Stanford Hospital and Clinics - Solid Organ Transplant


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  • The program was initiated with patient and provider interested party analysis questionnaires, forums and satisfaction surveys. Transplant Program medical and surgical directors sponsored grant applications and provided resources to aid in cost sharing and coordination for the core Transplant Diabetes team. The endocrine division supported an endocrinologist to provide in- and out-patient consultation to the Transplant team physicians and patients.   Directors of Clinical Nutrition and Pharmacy re-designed job descriptions to dedicate portions of full-time clinical staff working with the in-patient transplant population to provide support and continuity of care to the Transplant Diabetes Program. Algorithms, medical record forms, databases and patient plan of care strategies were created to support the Program’s protocols, goals and standards of care. These medical documents were presented and approved through hospital administration, nursing administration as well as the Pharmacy and Therapeutics and Nutrition Committees. The Program was actually started in response to a need to streamline education and minimize duplication of effort by multiple healthcare providers working directly with the transplant DM population. Support grew from users of the Program (the patients and their families) and the Transplant Nurse Coordinators who were dealing directly with these patients on a daily basis.   The Coordinators provided the link to the Transplant Physicians, Transplant Surgeons, and Transplant Physician Assistants who wrote the orders to implement Program recommendations and to refer patients into the Program. The Transplant Program Directors were compelled to provide support for research, to secure clinic space, and funding for the Program Research Coordinator. Transplant Program Directors, Department Directors and Clinic Managers were also in a position of advocacy to the hospital and clinic administrators supporting further growth and integrity of the Program. The directors of each transplant group have worked cooperatively to provide funding. Careful attention to building strong and positive relationships with each discipline involved in the transplant process has been key to the growth, success, and improved outcomes of the Program, which translates to enhanced DM care. The Program’s research supports these benefits and furthers the studies of other medical and educational interventions to improve patient outcomes.   We appreciate the positive working relationships that have been nurtured from the beginning of this Program. Focus on a common goal is necessary for the success of every program. The spirit of collaboration and interdisciplinary team building - which is now becoming more popular in all fields - has been the key to our growth and success
  • Work flow
  • Because the diagnosis of PTDM has no universally accepted definition, our Program used the standard diagnostic criteria provided by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus in addition to having any one of the following:   Fasting Blood Glucose (FBG) > 126 mg/dL on two or more occasions Random glucose of >200 mg/dL with symptoms on two or more occasions
  • Early, patient-centered, transplant-specific DM self-management education in conjunction with close follow-up has established the Transplant Diabetes Program as unique within the transplant community. The complex nature of multi-organ transplantation carries potential side effects, which are amenable to early intervention. Patients educated in the Transplant Diabetes Program are empowered with a pro-active approach to DM management that helps assure a positive outcome in the transplantation process. When patients are provided with early consistent DM education, from a multi-disciplinary team, the variables effecting good health are better appreciated and they become more pro-active in their care. Active members of the Transplant Diabetes Program share a high level of commitment to the transplant population and their complicated medical management. Insight into the contributing factors which impact DM and transplant care is a level of expertise that sets the Transplant Diabetes Program apart from the general DM education programs. Transplant Diabetes Program patients thrive on this additional sense of empathy, compassion, close follow-up and individualized care. This patient-centered approach dictates developing realistic DM care plans and has lead to the significant outcomes within our patient population. Our quick and close follow-up time has often resulted in calls from our patients for non-DM related questions simply because they have found the Transplant Diabetes Program to be accessible, non-judgmental, practical, and upbeat. Providers also gladly refer patients, trusting in the continuity of care, documentation and reliability of our team’s feedback.
  • Stanford Hospital and Clinics - Solid Organ Transplant

    1. 1. Diabetes Best Practices Symposium Sponsored by AMGA and Merck & Co., Inc.. October 21-22, 2009 Detroit, MI Stanford Hospital and Clinics Solid Organ Transplant Transplant Diabetes Program Add your company logo here
    2. 2. Medical Group Profile <ul><li>The Transplant Diabetes Program started in 1995 </li></ul><ul><li>2 sites/clinics </li></ul><ul><li>29 MDs (30% transplant surgeons; 70% medicine physicians) + 1 endocrinologist part-time </li></ul><ul><li>>8 specialties (pre- and post- transplant Hepatology, Nephrology, Pulmonology, Cardiology) </li></ul><ul><li>750 +/- outpt visits/year (includes return/follow-up) </li></ul><ul><li>EPIC system of Electronic Medical Records being implemented in phases over the past 18 months </li></ul><ul><li>Patients are Pre- and Post-solid organ transplant </li></ul><ul><ul><li>Organ failure </li></ul></ul><ul><ul><li>Polyimmunosuppressive medications </li></ul></ul><ul><ul><li>Disease and ethnicity-associated </li></ul></ul>Go to view/Master/Slide Master and Insert your company logo here
    3. 3. Team Composition <ul><li>over 70 members in a multi-disciplinary team including : </li></ul><ul><li>Transplant Nephrologists </li></ul><ul><li>Transplant Hepatologists </li></ul><ul><li>Transplant Cardiologists </li></ul><ul><li>Transplant Pulmonologists </li></ul><ul><li>Transplant Surgeons </li></ul><ul><li>Endocrinologist </li></ul><ul><li>Transplant Nurse Coordinators </li></ul><ul><li>Transplant Social Workers </li></ul><ul><li>Transplant Pharmacists </li></ul><ul><li>Transplant Dietitians </li></ul><ul><li>Transplant DM Educator and Program/Research Coordinator. </li></ul><ul><li>A core group of 6 taken from the above make up the actual day-to-day working force. </li></ul>
    4. 4. Diabetes Goals & Objectives <ul><li>Decrease DM-related hospital readmissions of multi-organ post-transplant recipients with pre-existing and post transplant diabetes (PTDM). </li></ul><ul><li>Pre-transplant fasting blood glucose of 80-120 mg/dl. </li></ul><ul><li>Decrease or prevent DM complications such as cardiovascular disease in a high risk population. </li></ul><ul><li>Prolong transplant graft survival. </li></ul>
    5. 5. Diabetes Intervention & Population Baseline <ul><li>Percent of total who develop PTDM or have DM prior to transplant </li></ul><ul><li>: </li></ul><ul><ul><li>by organ : </li></ul></ul><ul><ul><ul><li>40% kidney </li></ul></ul></ul><ul><ul><ul><li>37% liver </li></ul></ul></ul><ul><ul><ul><li>30% heart </li></ul></ul></ul><ul><ul><ul><li>32% lung and heart/lung </li></ul></ul></ul><ul><ul><li>by sex : </li></ul></ul><ul><ul><ul><li>57% male </li></ul></ul></ul><ul><ul><ul><li>43% female </li></ul></ul></ul><ul><li>by ethnicity: </li></ul><ul><ul><ul><li>47% Caucasian </li></ul></ul></ul><ul><ul><ul><li>24% Hispanic </li></ul></ul></ul><ul><ul><ul><li>11% Asian </li></ul></ul></ul><ul><ul><ul><li>6% Pacific Islander </li></ul></ul></ul><ul><ul><ul><li>4% Indian sub-continent </li></ul></ul></ul><ul><ul><ul><li>2% Black </li></ul></ul></ul><ul><ul><ul><li>1% Middle Eastern </li></ul></ul></ul><ul><ul><ul><li>1% Native American </li></ul></ul></ul>
    6. 6. Diabetes Intervention & Population Baseline <ul><li>Overall Population Composition: </li></ul><ul><ul><li>8% type 1 DM </li></ul></ul><ul><ul><li>65% type 2 DM </li></ul></ul><ul><ul><li>27% PTDM </li></ul></ul><ul><li>For the type 1 mean duration of disease: </li></ul><ul><ul><li>kidney and liver group= 17.8 years </li></ul></ul><ul><ul><li>Heart, heart/lung group= 24.3 years </li></ul></ul><ul><li>For the type 2 mean duration of pre-existing DM </li></ul><ul><ul><li>kidney and liver group= 12.4 years </li></ul></ul><ul><ul><li>Heart, heart/lung group= 7.4 years </li></ul></ul>
    7. 7. Diabetes Intervention & Population Baseline <ul><li>Registry equivalent: </li></ul><ul><ul><li>“ TransChart” </li></ul></ul><ul><ul><li>Integrated Solid OrganTransplant database </li></ul></ul><ul><ul><li>Coordinates data collection & communication </li></ul></ul><ul><ul><li>Contains a Txp/DM registry </li></ul></ul><ul><ul><li>Accessed by the Transplant RN Coordinator (pre and post), Transplant Social Worker, Transplant Physician and Surgeon, Transplant RD (pre and post), Transplant PharmD, Transplant CDE, and Transplant Insurance Coordinators </li></ul></ul>
    8. 8. Diabetes Intervention & Population Baseline <ul><li>Behind-the-scenes work: </li></ul><ul><li>Interested party analysis and satisfaction surveys done to identify common needs </li></ul><ul><li>Secure multi-departmental support and buy-in through mutual gain </li></ul><ul><ul><li>Staffing, support, revenue </li></ul></ul><ul><ul><ul><li>Solid Organ Transplant </li></ul></ul></ul><ul><ul><ul><li>Clinical Nutrition </li></ul></ul></ul><ul><ul><ul><li>Pharmacy </li></ul></ul></ul><ul><ul><ul><li>Endocrinology </li></ul></ul></ul><ul><ul><li>Directors of departments support key to champion Program development </li></ul></ul>
    9. 9. Diabetes Intervention & Population Baseline <ul><li>Work flow changes: </li></ul><ul><li>RD and Program/Research Coordinator set aside time to: </li></ul><ul><ul><li>Provide routine duties for inpatient care </li></ul></ul><ul><ul><li>Develop Program materials </li></ul></ul><ul><ul><li>Designate established outpt clinic times </li></ul></ul><ul><ul><li>Coordinate space allocation </li></ul></ul><ul><ul><li>Secure initial grant funding </li></ul></ul><ul><ul><li>Meet with department Directors to secure support </li></ul></ul><ul><ul><li>Inservice Solid Organ Transplant Team to services/benefits provided </li></ul></ul>
    10. 10. Diabetes Intervention & Population Baseline <ul><li>Information Technology </li></ul><ul><li>TransChart (Solid Organ Txp Database and communication mode) </li></ul><ul><li>Down-loadable glucose meters </li></ul><ul><li>CGMS (selectively through Endocrinology) </li></ul><ul><li>Website </li></ul><ul><li>Email, telephone, and fax </li></ul>
    11. 11. Diabetes Intervention & Population Baseline <ul><li>Changing MD Practice : </li></ul><ul><li>Inservices </li></ul><ul><ul><li>Developing usable tools and resources </li></ul></ul><ul><ul><ul><li>Txp/DM Reference Tool </li></ul></ul></ul><ul><li>Research studies involving glycemic control </li></ul><ul><li>Close attention to transplant protocols </li></ul><ul><li>Visibility </li></ul><ul><ul><li>Attending and participating in rounds </li></ul></ul><ul><ul><li>Attending and participating in transplant team meetings </li></ul></ul><ul><li>One-on-one meetings </li></ul><ul><ul><li>Identifying common goals </li></ul></ul><ul><ul><li>Learning to speak toward MD’s goals </li></ul></ul>
    12. 12. Improvement Interventions <ul><li>Transplant Diabetes Reference Tool </li></ul><ul><ul><li>For outpatient use </li></ul></ul><ul><ul><li>Pocket-sized format </li></ul></ul><ul><ul><li>Quick reference regarding treatment modality options </li></ul></ul><ul><ul><ul><li>Transplant-specific considerations </li></ul></ul></ul><ul><ul><li>Standards referenced </li></ul></ul><ul><ul><ul><li>Diagnostic criteria </li></ul></ul></ul><ul><ul><li>Contact information </li></ul></ul><ul><ul><li>Guidelines for ordering consults </li></ul></ul><ul><li>Pre-printed diabetes supplies order form </li></ul><ul><ul><li>For discharge and outpatient use </li></ul></ul><ul><ul><li>Quick, standardized for transplant needs </li></ul></ul><ul><li>Establish and reinforce Program standards </li></ul><ul><li>Convenient and perceived as time-saver </li></ul>
    13. 13. Measures Used <ul><li>As no universally accepted definition of Post-Transplant/New Onset DM, identification based on: </li></ul><ul><ul><li>Standard diagnostic criteria from the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus </li></ul></ul><ul><ul><li>And one of the following: </li></ul></ul><ul><ul><li>Fasting Blood Glucose (FBG) > 126 mg/dL on two or more occasions </li></ul></ul><ul><ul><li>Random glucose of >200 mg/dL with symptoms on two or more occasions </li></ul></ul><ul><li>Efficacy determined by utilizing pre-established, evidence-based standards from: </li></ul><ul><ul><li>American Diabetes Association (ADA) </li></ul></ul><ul><ul><li>American Association of Diabetes Educator (AADE) </li></ul></ul><ul><ul><li>American Transplant Congress (ATC) Clinical Practice Guidelines </li></ul></ul>
    14. 14. Measures Used <ul><ul><li>quarterly laboratory values </li></ul></ul><ul><ul><li>medical record review </li></ul></ul><ul><ul><li>compilation of patient satisfaction survey </li></ul></ul><ul><ul><li>pre- and post-transplant DM knowledge assessment test </li></ul></ul><ul><ul><li>tracking of hospital readmissions </li></ul></ul><ul><ul><li>measurements of lipids </li></ul></ul><ul><ul><li>quarterly HbA1c </li></ul></ul><ul><ul><li>Creatinine </li></ul></ul><ul><ul><li>pre- and post-transplant body mass index (BMI) </li></ul></ul><ul><ul><li>neuropathy screening </li></ul></ul><ul><ul><li>annual eye and foot exam monitoring </li></ul></ul><ul><ul><li>continued smoking cessation </li></ul></ul><ul><ul><li>monthly review of home blood glucose logs </li></ul></ul><ul><ul><li>hospital readmission for DM-related complication tracking </li></ul></ul><ul><ul><li>patient and provider satisfaction surveyed </li></ul></ul><ul><ul><li>transplant rejection reviewed. </li></ul></ul>
    15. 15. Challenges or Obstacles <ul><li>Funding </li></ul><ul><ul><li>Advocate for less expensive health care professionals rather than MD </li></ul></ul><ul><ul><li>Develop protocols to support increased use of allied health professionals. </li></ul></ul><ul><ul><li>Look for JCAHO standards to support increased staffing </li></ul></ul><ul><li>Space </li></ul><ul><ul><li>Flexibility </li></ul></ul>
    16. 16. Outcomes and Successes <ul><li>Improved lipid levels </li></ul><ul><li>Improved average initial HbA1c of 8.8%, with an average value of 7.2% following a minimum of three months of management </li></ul><ul><li>stable creatinine and BMI </li></ul><ul><li>95% average compliance for annual neuropathy, eye, and foot exams </li></ul><ul><li>mandatory compliance to smoking cessation criteria for organ transplantation </li></ul><ul><li>home blood glucose logs showed a 80% compliance to pre-transplant blood glucose of 80-140 mg/dl and post-transplant to 80-200 mg/dl </li></ul><ul><li>40% reduction of DM-related re-admissions one year post-transplant </li></ul><ul><li>95% patient satisfaction rating </li></ul><ul><li>94% provider satisfaction rating </li></ul><ul><li>26% decrease in the incidence of rejection </li></ul>
    17. 17. Outcomes and Successes <ul><li>% patients in control (A1c<7%): </li></ul><ul><ul><li>21% improvement (statistical significance=12, p>.05) </li></ul></ul><ul><li>Diabetes-related hospital readmissions: </li></ul><ul><ul><li>37% improvement (statistical significance=6.96, p>.05) </li></ul></ul><ul><li>One year patient survival rates by organ: </li></ul><ul><ul><li>Kidney 98% (highest nationally) </li></ul></ul><ul><ul><li>Liver 90% </li></ul></ul><ul><ul><li>Heart 83% </li></ul></ul><ul><ul><li>Lung 86% </li></ul></ul><ul><ul><li>Heart/Lung 92% </li></ul></ul>
    18. 18. Outcomes and Successes <ul><li>Patient outcome/process-centered </li></ul><ul><li>Transplant-specific, unique within the transplant community </li></ul><ul><li>Designed to empower the txp patient </li></ul><ul><li>Pro-active intervention and education </li></ul><ul><li>Consistently reliable follow up </li></ul><ul><li>Strong communication </li></ul><ul><ul><li>Aware of txp protocols and effect on glycemic control </li></ul></ul><ul><ul><li>Shaped SHC MOTC—steroid-free kidney txp protocol </li></ul></ul><ul><li>Enhance the overall Multi-Organ Transplant Program as a “client” of Txp/DM Program </li></ul>
    19. 19. Future Steps <ul><li>Develop protocol for Transplant Pharmacists to adjust DM medications </li></ul><ul><li>Secure funding for inpatient/outpatient Cystic Fibrosis Dietitian </li></ul><ul><li>Support staff development for Physician Assistant or Nurse Practitioner for Transplant Diabetes Program </li></ul>
    20. 20. Lessons Learned <ul><li>Find a champion(s) </li></ul><ul><ul><li>tell your Administrator what you are doing, show your Boss what you are accomplishing </li></ul></ul><ul><li>Collaborate, define common goals </li></ul><ul><ul><li>Learn to define goals in “meaningful” language </li></ul></ul><ul><li>Rather than sing louder, teach the song to more people </li></ul>