Jon T. Knezevich, Pharm.D., BCPS, DPLA; Colleen M. Malashock, Pharm.D., BCPS, DPLA;
Andjela T. Drincic, M.D.;Nicholas Crites, Pharm.D., DPLA; Stacie J. Ethington, MSN, RN-BC;
Shelly Lautenbaugh, RN, BSN, CDCES; Christopher Bultsma, Pharm.D., BCPS;
Brian Schmer, Pharm.D., M.S.; Craig Reha, Pharm.D., BCPS
Nebraska Medicine
Omaha, Nebraska
Pharmacist stewardship has proven a highly successful model for driving best practice, enhancing safety, and promoting cost-effective use of medication therapy. Nebraska Medicine sought to use the tenets and tools of the stewardship model to improve outcomes associated with the complex, high-risk medication-use processes surrounding glucose management in the inpatient environment. The novel role of Diabetes Stewardship Coordinator was created in January 2016 at our academic teaching institution to improve safety, decrease patient harm, enhance education efforts, and optimize outcomes related to acute glycemic management.
The CDC has classified diabetes as a pandemic. Roughly 10% of the United States population has a confirmed diagnosis of diabetes that disproportionality impacts roughly 30% of all hospitalized patients. Inpatient hypoglycemia has a significant economic and clinical impact on healthcare systems. The diabetes stewardship pharmacist works across disciplines to address and safely manage glycemic control issues.
Centralized monitoring of all inpatients is critical to the success of the Diabetes Stewardship Program. An electronic, glycemic focused, patient-specific dashboard serves as a valuable surveillance tool providing up-to-date snapshots of blood glucose variation. The stewardship pharmacist works in concert with an empowered team of clinicians to initiate interventions aimed at improved glucose control, enhanced medication safety, and reduction of adverse events. The most common intervention documented by pharmacists (mean 4 interventions daily) is the adjustment of insulin regimens for blood glucose ≥ 180 mg/dL. This frequent intervention avoids the clinical inertia often experienced in the inpatient setting. Safely bringing blood glucose values into range improves wound healing, decreases length of stay, and avoids complications that are frequently implicated in healthcare waste. The empowerment these clinicians demonstrate stems from the discipline-specific education received as part of the stewardship program.
The alignment of vision and close collaboration between the stewardship pharmacist and the Diabetes Endocrinology & Metabolism (DEM) division of Internal Medicine has served as a catalyst for many safety-related and performance-based improvements in the care of patients with glycemic control issues. Using patient stay blood glucose as the benchmark in both critical care and non-critical care populations, we have experienced a 65% reduction in blood glucose readings < 70 mg/dL in critical care units and nearly a 50% reduction in non-critical care. This translates to an estimated cumulative reduction of 0.46 days in length of stay and greater than $690,000 in cost avoidance annually.
Since implementing the Diabetes Stewardship Program, our institution has received recognition as a “Top Performer” by the Society of Hospital Medicine in the Glucose Control eQUIPS bi-annual (spring and fall) benchmarking report. This is an accomplishment that has been sustained for the past six consecutive reporting cycles beginning in Fall 2017. Many healthcare organizations are finding it difficult to address the increasingly acute medical needs of the growing diabetic patient population they serve. Given a pharmacist’s unique skill sets and diverse knowledge, a dedicated stewardship coordinator can serve as the leader to champion change and deliver interventions to improve patient care in this complex patient population.
