The rising cost of health care and particularly the diabetes related cost and its dire consequences to the national budget are in the newspapers everyday. But behind the scenes, in medical centers across the country, small changes in health care procedures are changing the way we practice medicine to make it more efficient and less costly. Joslin Diabetes Center and Beth Israel Deaconess Medical Center (BIDMC) are leaders in this movement.
With Osama Hamdy, MD, PhD, FACE director of Inpatient Diabetes Management at Joslin and Assistant Professor of Medicine Harvard Medical School, leading the charge, the way diabetes ketoacidosis (DKA) gets treated in hospitals may be changing. In conjunction with Joslin, BIDMC has instituted the, Emergency Variable Approach and Diabetes Education program nicknamed EVADE. A pilot of this program began on Sept. 1, 2013 with a total of 21 enrolled patients.
Hamdy and his team recognized that not all cases of DKA are created equal and that mild and moderate presentations could be successfully managed in the emergency room (ER), leading to better patient care and cost savings. EVADE trains ER personnel to handle less serious cases of DKA in the ER and discharge the patient within 24 hours after getting specialized diabetes consultation and customized diabetes education to prevent recurrence of the DKA.
Drs. Peter Smulowitz and Carrie Tibbles from the ER simplified the flow of the protocol and made it easy for the busy ER doctors and nurses to follow, and Dr. Larry Nathanson created an automated alarm signal derived from the initial ER lab work that automatically distributes a call to the EVADE team at both Joslin and BIDMC to start the timely intervention. “It is like an Orchestra that plays in great harmony to help patients in time-efficient manner” said Dr. Hamdy
DKA is a very serious medical condition and it has always been treated by admission to the intensive care unit of the hospital. People diagnosed with DKA usually spend 1 to 2 days in the ICU, and another day in the regular hospital ward.
DKA most often happens in people with type 1 diabetes, when there is insufficient insulin available. Lack of available insulin prevents the body’s cells from using glucose supplies and the body begins to burn fat for fuel and thus produces toxic acidic metabolites called ketone bodies. Rising blood glucose levels lead to dehydration, which sometimes is severe. Also excess acid from ketone bodies begins to lower the blood pH. People with severe DKA experience nausea, vomiting, thirst and fatigue and may even die if they do not get timely medical help to correct their dehydration, lower their blood glucose and clean their body from ketones.
Joslin created criteria to help ER personnel determine which DKA cases can stay in the ER and which need admission to the hospital. If a patient is a candidate to stay in the ER, the EVADE protocol is initiated and the ER personnel follows a simple paradigm for IV insulin administration and hydration prescription. Joslin is notified whenever a patient starts the protocol. A nurse practitioner from the Joslin is sent to interview the patient, determine the factors that led to DKA and make recommendations about the patient’s follow up care. In turn she alerts one of the Joslin nurse educators who provides the patient education to help prevent a repeat episode. Patients are also set up with a follow-up outpatient appointment at the Joslin or encouraged to promptly see their regular health care provider.
Data from the first few months of the program show positive results. Of the 21 patients enrolled in the pilot, 12 were admitted to the hospital and 9 were discharged after only treatment in the emergency room. This resulted in a 42 percent reduction in hospital admission rate. The average length of the stay for patients who were admitted was 7.5 days. This means that by taking care of those 9 patients in the emergency room rather than admitting them, the patients and the hospital avoided approximately 67.5 days of admission, total.
Although we think of the cost of diabetes medicines or co-pays when we see our health care providers as a big hit on our personal budgets, this isn’t why diabetes is a major drain on hospital budgets. Treating severe hyper- and hypoglycemia are the big ticket items associated with expensive hospital stays. Reducing hospital admissions and length of stay while making sure people get the quality of care they need is a must if we are going to contain costs.
According to Dr. Hamdy the cost of one admission to the ICU is on average $13,000 and admission to hospital floor is about $7,000. The 24 hour management in the ER is a small fraction of this cost. According to the American Diabetes Association, the cost diabetes is approximately $245 billion per year and the biggest chunk of that cost (43 percent) is spent in hospital care. It is easy to see how this initiative will make a big difference if hospitals across the nation follow the Joslin-BIDMC EVADE model.
When the program began, “we estimated that Beth Israel could reduce hospital admissions for DKA by 10 percent, but the initial observation is way beyond our expectation,” said Dr. Hamdy. “We are collecting data and if all goes as planned we hope to export the program to other hospitals. We also think that Joslin-BIDMC will become the Mecca for treating diabetes emergencies in the New England area.”