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TRANSCRIPT

Jordan “Watson” Messler: Sherlock, I haven’t seen you since the missing glucometer incident last month, when you had to manage that patient with diabetes by olfactory sense only.

Robby “Sherlock” Booth: Ah yes, years overseas has helped me train my nose to detect any glucose irregularity. And you, Watson, I can see you at the diabetes conference in Germany, your sugars are out of control and your dog stole your lunch.

Jordan “Watson” Messler: By Jove, Sherlock, how is that possible from a mere glance?

Robby “Sherlock” Booth: Well, it’s quite obvious. A dog-eared copy of the EASD scientific program is in your hand. Your CGM is missing. And your dog brought me this sandwich.

How is that glycemic work going back at St. Bart’s Hospital?

Jordan “Watson” Messler: Splendid! Splendid! Let’s go to case one, the case of the missing sugars. Our hypoglycemia is now infinitesimally small, very tiny. In fact, I have the exact number here. It is 0.5 percent of all BGs checked. Success! Not an issue anymore, Sherlock. In fact, I’ve sent a telegram to disband the committee.

Robby “Sherlock” Booth: Is that the severe hypoglycemia rate? Less than 40?

Jordan “Watson” Messler: Yes, exactly.

Robby “Sherlock” Booth: Watson, you see, but you do not observe. In fact, the problem is greater than I suspected. There is much work to be done.

Jordan “Watson” Messler: What can you possibly see that I have not already?

Robby “Sherlock” Booth: Well, last year you had 200,000 BGs. The rate of hypoglycemia at 0.5 percent represents 500 instances of severe hypoglycemia. Not a small problem at all. This means 500 adverse events. I wrote a treatise on hypoglycemia and I know it is possible to achieve a 0.1 percent rate, which is an 80 percent reduction from your current situation. That’s 400 needless, adverse events. Those patients would not like to hear that the team has been disbanded.

Jordan “Watson” Messler: When you say it that way, the London fog within the data clears right up, Holmes. I will institute a new protocol straight away.

One month later, a study in paper protocols.

I’ve looked into all the IV insulin paper protocols and it seems they’re all identical. I ran a study at BART with the interns. Three patients treated with various protocols, and the average glucose is the same for all.

Robby “Sherlock” Booth: Let me see that graphic. Yes, all of these patients do have the same average glucose.

You know what the same average gets you? Nothing! Look at this diagram from my old friend in Baskerville. These charts all have the same average. And this one resembles an old hound or Jurassic creature. Let’s take a look at these patients again. Let’s see, patient number one. This first case, the sugars are bouncing up and down, like a horse and buggy ride on cobblestones.

And patient number two, on this interesting protocol, too much out of range. You see more variability than an Offenbach Violin Concerto. And patient number three, yes, Glucommander. There you go, like a Stradivarius. Perfect, the lowest rates of hypoglycemia, and the most in range. It’s really elementary, my dear Watson.

This Glucommander graph, eGMS is the answer.

Jordan “Watson” Messler: Yes, of course. How did I not see that? I will get my interns to put this Glucommander in place straight away.

One month later, the adventures in timeliness.

Well, you were right again, Holmes. I’ve informed our team and sent the carrier pigeons to disband the committee.

Our hypoglycemia rates are at a record low and the blood sugar checks are perfectly timed. Look at this! The BG timeliness is 90 percent with record low rates of hypoglycemia.

Robby “Sherlock” Booth: Excellent! Perhaps premature though. The Baker Street Irregulars informed me about a particular Nightingale Nursing Ward that seemed to wander astray like a street urchin.

I wonder why that is. The game is afoot.

Yes, Unit 3 as I suspected. The only unit without 0 percent hypoglycemia. It must be BG timeliness. I should have seen that coming. The 7 percent solution is making my mind weaker. Of course, the cholera outbreak caused chaos on the units. Unit 3 had a nursing shortage, and the nurses haven’t checked glucose in a timely fashion.

Jordan “Watson” Messler: What do you mean, Sherlock? Look here. I reported it was 90 percent BG checks on time.

Robby “Sherlock” Booth: Yes, most of the units are doing quite well, but if you examine closer, Unit 3 is off the charts. 50 percent timeliness rates. 90 percent doesn’t mean no room for improvement. There’s always variation. 90 percent is not the win you think.

There’s always room to improve.

Jordan “Watson” Messler: It seems so logical in hindsight.

One month later, the Hound of the Acidoses.

Well, you were right again, Holmes. Once you cleansed the Thames, the outbreak subsided, the nurses informed me of the underlining BG timeliness, the new hypoglycemia rates are back to normal for all the units.

I do have a most perplexing case that’s been gnawing at me like a London sewer rat. A young patient, struck with DKA, recovered mightily with the Glucommander, yet as soon as she switched to a SubQ formulation, her blood sugar rose again. Higher than the top of St. Paul’s Cathedral.

Robby “Sherlock” Booth: Sherlock, you lack patience with your patients. Yes, the sugar was normal, but the full picture was not in view. She lacked the criteria to transition. You can see here, her glucose was in a normal range, but these orange circles are her anion gap, elevated for days. Her acidosis remained high. And didn’t you get an alert from Glucommander about anion gap elevation? She wasn’t ready, even though you thought she was.

Jordan “Watson” Messler: Yes, yes, remarkable. Why is it always so clear once I hear it from you?

Robby “Sherlock” Booth: And I’ve caught the culprit who transitioned your patient too soon.

Jordan “Watson” Messler: Of course.

One month later, the CMS mystery, hypoglycemia at the expense of hyper.

Well, Sherlock, I’ve sent smoke signals to disband the committee. Our work here is done.

Robby “Sherlock” Booth: Well, that seems most agreeable. However, you may want to keep that committee after all. The glycemic management team’s work is never done. And I can no longer keep an eye on your travails as I have a new case. I’m off to Reichenbach Falls. Now, before I go, did you see these measures?

CMS will be watching. Closer than Scotland Yard, they will be tracking your low and high glucose rates.

Jordan “Watson” Messler: What are these new measures?

Robby “Sherlock” Booth: Well, CMS added two new eCQMs for Severe Hyper and Severe Hypo. I pulled your eCQM report. 0.1 percent hypo rates. Congratulations, your team may be in the top for hypoglycemia.

We should definitely report it. It’s worthy of the Queen’s recognition. But while we’re at it, let’s look at our hyperglycemia rates. Wow, looks like there’s work to be done. Higher than we hoped. Ouch! But that hyperglycemia problem, CMS should have made this a balanced measure, as there’s benefit in reporting them both together.

Jordan “Watson” Messler: Ah yes, yes, the famous scales of glycemic justice. I’ll wire the team. Let’s keep that committee.

Robby “Sherlock” Booth: Jolly good idea, chap. After all this case work, I’m famished. Perhaps I’ll have some of that sandwich after all.

Well, thanks for joining us for the Data Detectives. These scenarios are all based on real cases. We wanted to remind everyone that it’s important to critically examine all the data, don’t jump to conclusions, and when the data is used properly, it can generate excellent insights and drive improvement.

Jordan “Watson” Messler: Agree completely, Robby. Most importantly, don’t disband that committee. Be sure you have a team looking at glycemic improvement. Thanks so much for joining the Data Detectives.

SOP #34

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