DKA HHS Insulin Infusion Advisors Video

DKA HHS Insulin Infusion Advisors Video

January 14, 2020 0 By Jose Scott


Hello. This video will review our custom
Insulin Infusion Advisors We created these advisors in order to
help improve inpatient insulin management
for hyperglycemic states. Our team is pleased to report that these
innovations were recognized with Cerner’s
2015 Intelligence Connect Award. All of the solutions we will demonstrate
today are in production demands at
multiple facilities and have led to improved outcomes
primarily to reduce hypoglycemic episodes. Our insulin advisors help physicians and
nurses efficiently manage complex
inpatient hyperglycemic states
in an evidence-based manner. Using the M-pages platform, we were able
to build four robust advisors. The first and second are Diabetic
Ketoacidosis (DKA), and Hyperglycemic Hyperosmolar State
advisors or (HHS). These are based on American Diabetic
Association guidelines. The third and fourth advisors are Post
Cardiac Surgery and Critical Care Insulin
Infusion Advisors. These are based on the Portland protocol These advisors have helped standardize
and improve care for patients with these
conditions at multiple facilities. Let us demonstrate the functionality of
the diabetic ketoacidosis order. We have a patient who presented to the ED
with a glucose of 550 and he is a known
diabetic. The ED provider has started the patient
on normal saline intravenous fluid, and
an insulin infusion. Subsequently labs were sent and the
patient was confirmed to have DKA. The order can be placed either by
clicking on the Advisor folder on the
home screen or by typing in DKA. Patient data is available for review on
the right side of the screen. This includes the patient’s weight, vital
signs, relevent labs, such as basic
metabolic panel, arterial blood gas,
and diabetic home medications. Notice on the top we have two different
tabs. The first one is Protocol orders. This tab is used by clinicians to place
orders. The next tab is patient management. This tab is used by nurses to manage
the patient. The default view for clinicians would be
the Protocol orders tab and the default
view for nurses would be the patient
management tab. The protocol content can be accessed by
clicking on the top right hand corner
question mark symbol either by the
clinician or the nurse. The same protocol is also available on
forms on demand for users to be able to
use during unforeseen downtime. The patient has confirmed DKA and now the
ED physician continues to place the
protocol orders. The clinician clicks on the protocol
orders and notice we have the initial
phase and the subsequent phase. The Initial Phase is intended for ED
physician use during the first 4 hours of
patient management until the corrected
sodium is back. This occurs with resulting of the basic
metabolic panel. In rare instances where the patient
develops DKA in-house, inpatient
providers will initiate both phases. Phase 2 is intended primarily for
inpatient providers and starts after
return of corrected sodium from the first
4 hour basic metabolic panel. Let’s start with initial phase orders. The advisor calculates intravenous fluid
requirements based on ADA guidelines. Notice that in this case it is 700 ml per
hour for 4 hours. The provider can discontinue existing
fluids from within the advisor and choose
to place the new order. The provider also has the option to
modify the fluid rate as clinically
indicated. The next section is acidosis correction. In this case the patient’s bicarb is less
than 5 and the ph is less than 7. Hence, you see an order placed here for
bicarb. I will select the order for bicarb and
move to the next section which is Glucose
correction. In this case the patient is already on
an insulin drip, hence, I would ignore
the drip order. Since patient’s magnesium, phosphorus and
potassium are low you see orders for all
three electrolytes displayed. I am going to select these. Notice we also have options for labs
which the provider can order from within
the advisor. There is also an option for notify
provider and a finger stick glucose. The notify provider allows the clinician
to customize the alert requirement to
their preference. In this case, I am going to select both
and I will proceed to sign the advisor. Now I have our ED nurse who is going to
demonstrate the nursing workflow for
patient management. Notice that the table of contents now
displays the advisor for the nurse. Notice the change in color on the table
of contents since a new point of care
glucose has been resulted. Once the nurse clicks on the advisor, the
advisor launches and displays previous
glucose, current glucose, and most recent
insulin drip recommendation. If the insulin drip rate is not current,
the nurse can exit the advisor by
clicking the exit button and update the
rate in I-view. The nurse has to validate previous
glucose value for the confirm button to
be displayed. Once confirmed, the nurse is presented
with an insulin titration change, and a
prompt for a change in fluid management. Notice there is also an option for the
nurse to order a lab and an option to
complete the provider notification within
the advisor. The nurse then continues to sign the
advisor, and proceed to care for the
patient by following the recommendations. In between new glucose results, the nurse
can always access the most recent
recommendation made by the advisor by clicking the advisor from the table of
contents. I will now hand over the patient’s care
to the clinician who is proceeding to
take phase two orders. The patient is seen by the inpatient
provider and ready for ordering the phase
two protocol. The provider can access the advisor
either by clicking on the table of
contents or by placing the order from the
order section of power chart. Notice the advisor recognizes and
defaults open to phase two orders as
phase one orders have already been signed. The advisor displays the fluid protocol
rate which is defaulted to 250 ml
per hour. The user can modify the fluid rate as
indicated. This information is stored by the advisor
and the fluid order is presented to the
nurse once corrected sodium has been
resulted or when glucose drops below 250. The provider has an option to determine
when phase two should be triggered by
selecting the BMP displayed in the drop
down window. In cases where phase two has been
initiated close to 4 hours from the
patient’s presentation, the provider has the option to trigger
phase two by placing a new BMP for now. Since the advisor has logic built in to
manage electrolytes, I will proceed to select the protocol
orders and the transition diet displayed
within the advisor. I will go ahead and sign the advisor and
the patient is now being transferred to
the intensive care unit for further
management. I have the critical care nurse here who
will demonstrate further functionality
and workflow in the intensive care unit. The patient is in the ICU and if you
notice the table of contents has turned
yellow alerting the nurse. Once I click on the table of contents,
and confirm the previous glucose, notice here
the recommendation not only displays
insulin titration, but also intravenous fluid change to D5
normal saline as the patient’s corrected
sodium has returned. I will go ahead and select the D5 normal
saline and discontinue the existing
fluid orders. Since the patient’s potassium is low,
notice there is also a recommendation for
potassium replacement which I will
proceed to order. Once I sign the advisor, these orders are
placed on the patient’s profile. The ICU nurse will continue to manage the
patient on an hourly basis by repeating
finger stick glucoses and returning to
the advisor. A few hours later, new labs have been
resulted and the patient’s anion gap has
resolved. Notice the table of contents turning
yellow alerting the nurse. The nurse clicks on the advisor and
notice we have transition orders for the
patient displayed. Patient’s anion gap is normal hence you
are seeing the transition orders. The advisor calculates total daily dose
based on the last six hours of insulin
infusion rates, which is displayed here in a table for
users to be able to review. The basal and the pre-meal dose are
calculated based on this and prefilled
for the nurse. The nurse now proceeds to call the
provider to confirm the transition orders. The provider has the option to change to
doses or just resume home insulin regimen
if clinically indicated. The advisor allows flexibility on the
timing of the administration of basal
insulin. Once the orders are confirmed with the
provider, the nurse proceeds to place
these orders and two hours after administration of
basal insulin subcutaneous dose, she will be required to discontinue
the insulin infusion and the advisor
order on the medication section in the
order profile. All orders placed within the advisor are
displayed in the patients order profile. The clinician should use clinical
judgement to discontinue each order as
indicated once the patient is ready to be
transitioned off of the advisor. Hyperglycemic Hyperosmolar state or HHS
functions similarly to Diabetic
Ketoacidosis except for the target glucose range for
dextrose administration is less than 300
for HHS and less than 250 for DKA. The transition logic for the HHS advisor
is based on serum osmolality unlike DKA
where the requirement is the closing of
the anion gap. This concludes the demo.