Clifton Springs Hospital & Clinic - Clifton Springs, New York

Enhancing Glycemic Control with Small Tests of Change

Overview: Clifton Springs Hospital & Clinic is a 262-bed not-for-profit health care system providing general acute care, primary care, nursing home care, cancer care, behavioral health and addiction recovery programs, and specialty care to residents of and visitors to the central Finger Lakes region.  Upon completion of a community needs assessment, the Clifton Springs Hospital and Clinic Board of Trustees supported the recommendations of administration and the medical staff to make improving diabetes care a strategic priority.  One goal of this initiative was to develop and implement a comprehensive plan that would result in at least a 10 percent decrease in the number of inpatient hyperglycemic experiences in 2007.

Using the "Plan-Do-Study-Act" model, the hospital analyzed its current situation using medical record audits, length of stay, and other patient-related data.  The hospital's past successes in applying some of the "change concepts" endorsed by the Institute for Healthcare Improvement assisted it in formulating a plan, which included:

  • Forming a multidisciplinary advisory committee
  • Developing comprehensive educational programs for clinical staff and physicians
  • Developing and implementing standardized orders
  • Creating education tools for patients and families
  • Establishing glycemic management protocols
  • Implementing several process changes
  • Introducing glycemic management software tools in the intensive care unit (ICU)

Impact: As the incidence of diabetes continues to grow, better controls in the inpatient setting are crucial.  Benefits of improved glycemic control can be seen in lower infection rates, improved wound healing, lower morbidity and mortality rates, and decreases in the length of hospital stays.  Clifton Springs Hospital showed improvements in several areas.  For example:

  • ICU glucose readings were less than 150mg/dl, 32 percent of the time in 2006, with an increase to 50 percent in 2007.  In addition, the non-ICU settings saw a modest increase in glucoses less than 150mg/dl of 42 percent in 2006 to 46 percent in 2007.
  • Mean of 13.5 percent of all ICU glucoses fell within the very tight glucose range of 80 to 110mg/dl in 2006, with an increase to 21.2 percent in 2007.
  • Average length of stay for diabetic inpatients dropped by 0.5 day from base year 2005 to 2007.
  • Long-term care patients showed a 2.8 percent decrease in Hemoglobin A1C results from 2006 to 2007 because the education and protocols were done enterprise-wide.
  • Medical record documentation pertinent to diabetes management increased from 74 percent in 2005 to 82 percent in 2007.
  • Of the patients on insulin drips handled under the conventional protocols, 14 percent achieved a glucose target of less than 150mg/dl in an average of nine hours.  In the patients managed with the new glucose control software, 100 percent reached their target ranges, which varied from 80 to 145mg/dl, in an average of 7.19 hours.  There was a 4 percent hypoglycemic rate in the conventional protocol, as compared with a 2 percent rate in the patients managed with the software tool.
  • The percentage of patients having a glucose level obtained within 24 hours of admission increased from 92 percent in 2005 to 100 percent at the end of 2007.

As the hospital maintains its focus on diabetes, there is continued improvement in most categories.  Consistent with American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) recommendations, the hospital has changed its glycemic parameters.  The upper target limit is now at 180 mg/dl, so an exact comparison cannot be done to previous years.  However, 2009 YTD percentages of glucose results less than 180 mg/dl are 63 percent for ICU and 64 percent non-ICU acute care areas.

The average length of stay for diabetes patients has continued its decline with a 0.89 day decrease from baseline year 2005 to YTD 2009.

Further, there is continued increase in use of glycemic management software utilized with insulin drips in the ICU with 100% use for diabetes patients on insulin drips for YTD 2009.  Use of the software has been expanded to now include the Emergency Department.  Episodes of hypoglycemia with use of glycemic management software remain at 2 percent.

Challenges/success factors: Continually reinforcing the importance of frequent glucose monitoring to evaluate potentially rapid-changing levels and insulin requirements is vital.  It's also important to continually evaluate and monitor variables related to glycemic management.

Future direction/sustainability: Clifton Springs' focus on diabetes remains an ongoing process with identification of ways to improve glycemic control and patient outcomes a priority.  Physician order sets, policies, and protocols are updated based on experiences specific to the hospital while still meeting standards of care.  The hospital's Joint Center has incorporated a requirement that diabetes patients undergoing joint replacement surgery have an A1c of < 7% (consistent with ADA guidelines) prior to admission.  Annual performance improvement projects related to diabetes are being identified.  In 2009, reviewing a percentage of all hypoglycemia events to identify root causes is being done.  Once data is aggregated, action plans will be developed and implemented to assist with hypoglylcemia rate reduction.

Advice to others: Start small.  Introduce new technology on a small scale.  Clifton Springs identified and worked to eliminate barriers to success before expanding to other areas.  Also keep in mind that although a computerized glycemic management software system can be an effective and efficient tool in normalizing glucose levels, automation cannot take the place of reliable processes and critical thinking.

Contact: Susan Ullrich, RN, CDE
Diabetes Program Director
Telephone: (315) 462-0220



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