get you a better hypoglycemia rate in terms of being lower because taking that into account, yeah,  that feature within EndoTool is key in patients that have renal insufficiency.

5:44
We’ve actually shown our own internal data analysis that patients have GFR less than 20 have no higher incidence of hypoglycemia than those that have GFR greater than 60.

5:55
So it is real, it allows patients to be with renal insufficiency to be treated without development of hypoglycemia.

6:03
And I think that that wraps things up for our questions today.

6:09
And I just want to thank our panelists for their participation today.

6:12
I think it’s been a really worthwhile discussion and just want to thank you again for your participation.

6:20
And those that are on the webinar, if they have questions or would like to discuss things further, please don’t hesitate to reach out to me.

6:27
And my email, I believe is on this final slide.

6:31
And please be on the lookout for future webinars.

6:35
So thank you everyone and enjoy the rest of your day.