Hospital pharmacists improve management of diabetes patients

In the United States, more than 29 million people have diabetes. That's up from the previous estimate of 26 million in 2010, according to the Centers for Disease Control and Prevention (CDC). The number of visits to physician offices and hospital outpatient and emergency departments by patients whose primary diagnosis is diabetes is 37.3 million. In addition, CDC data reveal that the number of discharges citing diabetes as first-listed diagnosis is 635,000, and the average length of stay is 4.6 days.

Medication reconciliation

At UF Health Shands Hospital in Gainesville, Fla., pharmacists are members of a multidisciplinary group known as the diabetic care taskforce (DCTF).

See also: Collaboration in transitional care

Kenneth KomornyThe group’s primary responsibility, according to Kenneth Komorny, BS Pharm, PharmD, assistant director of clinical pharmacy services, is to drive glycemic order-set creation, involvement in formulary decisions, and design of clinical practice. 

"Pharmacists are involved from an education standpoint, and that's something UF Health Shands is trying to focus on," said Komorny.

Over the past 12 months, according to Komorny, the pharmacy has intensified its work with medication reconciliation performed at admission; it has set a fiscal goal and expects to perform admission medication reconciliation for 10,000 patients.

"We are working on a proposal now for comprehensive admission medication reconciliation, so that every patient who touches UF Health Shands receives admission med reconciliation by a pharmacy team," said Komorny. 

This is critical for patients with diabetes, he said, because antihyperglycemic medications are among the most common medications prescribed for hospitalized patients.

The pharmacist’s POV

Gina CaliendoWhen it comes to the diabetic patient, pharmacists bring something different to the table. They look at things from a different perspective than that of nurses, dieticians, or physicians, said Gina Caliendo, PharmD, BCPS, director of clinical pharmacy services at Mount Sinai Hospital in New York City.

See also: MTM cuts hospital readmissions

"We focus on the medications, the impact of the medications on the patient's life, and how patients can fit their meds into their daily activities, and we look at the impact that's going to have," said Caliendo.

She cited the example of a patient afraid of needles. To try to sell that patient on a regimen requiring four to five finger sticks daily might not be the most effective approach. "Maybe we need to look at something a little bit different, work with the team to come up with a methodology to treat the patient that's actually going to fit with the patient's needs and desires," said Caliendo.

Another strength pharmacists bring to patient care is a focus on medication safety. Diabetes medications can cause side effects, and pharmacists are well positioned to identify them, as well as to present methods to reduce the risk of errors or complications connected with diabetes care, Caliendo said. The role of the pharmacist is to focus not just on the individual patient, she added, but also on a systemic approach to reducing the risk associated with management of patients with diabetes.

Inpatient care

On the inpatient side, pharmacists are often involved in dosing optimization, selection of therapeutic agents, and management of side effects.

Stacy ElderAt The Johns Hopkins Hospital, in Baltimore, Md., clinical pharmacists round with the inpatient care team.

"I can help with management of diabetes, if they are taking insulin or other agents, based on all the other things that are playing into their diabetes," said Stacy Elder, PharmD, clinical pharmacy specialist, adult internal medicine.

Some of those considerations include in-hospital management of not just high blood sugar, but also critical illness, other medications, and nutritional status, all of which play into the day-to-day adjustments to patients’ medications, she said.

"We do a lot with that on the care team, making recommendations or working with the physician to come up with the optimal plan for every patient," said Elder.

Pharmacy/nursing alliance

Courtney Puentes, BSN, RN, CDE, a diabetes nurse clinician at UF Health Shands Hospital, said that the communication between pharmacy and nursing plays an important role in the treatment of the diabetic patient.

 "The multidisciplinary approach works. I've worked with some of the pharmacy quality projects in the past; it's great to have all the different disciplines, because everybody usually brings something unique to the team," said Puentes.

"It’s a collaborative team effort between pharmacy and nursing, especially with respect to making sure that the patient who has diabetes is discharged on the appropriate medications," said Mary Beth Clark Wald, BSN, RN, CDE, inpatient diabetes educator at Emory University Hospital (EUH), in Atlanta, Ga.

There is a large transplant population at EUH, said Wald. "The transplant pharmacists engage in medication education, and then they involve nursing to educate patients on how to do blood sugars and give themselves insulin," she said, noting that many transplant patients end up with steroid-induced diabetes.

"When we rolled out a new and improved insulin-drip protocol that we use housewide, pharmacists were very instrumental in helping us to write the proper protocol and get the proper target ranges of blood sugar," she said.

Tish KubanIn addition, at EUH, pharmacy is involved in the development of protocols such as the one for diabetic ketoacidosis (DKA).

"Whether it’s DKA protocol or insulin pump or insulin drip protocol, or changing protocols based on best practices or new studies that are coming out in the literature, we do work together and develop our action plans, and these go through our medical staff committees, like our pharmacy and therapeutics committee, to be approved," said Tish Kuban, RPh, MBA, director of pharmaceutical services for EUH.

"It is a multidisciplinary effort at Emory University Hospital. We know that diabetic management is extremely critical to delivering excellent patient and family-centered care," said Kuban.

 Pharmacists in demand

When it comes to inpatient management of diabetic patients, more and more hospitals are starting to employ team-based care, with pharmacists as integral team members.

Vicki Basalyga"Right from the get-go, pharmacists are involved. They can be either informatics pharmacists or clinical specialists sitting on a committee, making sure that we are not missing anything from a drug standpoint," said Vicki Basalyga, PharmD, BCPS, director of the section of clinical specialists and scientists at the American Society of Health-System Pharmacists (ASHP).

Another practice is evident too, said Basalyga: bundled care. "Bundling is looking at evidenced-based inventions and applying them to improve the management of a disease state. These can be pharmacological and nonpharmacological in nature, but are ‘bundled’ together to improve management of the patient."

Why is it important to involve a pharmacist with the inpatient diabetic patient? "A lot of pharmacists are board-certified," said Basalyga. "I would include residency training, as well.  Both of these, in addition to experience, complement a pharmacist’s ability to critically evaluate a patient on rounds."

Pharmacists look at the picture and see something a little bit different than what the physician and nursing teams are seeing, she said. "A pharmacist is aware of the drug-drug as well as drug-disease state interactions that can occur while a patient is admitted to the hospital."

In addition, pharmacists can recommend certain drug therapies that may help a diabetic patient, such as monitoring for adverse effects of steroid use in an ICU patient or helping optimize the timing of medications to prevent interactions.

Education and discharge counseling

Increasingly, pharmacists are playing a key role in discharge medication education and reconciliation, ensuring that as patients leave the hospital, they are familiar with their medications and how they are supposed to take them, as well as of the associated risks.

At Mount Sinai, pharmacists work with nursing, physicians, dieticians, and diabetes educators to develop educational material. The pharmacy developed drug-related flash cards that are given to patients upon discharge. The cards highlight facts about a drug, including what it's used for, the major side effects, and important signs to look for, as well as how long the patient will need to take the medication.

"Pharmacists address major key counseling points. We broke that down to something very simple, so that patients could look at something quick and easy and not be overwhelmed with a five-page handout," said Caliendo.

Dan GriffithAt EUH, pharmacists are part of a multidisciplinary nutrition-support team that gives close attention to the hospital’s diabetic patient population. In addition to teaching patients the importance of blood-sugar control, nutritional support is an essential component of the discharge process for diabetic patients.

"Compliance is a big problem, especially when they are at home and they are directing their own care," said Dan Griffith, RPh, BCNSP, clinical pharmacist for the nutrition and metabolic support service at EUH.

 "We do follow-up once a week with our home patients that are on parenteral nutrition, and we also give the nurses updates," he said.

Transitions of care

Transition of care is an area in which pharmacists are increasing their presence.

"They are talking to patients in their rooms about medications when they are about to be transitioned to outpatient status, to make sure that there are no lingering questions about their medications, and they also address questions about adherence. This has a big impact," said Basalyga.

Results of a study published in The American Journal of Managed Care in October 2010 revealed that good inpatient and transition-care initiatives and outpatient follow-up helped to reduce unscheduled readmissions among diabetic patients.

Experts point out that teaching strategies for diabetic patients who have already received education - perhaps during previous hospitalizations for other comorbidities - will differ from presentations made to discharge patients newly diagnosed with diabetes. They may require a different approach and a different treatment strategy, said Elder.

In addition to providing medication education and reconciliation to discharge patients, UF Shands has a “meds-to-beds” program, a concierge-style initiative to ensure that patients walking out the door will actually have their meds in hand.

Medication adherence

Ensuring that the patients are adhering to their medication regimens is one of the biggest struggles, said Komorny.

"A lot of times hospitals like to say, ‘Take this package of stuff to look at’ or ‘Here's a brochure’ – it's fairly impersonal," Komorny said. "What we want to do is to make the experience very personal, so that the pharmacist is talking with the patient one-on-one, quizzing them on what the drug is for and what would they do if this happens."

Finally, Komorny believes that when patients are fully engaged in their therapy, medication adherence will be optimized, and that will ultimately lead to better patient outcomes. 

Anthony Vecchione is a healthcare journalist based in New Jersey.