Coyne, Cathy A, PhD, MPH

Habeck, Cara, RN, CDE

Hamadani, Roya, MPH

Harper, Gregory R, MD, PhD

Kincaid, Hope, MPH, CPH

Kratz, Melissa, RN, MSN, AOCN

Najarian, Joyce, MSN, RN, CDE

Perilli, Gretchen, MD

Sharma, Janelle M, DNP, CRNP

Shearburn, Patricia, RN, MSN, AOCN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksPatient Care Services / NursingDiabetes Care Management in the Cancer Center:Challenging Current Models of Care to OptimizeOutcomes for a Complex PopulationCara Habeck RN, CDELehigh Valley Health Network, Cara.Habeck@lvhn.orgJoyce Najarian MSN, RN, CDELehigh Valley Health Network, Joyce.Najarian@lvhn.orgGregory R. Harper MD, PhDLehigh Valley Health Network, Gregory.Harper@lvhn.orgGretchen Perilli MDLehigh Valley Health Network, gretchen_a.perilli@lvhn.orgJanelle M. Sharma DNP, CRNPLehigh Valley Health Network, Janelle_M.Sharma@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursingPart of the Endocrine System Diseases Commons, Medical Education Commons, NeoplasmsCommons, and the Nursing CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtHabeck, C., Najarian, J., Harper, G., Perilli, G., Sharma, J., Kratz, M., Shearburn, P., Coyne, C., Kincaid, H. & Hamandani, R. (2104,August 6-9). Diabetes Care Management In the Cancer Center: Challenging Current Models of Care to Optimize Outcomes for a ComplexPopulation. Poster session presented at the AADE 2014 National Conference/ American Association of Diabetes Educators, Orlando,FL.AuthorsCara Habeck RN, CDE; Joyce Najarian MSN, RN, CDE; Gregory R. Harper MD, PhD; Gretchen Perilli MD;Janelle M. Sharma DNP, CRNP; Melissa Kratz RN, MSN, AOCN; Patricia Shearburn RN, MSN, AOCN;Cathy A. Coyne PhD, MPH; Hope Kincaid MPH, CPH; and Roya Hamadani MPHThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/patient-care-services-nursing/333Lehigh Valley Health Network, Allentown, PennsylvaniaCara Habeck, RN, CDE and Joyce Najarian, RN, MSN, CDEDiabetes Oncology Program Colleagues: Gregory Harper, MD, PhD, Gretchen Perilli, MD, Janelle Sharma, DNP, CRNP, Melissa Kratz, MSN, AOCN, Patricia Shearburn, MSN, AOCN, Cathy Coyne, PhD, MPH, Hope Kincaid, MPH, CPH, and Roya Hamadani, MPHPROJECT PURPOSEPeople with concurrent diabetes and cancer are more likely to have a poor prognosis, increased infection rates, and shorter median survival times. Optimal management of diabetes and cancer is rarely supported by standard models of healthcare, but may be improved by collaborative communication efforts and effective integration of diabetes education for patients and healthcare providers in the cancer center. The Diabetes Oncology Program (DOP) was a grant funded initiative that served patients with diabetes and actively treated cancer over a nine month period.BACKGROUND•		Oncology nurses and providers are often uncomfortable managing abnormal blood glucose levels •		Many oncology treatment plans directly impact glycemic control   •		Patients undergoing active cancer treatment  tend to experience “appointment fatigue” which contributes to limited diabetes or primary care follow-up, and negatively impacts glycemic controlIMPLEMENTATION IN CANCER CENTER•		Endocrinologist led education session for oncology nurses •		Referral process developed:  	 	 –	 	Diabetes/	Hyperglycemia	screening	tool		 	 –	 	Hyperglycemia	triage	process	for	oncology	RNs	and	staff•		Hyperglycemia clinical practice guideline (CPG) developed for chemotherapy infusion staff to standardize:	 	 –	 	Monitoring	blood	sugars		 	 –	 	Providing	urgent	insulin	doses	•		Oncology provider order sets developed: 	 	 –	 	Diabetes	diagnosis	to	problem	list	in	oncology	EMR	 	 –	 	A1c	collection		 	 –	 	CPG	activation	with	chemotherapy	treatment		•		Individualized diabetes education and diabetes care management for patients throughout active cancer treatment 	 	 –	 	CDE/	NP	visits	coordinated	with	time	and	location	of	oncology	appointments	•		CDE facilitated communication between oncology, diabetes and  primary care providers (PCP)Diabetes Care Management in the Cancer Center: Challenging Current Models of Care to Optimize Outcomes for a Complex Population © 2014 Lehigh Valley Health NetworkPOST PROGRAM TRANSITION•		Developed a diabetes and cancer patient education handout •		CPG revised for oncology staff to triage and manage hyperglycemia independently from CDE   •		Action plans for oncology offices: 	 	 –	 	Triage	process	for	responding	to	hyperglycemia	in	random	labs		 	 –	 	Communicate	chemotherapy	/	steroid	regimen	to	PCP	prior	to	treatment	cycle	 	 –	 	Request	that	PCP	refer	patient	to	outpatient	diabetes	education		 	 –	 	Assist	patients	without	a	PCP	to	establish	care	with	a	provider	for	chronic	care		•		Diabetes oncology “teachback” education tool designed by oncology nurses PROGRAMCHALLENGES•		Short duration of program•		Lack of long term funding to support CDE within cancer center •		Defining communication processes between primary care/endocrinology/ oncology providers•		Declining patient ability and/or interest in DM self- management as health status deteriorated or treatment impact intensified•		Inconsistent emphasis on glycemic control by PCPs during steroid or cancer treatmentsPOST PROGRAM GOALS•		Develop an annual diabetes /oncology nurse education course addressing: 	 	 –	 	Glycemic	control	standards		 	 –	 	Diabetes	medications	 	 –	 	Troubleshooting	abnormal	blood	sugars	in	the	setting	of	steroids	and	cancer	treatments	 	 –	 	Common	cancer	treatment	related	complications	and	impact	on	glycemic	control		•		Standardize triage processes and communication tools between oncology and primary care teams regarding: 	 	 –	 	Uncontrolled	hyperglycemia		 	 –	 	Steroid	use	 	 –	 	Lab	orders	and	lab	result	sharing•		Reinforce the importance of regular PCP follow up throughout cancer treatments for improved management of chronic conditionsHyperglycemia CPG Hypoglycemia CPGOutpatient Oncology Hyperglycemia Triage AlgorithmHyperglycemia Algorithm for Adult Patients with Cancer and Diabetes in Chemotherapy Infusion Areas                        BG trending up  No Diabetes Diagnosis  Pt to ER for further evaluation/ treatment  BG < 70 Activate hypoglycemia CPG and treat per guideline Infusion RN treats hyperglycemia with Humalog per ISF scale, see Attachment C Blood Glucose (BG) > 200mg/dl per same day labs, lab results within the past 72 hours or patient has overt symptoms of hyperglycemia BG trending down 1) Pt may return home 2) Infusion RN: a.) review s/sx and treatment of hypoglycemia b.) instruct pt to recheck BG in 2 hours if able   3) PCP f/u encouraged within 1-2 weeks Known Diabetes 1) Discharge home if patient has insulin and clear sick day insulin dosing instructions at home 2) ER if patient c/o abdominal pain, nausea, or is a poor historian 3) If discharged home: obtain order from oncology provider Infusion RN: refer to activated CPG or request Diabetes CPG activation Infusion RN: per CPG check BG level by POC testing BG ≥200 Infusion RN: notifies outpatient oncology provider of POC blood sugar result Outpatient oncology office responsibility: 1)  Insulin sensitivity factor (ISF) ordered by oncology provider, attachment B 2)  PCP notification and outpatient diabetes education referral as needed  Infusion RN rechecks POC BG 1 hour after insulin dose  BG >400        Notify Oncology Provider BG 200-399 Notify Oncology Provider for additional orders and follow flow  Hypoglycemia Algorithm for Adult Patients with Cancer and Diabetes in the Cancer Center     Patient demonstrates signs/symptoms of hypoglycemia Able to swallow: -15grams oral glucose(Dex4) If Dex4 refused: -4oz clear juice(no OJ for renal impaired) -6oz regular soda -8oz skim milk Has PEG tube: -15grams oral glucose(Dex4) via tube Unable to safely take treatment PO, no PEG access Remain with patient, keep HOB elevated  IV or PICC access Inject Dextrose 50%, 25ml IV push  No IV access  Inject glucagon  SQ or IM: -under 5 yrs: 0.5ml  -over 5 yrs: 1ml  Pt is conscious Pt is unconscious -Call Rapid Response Team -Triage pt to ER Recheck BG  in 15 minutes BG < 70 BG > 70 Repeat algorithm x1 BG remains < 70 after two treatment cycles or patient status deteriorates, contact provider for further orders Document -Provide snack (carbohydrate and protein, ie: peanut butter or cheese with crackers) or meal -Provide tube feed as applicable -Educate pt re hypoglycemia prevention -May discharge pt to home if blood sugar > 100 and asymptomatic -Contact chemotherapy infusion area that urgent Blood Glucose (BG) check is needed LVH-M:484-884-1776, LVH-CC: 610-402-1776 -If BG < 70:   1) Notify provider                        2) Follow treatment algorithm                                            OptimalDiabetes andCancer DiseaseManagementRefreshRenewRechargeCDE Care ManagerCollaborationTREATMENT IMPACT:								•			Surgery 								•		Chemotherapy								•		Radiation								•		Steroid treatments								•			Increased infection risk   DISEASE IMPACT:						•			Transitions in/out of hospital 						•		Varied self-management           ability						•		Varied appetite, energy             level, pain level, stress,             dehydration Outpatient Oncology Hyperglycemia Triage Process                             Known Diabetes Notify PCP or diabetes provider of chemo/ steroid treatment plan  PCP follow-up needed Provider communication sheet and referral for diabetes education faxed to provider  Uncontrolled blood sugars /  Cancer treatment includes chemotherapy and steroids Undiagnosed Diabetes Notify PCP of random glucose result >200 Notify PCP of chemo/ steroid treatment plan PCP follow-up needed Provider communication sheet and referral for diabetes education faxed to provider.     No PCP Oncology provider: refer patient to 610-402-CARE for PCP referral  Oncology provider: triage level of care needed: oncology NP same day visit vs ER   Level of Urgency for provider follow-up Glucose <200: non urgent referral (10-14 days) Glucose >200: priority referral (within 3-5 days) Glucose >400: urgent referral (within 24-48 hours) Provider Notification Tools 1. Fax cover sheet:  o Patient name, DOB, MR#, oncologist name o Chemotherapy regimen, start date o Steroid regimen, start date o Glucose Level  2. Outpatient Diabetes Education Referral :  o Level of urgency o  Individual/ 1:1 education selection o Provide type of cancer/steroid use/ other important status details 

Diabetes Care Management in the Cancer Center:  Challenging Current Models of Care to Optimize Outcomes for a Complex Population

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1335&context=patient-care-services-nursing

Diabetes Care Management in the Cancer Center: Challenging Current Models of Care to Optimize Outcomes for a Complex Population

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