Initiating Insulin in the Emergency Center and Urgent Care to Prevent Hospital Admission for Patients with Hyperglycemia: A Unique Insulin Starter Kit.

BACKGROUND: Clinicians in the Emergency Center (EC) and Urgent Care (UC) can play a vital role in preventing hospital admissions and improving outcomes of patients with newly diagnosed diabetes or pre-existing diabetes who present with hyperglycemia and the need to initiate insulin. METHODS: This article describes a unique EC/UC discharge insulin starter kit protocol with clinician instructions via an Electronic Medical Record (EMR) order set that includes: starting doses for insulin, a prescription for glucose monitoring supplies, and an emergent referral to diabetes education at International Diabetes Center. Patients receive insulin during the EC/UC visit and are provided an insulin pen to take home. Nurses from the EC or UC review and provide educational material on how to use an insulin pen, treating hypoglycemia and healthy eating. The Certified Diabetes Care and Education Specialist (CDCES) sees patients within 24-72 hours after the referral is placed. RESULTS: Within our single healthcare system's EC and UC (multiple sites), the kit has enabled clinicians to metabolically stabilize patients and decrease the need for hospitalization without experiencing hypoglycemia. In the recent three years of use, of 42 patients given the insulin starter kit, there were only 2 patients with repeat EC/UC visits within the first six months (1 hyperglycemia and 1 hypoglycemia). CONCLUSIONS: An insulin starter kit and EMR-based order set initiated in the EC/UC setting is a tool that can be used to improve the quality of care for people with newly diagnosed or pre-existing diabetes experiencing significant hyperglycemia.

Trial of a New Diabetes Education Model: Closing the Gap in Health Disparity for People with Diabetes.

BACKGROUND: Quality measures relating to diabetes care in America have not improved between 2005 and 2016, and have plateaued even in areas that outperform national statistics. New approaches to diabetes care and education are needed and are especially important in reaching populations with significant barriers to optimized care. METHODS: A pilot quality improvement study was created to optimize diabetes education in a clinic setting with a patient population with significant healthcare barriers. Certified Diabetes Care and Education Specialists (CDCES) were deployed in a team-based model with flexible scheduling and same-day education visits, outside of the traditional framework of diabetes education, specifically targeting practices with underperforming diabetes quality measures, in a clinic setting significantly impacted by social determinants of health. RESULTS: A team-based and flexible diabetes education model decreased hemoglobin A1C for individuals participating in the project (and having a second A1C measured) by an average of -2.3%, improved Minnesota Diabetes Quality Measures (D5) for clinicians participating in the project by 5.8%, optimized use of CDCES, and reduced a high visit fail rate for diabetes education. CONCLUSIONS: Diabetes education provided in a team-based and flexible model may better meet patient needs and improve diabetes care metrics, in settings with a patient population with significant barriers.

Effect of Professional CGM (pCGM) on Glucose Management in Type 2 Diabetes Patients in Primary Care.

BACKGROUND: Little data exists regarding the impact of continuous glucose monitoring (CGM) in the primary care management of type 2 diabetes (T2D). We initiated a quality improvement (QI) project in a large healthcare system to determine the effect of professional CGM (pCGM) on glucose management. We evaluated both an MD and RN/Certified Diabetes Care and Education Specialist (CDCES) Care Model. METHODS: Participants with T2D for >1 yr., A1C ≥7.0% to <11.0%, managed with any T2D regimen and willing to use pCGM were included. Baseline A1C was collected and participants wore a pCGM (Libre Pro) for up to 2 weeks, followed by a visit with an MD or RN/CDCES to review CGM data including Ambulatory Glucose Profile (AGP) Report. Shared-decision making was used to modify lifestyle and medications. Clinic follow-up in 3 to 6 months included an A1C and, in a subset, a repeat pCGM. RESULTS: Sixty-eight participants average age 61.6 years, average duration of T2D 15 years, mean A1C 8.8%, were identified. Pre to post pCGM lowered A1C from 8.8% ± 1.2% to 8.2% ± 1.3% (n=68, P=0.006). The time in range (TIR) and time in hyperglycemia improved along with more hypoglycemia in the subset of 37 participants who wore a second pCGM. Glycemic improvement was due to lifestyle counseling (68% of participants) and intensification of therapy (65% of participants), rather than addition of medications. CONCLUSIONS: Using pCGM in primary care, with an MD or RN/CDCES Care Model, is effective at lowering A1C, increasing TIR and reducing time in hyperglycemia without necessarily requiring additional medications.

Impact of modem-transferred blood glucose data on clinician work efficiency and patient glycemic control.

BACKGROUND: Communication of blood glucose (BG) results between patients and health care providers (HCPs) is of established benefit and remains a critical part of the diabetes management process. Currently, HCPs typically receive BG data from patients at the time of clinic visits or by telephone. The Accu-Chek Acculink modem (Roche Diagnostics Corp., Indianapolis, IN) provides an additional and attractive option that can potentially facilitate this communication. METHODS: To assess the impact of modem transfer of BG, we studied 47 participants with diabetes enrolled in a diabetes education program. Subjects were randomized to weekly communication of BG data to their HCP by either telephone (n = 23) or modem (n = 24) for 4 weeks. Mean age (+/- SD) was 44 +/- 15 years, 62% were female, 74% used insulin, 53% had type 1 diabetes, and mean baseline glycosylated hemoglobin (A1C) was 8.8% (range 5.2-13.2%). RESULTS: There were no differences between groups in the amount of time the HCP spent analyzing BG data and communicating with patients (12.6 +/- 6.1 min/week in the telephone group and 11.5 +/- 5.1 min/week in the modem group) or in the number of patient and HCP attempts needed to make contact. There were similar improvements in A1C between groups (change of -0.4 +/- 0.7% in the telephone group and -0.9 +/- 1.4% in the modem group, P = 0.18). BG data provided by telephone had a 6% error rate, in contrast to modem-sent data, which were transmitted without error. CONCLUSIONS: Modem transfer of BG data can provide an accurate and clinically useful option for communication between patients and their HCP and has comparable effects on A1C.