Successful Models of Implementation

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Successful Models of Implementation

  1. 1. Successful Models of Implementation
  2. 2. Hyperglycemia: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital Umpierrez G., et al. J Clin Endocrinol Metab . 2002;87:978 – 982. 62% 26% 12% n=2,020 * Hyperglycemia: Fasting BG ≥126mg/dL or random BG ≥200 mg/dL x 2
  3. 3. Umpierrez G., et al. J Clin Endocrinol Metab . 2002;87:978-982; Levetan CS, et al. Diabetes Care. 1998;21:246-249; Krinsley JS. Mayo Clin Proc . 2003;78:1471-1478; Falciglia M, et al. Abstract Presented at: American Diabetes Association 66 th Annual Scientific Sessions; June 11, 2006; Washington, DC. Abstract 19-LB. Hyperglycemia is Common in Hospitalized Patients <ul><li>Noncritically ill medical/surgical: 38% </li></ul><ul><li>Intensive care units (ICU): 29% – 100% </li></ul><ul><ul><li>Episode of glucose >110 mg/dL: 100% </li></ul></ul><ul><ul><li>Episode of glucose >200 mg/dL: 31% </li></ul></ul><ul><ul><li>Mean glucose >145 mg/dL: 39% </li></ul></ul>
  4. 4. Number (in Thousands) of Hospital Discharges with Diabetes, US, 1980 – 2003 CDC. Available at http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Accessed March 5, 2006. From 1980 through 2003, the number of hospital discharges with diabetes as any-listed diagnosis more than doubled (from 2.2 million to 5.1 million discharges)
  5. 5. And these patients are located throughout the hospital. Obstetrics Cardiac Care Dialysis Emergency Med-Surg Unit Rehab Home Health Pediatrics
  6. 6. ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468 Hyperglycemia in the Hospital <ul><li>A quality of care issue </li></ul><ul><li>A patient safety issue </li></ul><ul><li>A length of stay issue and a cost issue </li></ul><ul><li>There is an increased awareness among multiple stakeholders and a desire to change the current practice </li></ul><ul><li>There remain multiple challenges and barriers to practice change </li></ul>
  7. 7. Perceived Barriers to Management of Inpatient Hyperglycemia <ul><li>Knowing what insulin type or regimen works best </li></ul><ul><li>Unpredictable timing of patient procedures </li></ul><ul><li>Risk of causing patient hypoglycemia </li></ul><ul><li>Knowing how to adjust insulin </li></ul><ul><li>Unpredictable changes in patient diet and mealtimes </li></ul><ul><li>Knowing best options to treat hyperglycemia </li></ul><ul><li>Glucose management not adequately addressed on rounds </li></ul><ul><li>Patient not in hospital long enough to control glucose adequately </li></ul><ul><li>Lack of guidelines on how to treat hyperglycemia </li></ul><ul><li>Preferring to defer management to outpatient care or to another specialty </li></ul><ul><li>Knowing how to start insulin </li></ul><ul><li>Knowing when to start insulin </li></ul>
  8. 8. Improving Inpatient Diabetes Care: A Call to Action Consensus Conference <ul><li>January 30 –31, 2006 </li></ul><ul><li>Washington, DC </li></ul><ul><li>www.aace.com </li></ul><ul><li>Sponsors </li></ul><ul><li>American College of Endocrinology, American Association of Clinical Endocrinologists and American Diabetes Association </li></ul><ul><li>Co-Sponsors </li></ul><ul><li>American Association of Critical-Care Nurses </li></ul><ul><li>American Association of Diabetes Educators </li></ul><ul><li>American Heart Association </li></ul><ul><li>American Society of Anesthesiologists </li></ul><ul><li>Joint Commission on Accreditation of Healthcare Organizations </li></ul><ul><li>Society of Critical Care Medicine </li></ul><ul><li>Society of Hospital Medicine </li></ul><ul><li>Veterans Health Administration </li></ul><ul><li>Participating Organization </li></ul><ul><li>American College of Cardiology </li></ul>
  9. 9. Improving Inpatient Diabetes Care: A Call to Action Consensus Conference <ul><li>AACE/ADA Consensus Conference Statement </li></ul><ul><li>ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract . 2006;12:458 –468. </li></ul><ul><li>ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care . 2006;29:1955–1962. </li></ul>
  10. 10. ACE/ADA Major Recommendations for Optimal Glycemic Management in Hospitalized Patients <ul><li>Identify elevated blood glucose in all hospitalized patients </li></ul><ul><li>Establish a multidisciplinary team approach to diabetes management in all hospitals </li></ul><ul><li>Implement structured protocols for aggressive control of blood glucose in ICUs and other hospital settings </li></ul><ul><li>Create educational programs for all hospital personnel caring for people with diabetes </li></ul><ul><li>Plan for a smooth transition to outpatient care with appropriate diabetes management </li></ul>
  11. 11. ACE/ADA: Standardize Insulin Therapy to Reduce Errors <ul><li>Single Insulin Infusion Concentration </li></ul><ul><li>Single Insulin Infusion Protocol </li></ul><ul><li>SC Insulin order set </li></ul><ul><li>Hypoglycemia Protocol </li></ul><ul><li>Guidelines for Transitions </li></ul><ul><ul><li>IV to SC </li></ul></ul><ul><ul><li>Back to ambulatory regimen </li></ul></ul><ul><li>Guidelines for Special Situations </li></ul><ul><ul><li>Enteral Nutrition </li></ul></ul><ul><ul><li>Parenteral Nutrition </li></ul></ul>IV = intravenous; SC = subcutaneous. ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract . 2006;12:458 –468. Clement S., et al; ADA Diabetes in Hospitals Writing Committee. Diabetes Care . 2004;27(2):553–591. ADA. Diabetes Care . 2008;31:S12–S54.
  12. 12. ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract . 2006;12:458 –468. Successful Strategies for Implementation <ul><li>A champion is needed to lead the multidisciplinary steering committee to drive the development of initiatives </li></ul><ul><ul><li>Medical staff, nursing and case management, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, administration </li></ul></ul><ul><li>Assessment of current processes, quality of care, and barriers to practice change </li></ul>
  13. 13. ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract . 2006;12:458 –468. A Champion is Needed to Lead the Development of the … <ul><li>Standardized order sets </li></ul><ul><li>Protocols, algorithms </li></ul><ul><li>Policies </li></ul><ul><li>Educational programs (physicians and nurses) </li></ul><ul><li>Metrics for evaluation </li></ul><ul><ul><li>A system to track hospital glucose data in an ongoing basis </li></ul></ul><ul><ul><li>Assess the quality of care delivered </li></ul></ul><ul><ul><li>Continuous improvement of processes and protocols </li></ul></ul>
  14. 14. Successful Models <ul><li>Consultant Model </li></ul><ul><li>Diabetes Team Model </li></ul><ul><li>System-Wide Model </li></ul>
  15. 15. Endocrinologist as a Consultant <ul><li>Endocrinologist is called in to consult on patients identified with DM / hyperglycemia </li></ul><ul><li>Writes orders and communicates the plan to others </li></ul><ul><li>Follows patients through hospital stay, makes therapeutic adjustments </li></ul><ul><li>Coordinates discharge and follow-up visits </li></ul>
  16. 16. Advantages of the Consultant Model <ul><li>Positions Endocrinologists as leading experts in inpatient glycemic control practice </li></ul><ul><li>Can bill for services </li></ul>
  17. 17. Disadvantages of the Consultant Model <ul><li>If nearly 40% of hospital inpatients have hyperglycemia, endocrinologist consultant cannot care for all of them </li></ul><ul><li>Must wait for a consulting request </li></ul><ul><ul><li>May not be called each time it is appropriate </li></ul></ul><ul><li>Knowledge and skills are limited to few personnel </li></ul>
  18. 18. Keys to Success with the Consultant Model <ul><li>Hospital-wide understanding of the importance of calling for an endocrinologist consult </li></ul><ul><li>Ability to tap in to other resources to manage large volumes of patients </li></ul>
  19. 19. Newton CA, et al. Endocr Pract . 2006;12(suppl 3):43 –48. Diabetes Team Model <ul><li>Nurses (NP or APN) / case managers interact daily with residents, attending physicians, and nursing staff to improve glycemic management </li></ul><ul><li>Conducts patient screenings to identify those with elevated glucose levels </li></ul><ul><li>Uncovers opportunities for improvement in glycemic management and makes recommendations to the medical team </li></ul>Endocrinologist as the Medical Director; leads a multidisciplinary team to manage patient care on an ongoing basis.
  20. 20. Advantages of the Team Model <ul><li>Strengthens multidisciplinary approach to care of DM / hyperglycemia patients </li></ul><ul><li>Allows each professional to share different areas of expertise while standardizing systems </li></ul><ul><li>Clinical staff can become more specialized in effective DM management. Enhanced opportunities for higher level training </li></ul>
  21. 21. Disadvantages of the Team Model <ul><li>Administrative and medical staff leadership must see this as a priority, devote resources </li></ul><ul><li>Does not change culture to become more focused on diabetes hospital-wide </li></ul>
  22. 22. Keys to Success with the Team Model <ul><li>Must have streamlined, effective communication between team members </li></ul><ul><li>Systems must effectively identify hyperglycemic patients early in the stay, to allow the team to manage the care </li></ul><ul><li>Continuous education must be provided systematically throughout the institution – can be a combination of didactics, online learning, bedside rounds, etc. </li></ul>
  23. 23. Olson L, et al. Endocr Pract . 2006;12(suppl 3):35 –42. System-Wide Model <ul><li>Endocrinologist oversees hospital-wide program, which trains all clinical staff to identify and assist in managing patients with diabetes </li></ul><ul><li>Systematic hospital-wide program with all members of the clinical team enhancing diabetes knowledge / skills </li></ul><ul><li>Endocrinologist serves as “champion” and oversees development / implementation of protocols. Available as resource for complex cases </li></ul><ul><li>All clinical staff undergo training on DM / hyperglycemia, diabetes nurses serve as resources to house staff, and floor nurses manage routine care based on protocols </li></ul>
  24. 24. Advantages of the System-Wide Model <ul><li>Achieve hospital-wide cultural change when all clinical employees work toward a common goal </li></ul><ul><li>Effective resource utilization by disseminating skill / knowledge throughout the hospital </li></ul><ul><li>Facilitates standardization while respecting unit culture </li></ul><ul><li>Offers opportunities for systematic program roll-out. Evidence-based training can be offered hospital-wide. Or it can be rolled out gradually by coordinating between units “linked” by routine flow of patients (ie, Surgery ► Intensive Care ► Med Surg.) for consistency of care </li></ul>
  25. 25. Disadvantages of the System-Wide Model <ul><li>Units may “backslide” if no ongoing monitoring / accountability </li></ul><ul><li>More difficult to control day-to-day adherence to glycemic control practice </li></ul><ul><li>Staff turn-over creates need for ongoing training / awareness </li></ul>
  26. 26. Keys to Success with the System-Wide Model <ul><li>Commitment from top levels of clinical and administrative teams </li></ul><ul><li>Ongoing results monitoring of clinical and financial improvement. Sharing results system-wide </li></ul><ul><li>Active involvement of all key departments … nursing, lab, information services, billing, dietary, education and so on … </li></ul><ul><li>Communication and maintaining a high level of awareness among staff and physicians throughout the system </li></ul>
  27. 27. The Choice is Yours! Each hospital has different internal systems and resources available to implement an effective diabetes management program You can start by assessing your facility and its systems. You may choose to begin using a certain Model, then change as the program develops
  28. 28. The Next Step: Joint Commission’s Disease Specific Certification
  29. 29. The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCInformation . Accessed February 5, 2008. Joint Commission’s Disease-Specific Care Certification <ul><li>The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate disease management and chronic care services provided by direct care providers such as hospitals </li></ul><ul><li>Organizations may seek certification for clinical programs for virtually any chronic disease or condition </li></ul>
  30. 30. The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCInformation . Accessed February 5, 2008. Joint Commission’s Disease-Specific Care Certification <ul><li>Disease-Specific Care Certification uses a model that is flexible enough to apply to any disease management program. </li></ul><ul><li>The evaluation and resulting certification decision is based on an assessment of </li></ul><ul><ul><li>Compliance with consensus-based national standards </li></ul></ul><ul><ul><li>Effective use of evidence-based clinical practice guidelines to manage and optimize care </li></ul></ul><ul><ul><li>An organized approach to performance measurement and improvement activities. </li></ul></ul>
  31. 31. The Joint Commission. http://www.jointcommission.org/CertificationPrograms/cert_benefits.htm . Accessed February 6, 2008. Benefits of Joint Commission Disease-Specific Care Certification <ul><li>Attaining Joint Commission Disease-Specific Care Certification </li></ul><ul><ul><li>Strengthens community confidence in the quality and safety of care, treatment and services </li></ul></ul><ul><ul><li>Provides a framework for program structure and management </li></ul></ul><ul><ul><li>Provides a competitive edge in the marketplace </li></ul></ul><ul><ul><li>Validates compliance with nationally recognized standards by the preeminent health care evaluator </li></ul></ul><ul><ul><li>Improves risk management and risk reduction </li></ul></ul>Joint Commission Disease-Specific Care Certification is a measure of achievement
  32. 32. The Joint Commission. http://www.jointcommission.org/CertificationPrograms/cert_benefits.htm . Accessed February 6, 2008. Benefits of Joint Commission Disease-Specific Care Certification <ul><li>Attaining Joint Commission Disease-Specific Care Certification </li></ul><ul><ul><li>Provides education on good practices to improve business operations </li></ul></ul><ul><ul><li>Provides professional advice and counsel, thereby enhancing staff education </li></ul></ul><ul><ul><li>Can be a tool to attract and retain quality personnel </li></ul></ul><ul><ul><li>Recognized by select insurers and other third parties </li></ul></ul><ul><ul><li>Can fulfill regulatory requirements in select states </li></ul></ul>
  33. 33. The Joint Commission. Disease-Specific Care Certification Guide . 1 –30. Joint Commission Standards for Disease-Specific Care Certification: Overview <ul><li>Joint Commission Standards for Disease-Specific Care Certification </li></ul><ul><ul><li>Program management </li></ul></ul><ul><ul><li>Delivering or facilitating clinical care </li></ul></ul><ul><ul><li>Supporting self-management </li></ul></ul><ul><ul><li>Clinical information management </li></ul></ul><ul><ul><li>Performance measurement </li></ul></ul>
  34. 34. The Standards: Program Management The Joint Commission. Disease-Specific Care Certification Guide . 1 –30. <ul><li>Designing, implementing and evaluating the program </li></ul><ul><li>Defining leadership roles </li></ul><ul><li>Creating a relevant program for participants </li></ul><ul><li>Providing adequate access to care </li></ul><ul><li>Conducting the program in an ethical manner </li></ul><ul><li>Supplying reference resources to staff </li></ul>
  35. 35. The Joint Commission. Disease-Specific Care Certification Guide . 1 –30. The Standards: Delivering or Facilitating Clinical Care <ul><li>Using qualified, competent staff </li></ul><ul><li>Delivering or facilitating the delivery of care using clinical practice guidelines that are evidence-based </li></ul><ul><li>Individualizing care to meet the participant’s needs </li></ul><ul><li>Improving practice and services based on the use of performance measurement </li></ul>
  36. 36. The Joint Commission. Disease-Specific Care Certification Guide . 1 –30. The Standards: Supporting Patient Self-Management <ul><li>Assessing patients’ self-management capabilities </li></ul><ul><li>Providing support for patients in self-management activities </li></ul><ul><li>Involving patients in developing the plan of care </li></ul><ul><li>Educating patients in the theory and skills necessary to manage their disease(s) </li></ul><ul><li>Recognizing and supporting self-management efforts </li></ul>Joint Commission standards mirror those of diabetes organizations with regard to patient self-management
  37. 37. The Standards: Clinical Information Management <ul><li>Proactively gathering and sharing information across the continuum to coordinate care across settings and over time </li></ul><ul><li>Providing easy access to participant-related information </li></ul><ul><li>Preserving participant confidentiality </li></ul><ul><li>Maintaining data quality and integrity </li></ul><ul><li>Integrating and interpreting data from various sources </li></ul>The Joint Commission. Disease-Specific Care Certification Guide . 1 –30.
  38. 38. The Standards: Performance Measurement <ul><li>Having an organized, comprehensive approach to performance improvement </li></ul><ul><li>Trending and comparing data to evaluate processes and outcomes </li></ul><ul><li>Using information garnered from measurement data to improve or validate clinical practice </li></ul><ul><li>Using participant-specific, care-related data </li></ul><ul><li>Evaluating the participants’ perceptions of quality of clinical care </li></ul><ul><li>Maintaining data quality and integrity </li></ul>The Joint Commission. Disease-Specific Care Certification Guide . 1 –30.
  39. 39. The Standards: Performance Measurement The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DCSPM/ . Accessed February 6, 2008. <ul><li>Effective July 1, 2007, specific performance measurement requirements were implemented for all certified programs including: </li></ul><ul><ul><li>Collection of monthly data points for both standardized and nonstandardized measures </li></ul></ul><ul><ul><li>Prior to initial certification, collection of a minimum of 4 months of performance measure data for each standardized and/or nonstandardized measure submitted at the time of application </li></ul></ul>
  40. 40. The Standards: Performance Measurement The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DCSPM/ . Accessed February 6, 2008. <ul><li>An additional performance measurement requirement for standardized measure data reporting is anticipated in 2008, following enhancements to the Joint Commission Connect ™, which will afford certified programs the capability for electronic data submission </li></ul><ul><li>The Joint Commission will aggregate the data submitted electronically and return it to certified organizations for comparative performance evaluation </li></ul>
  41. 41. ADA = American Diabetes Association The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Inpatient+Diabetes . Accessed February 4, 2008. Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care <ul><li>The Joint Commission and the ADA have identified that the most successful inpatient diabetes programs possess the following critical attributes: </li></ul><ul><ul><li>Specific staff education requirements </li></ul></ul><ul><ul><li>Written blood glucose monitoring protocols </li></ul></ul><ul><ul><li>Plans for the treatment of hypoglycemia and hyperglycemia </li></ul></ul><ul><ul><li>Data collection of incidence of hypoglycemia </li></ul></ul><ul><ul><li>Patient education on self-management of diabetes </li></ul></ul><ul><ul><li>An identified program champion or program champion team </li></ul></ul>
  42. 42. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 6, 2008. Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care: A Caveat <ul><li>This program applies to patients who have a medical history of diabetes: diabetes diagnosed and acknowledged by the treating physician </li></ul><ul><ul><li>This program does not apply to hospital-related hyperglycemia attributed to medications or other factors </li></ul></ul>
  43. 43. <ul><li>The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Inpatient+Diabetes . Accessed February 4, 2008 </li></ul><ul><li>The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. </li></ul>Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care <ul><li>Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care links their expectations to those of the ADA 1 </li></ul><ul><li>The major elements of The Joint Commission expectations are 2 </li></ul><ul><ul><li>General recommendations </li></ul></ul><ul><ul><li>Blood glucose targets </li></ul></ul><ul><ul><li>Preventing hypoglycemia </li></ul></ul><ul><ul><li>Diabetes care providers </li></ul></ul><ul><ul><li>Diabetes self-management education </li></ul></ul><ul><ul><li>Medical nutrition therapy </li></ul></ul><ul><ul><li>Blood glucose monitoring </li></ul></ul>
  44. 44. Joint Commission’s Certificate: General Recommendations NPO = Nothing by mouth. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-5BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. <ul><li>The Joint Commission: Patients with diabetes are identified as having diabetes in the medical record, at admission, and at discharge </li></ul><ul><li>Documentation reflects the </li></ul><ul><ul><li>Type of diabetes (if known) </li></ul></ul><ul><ul><li>Preadmission medications for diabetes control (including dosages) </li></ul></ul><ul><ul><li>Preadmission and current weight </li></ul></ul><ul><ul><li>Degree of control prior to admission; severity of hyperglycemia on admission </li></ul></ul><ul><ul><li>Level of comprehension and competence related to diabetes self-management activities </li></ul></ul><ul><ul><li>Nutritional screening results and nutrition management plan </li></ul></ul><ul><ul><li>Current and anticipated nutritional status (eg. NPO) </li></ul></ul>
  45. 45. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. Joint Commission’s Certificate: Blood Glucose Targets <ul><li>Joint Commission Expectation </li></ul><ul><ul><li>An A1c is drawn at the time of admission, unless the results of the patient’s A1c drawn within the last 60 days are known, or the patient has a medical condition or has received therapy that would confound the results </li></ul></ul>
  46. 46. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. Joint Commission’s Certificate: Preventing Hypoglycemia <ul><li>Joint Commission Expectation </li></ul><ul><ul><li>Plans for the treatment of hypoglycemia and hyperglycemia are established </li></ul></ul><ul><ul><li>A plan for coordinating administration of insulin and delivery of meals is implemented </li></ul></ul><ul><ul><li>Episodes of hypoglycemia are identified and contributing reasons for these are captured </li></ul></ul><ul><ul><li>Contributing reasons for episodes of hypoglycemia are evaluated for systemic trends </li></ul></ul><ul><ul><li>Written protocols are developed for management of patients on intravenous insulin infusions </li></ul></ul>
  47. 47. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. APN = Advanced practice nurse. Joint Commission’s Certificate: Diabetes Care Providers <ul><li>Joint Commission Expectation </li></ul><ul><ul><li>A multidisciplinary program team is identified with a designated team leader </li></ul></ul><ul><ul><li>The following groups working with patients with diabetes have had education specific to the management of diabetes </li></ul></ul><ul><ul><ul><li>Dieticians and others involved in medical nutrition therapy </li></ul></ul></ul><ul><ul><ul><li>Staff involved in point of care testing </li></ul></ul></ul><ul><ul><ul><li>Medical staff </li></ul></ul></ul><ul><ul><ul><li>Nursing staff, including APNs </li></ul></ul></ul><ul><ul><ul><li>Pharmacists </li></ul></ul></ul><ul><ul><ul><li>Physician assistants </li></ul></ul></ul>
  48. 48. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. Joint Commission’s Certificate: Self-Management Education <ul><li>Patients with newly diagnosed diabetes or educational deficits have at least the following educational components reflected in the plan of care </li></ul><ul><ul><li>Medication management, including how to administer insulin (when appropriate) and potential medication interactions </li></ul></ul><ul><ul><li>Nutritional management, including the role of carbohydrate intake in blood glucose management </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Signs and symptoms of hyperglycemia and hypoglycemia </li></ul></ul><ul><ul><li>Treatment of hyperglycemia and hypoglycemia </li></ul></ul><ul><ul><li>Importance of blood glucose monitoring and how to obtain a blood glucose meter </li></ul></ul><ul><ul><li>Instruction on use of blood glucose meter, if available </li></ul></ul><ul><ul><li>Sick day guidelines </li></ul></ul><ul><ul><li>Information for who to contact in case of emergency or for more information </li></ul></ul><ul><ul><li>Plan for post-discharge education or self-management support </li></ul></ul>
  49. 49. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. Joint Commission’s Certificate: Medical Nutrition Therapy <ul><li>Joint Commission Expectation </li></ul><ul><ul><li>Nutritional consultations are conducted for patients not consistently reaching glucose targets </li></ul></ul>
  50. 50. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf . Accessed February 4, 2008. Joint Commission’s Certificate: Blood Glucose Monitoring <ul><li>Joint Commission Expectation </li></ul><ul><ul><li>Written blood glucose monitoring protocols for patients with known diabetes are developed and include, at a minimum, the following: </li></ul></ul><ul><ul><ul><li>Measuring blood glucose upon admission </li></ul></ul></ul><ul><ul><ul><li>A plan for subsequent monitoring based on the patient’s </li></ul></ul></ul><ul><ul><ul><ul><li>Type of diabetes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Desired level of control </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Current treatment(s) (eg., use of steroids, TPN, etc) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Comorbidities and medical illnesses </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dietary status including patients who are NPO </li></ul></ul></ul></ul><ul><ul><li>Results of blood glucose monitoring are available to all members of the health care team </li></ul></ul><ul><ul><li>The patient and the practitioner managing his or her diabetes care after discharge are informed about the patient’s A1c results and any unresolved issues related to glucose management </li></ul></ul>TPN = total parenteral nutrition.

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