Disclosures –Anne Brittain, PhD RT(R)

(M)(QM), CPHQ

I have no disclosures as it pertains to this educational activity.

Reduction of Severe Hypoglycemia (<50mg/dL)

Goal: Reduce events of severe hypoglycemia 5% by the end of FY12.

Baseline Data

Out of 407,063 point of care blood glucose checks, there were 2,646 (0.64%) events of severe hypoglycemia as a system.

Richland-1,795 Events

Baptist-851 Events

Project Plan- 1st Five Weeks

• Establish cross campus team- Senior Leader, Physician Champion, Nursing Leader, Diabetes Education, CQPS-PIT, Pharmacy, Nutrition, Nursing Education, Endocrinology

• Select initial pilot units• Establish team aim and outcome/process

measures• Educate team on PI methodologies to be used • Complete process mapping• Determine opportunities

Project Plan- 6th week and beyond

• PDSA planning– Begin small, but fast, for initial trials (e.g. 1 pt,

1 day, 1 unit, etc.)– Perfect change (2 weeks max per unit/area)– Expand trials/Spread change

• Revise Policies & PGR’s, as needed

• Devise system to monitor hardwiring of improved process

Contact Information

• Anne Brittain-296-2308 Anne.Brittain@palmettohealth.org

• MaryJane Phipps-296-3622 Maryjane.Phipps@palmettohealth.org

• Heather Mann-296-3392 Heather.Mann@palmettohealth.org

DisclosuresI have no relevant financial

relationships with any commercial interests related to the content of this

activity – Shahid Aziz, MDFellow, Endocrinology

Inpatient Glucose Management

Shahid Aziz, MDFellow, Endocrinology

Hospital-related Hyperglycemia

• Upon admission: diagnosed diabetes, undiagnosed diabetes, illness-related hyperglycemia (assess for outpatient control: meter readings, HbA1c)

• Hospital course: glucose targets, adjustment and titration, education and teaching, safety

• At discharge: planning, self-management skills• Follow-up

The Increasing Rate of Diabetes in

Hospitalized Patients

Source: CDCAvailable at: http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm.

Per Capita Healthcare Expenditures

Hospital Costs Account for Majority

of Total Costs of Diabetes

Hogan P, et al. Diabetes Care. 2003;26:917–932.

Diabetes Doubles the Cost

Diabetes listed as a discharge diagnosis more than doubled from 1980 to 2006

Subcutaneous Insulin Injection Therapy:Insulin Requirements in Health and Illness

Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care.

2004;27:553–591. Reprinted with permission.

Units

Healthy(outpatient)

Sick/Eating(hospitalized)

Sick/NPO/TF/TPN

Basal

Prandial

Correction

Nutritional

NPO, no nutrition

A Useful Concept…

Strategies and Protocols for Achieving Inpatient

Glycemic Control

• Continuous variable-rate IV insulin drip

• Regular insulin

• Subcutaneous basal/bolus therapy

• Long-acting and rapid-acting insulin

• Premix / biphasic insulin • For selected patients

transitioning to outpatient care

Protocol Implementation

• Multidisciplinary team

• Administration support

• Pharmacy & Therapeutics Committee approval

• Forms (orders, flowsheets)

• Education: nursing, pharmacy, physicians & NP/PA

• Monitoring/Quality Assessment

Glucose Control in the Hospital and Inpatient Outcomes

A challenge and an opportunity to favorably impact patient care

• Open-heart surgery – Portland Diabetic Project 1987-2005

• Acute MI – DIGAMI 1 1995-99 DIGAMI 2 Eur Heart J 2005

• Surgical ICU – Leuven trial 1 N Engl J Med 2001

• Medical ICU – Leuven trial 2 N Engl J Med 2006

Indications for IV Insulin Drip

Think broad.…• DKA

• Hyperosmolar Hyperglycemic state (HHS)

• Postoperative period following open-heart surgery

• Critical care illness (surgical/medical)

• Myocardial infarction (MI) or cardiogenic shock

• NPO status in Type 1 diabetes

• Perioperative care

• TPN

• High-dose glucocorticoid therapy

• Organ transplantation

• Labor and delivery

What should the glucose targets be using IV insulin (insulin drip)

in critically ill patients?

Intensive versus Conventional Glucose Control in Critically Ill Patients

The NICE-SUGAR Study, New Engl J Med March 2009

• 6104 ICU pts, IV insulin to achieve a BG target of 81 to 108 (115) in the intensive group and 144 to 180 (144) in the conventional group.

• 3% increase in primary end point, death at 90 days (27.5%, vs. 24.9%, a 10% higher relative mortality). A significantly higher rate of severe hypoglycemia in the intensive-control group (6.8% vs. 0.5%)

Optimal Glucose Targets in Hospital Patients:

The ADA-ACE Consensus Statement based on the results of NICE-SUGAR

Diabetes Care, May 2009

Critically ill patients

• Use IV insulin in the majority of patients in the ICU setting

• Maintain glucose levels between 140 and 180 mg/dL

• Targets less than 110 mg/dL are NOT recommended

Noncritically ill (floor) patients

• Recommendations are based on “clinical experience and judgment”

• Premeal glucose targets should generally be <140 mg/dL

• Random glucose values <180 mg/dL

Protocol Implementation: a multidisciplinary effort

The Ideal IV Insulin Protocol

• Easily ordered and implemented

• Effective (gets to goal quickly)

• Safe (minimal risk of hypoglycemia)

Converting to Subcutaneous Insulin

• Establish 24-hour insulin requirement• Extrapolate from average over last 6–8 hours – if stable

• Give one-half amount as basal, rest as bolus

• Transition: stop drip half hour after a small SC dose of short-acting insulin and a SC dose of long-acting (basal) insulin

• Monitor a.c. (before meal) t.i.d., h.s.

• Correct all premeal blood glucose > 150 mg/dL

• Hospitalized patients often require high insulin doses to achieve target glucose

• Initial dose: Basal insulin 0.15 units / kg; titrate! based on am reading

• Provide both basal and bolus (prandial or nutritional) coverage

• Patients often need supplemental or correction insulin for premeal hyperglycemia

• Use of “Sliding Scale” Insulin Alone is Discouraged!

Use of Subcutaneous Insulin

Adult Nonpregnant Subcutaneous Insulin Order Set PHR (#6001)

What is the Role of ‘Sliding Scale’ Insulin?

• Sliding scale is retroactive / reactive coverage, treats hyperglycemia after it happens, may lead to glycemic excursions

• Should not be used as the sole method of insulin administration

• Quickly add, or adjust, the basal insulin dose and add scheduled bolus insulin if necessary

Risk Factors for Hypoglycemia in Inpatients

• Advanced age

• Decreased oral intake

• Chronic renal failure

• Liver disease

• Beta-blockers

• Inadequate glucose monitoring

• Lack of coordination between dietary, nursing, and transportation; mistiming of insulin and food

Key components of hypoglycemia prevention and management

protocolEndocrine Society Practice Guideline, Jan 2012

• Hospital-wide definitions for hypoglycemia and severe hypoglycemia.

• Guidance on discontinuation of sulfonylurea therapy and other oral hypoglycemic medications at the time of hospital admission.

• Directions for adjustments in insulin dose and/or administration of dextrose-containing iv fluids for both planned and sudden changes in nutritional intake.

• Specific instructions for recognition of hypoglycemia symptoms, treatment, and timing for retesting depending on glucose levels and degree of the patient's neurological impairment and for retesting of glucose levels.

• Standardized form for documentation and reporting of hypoglycemic events, including severity, potential cause(s), treatment provided, physician notification, and patient outcome.

Suggested nurse-initiated strategies for treating hypoglycemia

Endocrine Society Practice Guideline, Jan 2012

• For treatment of BG below 70 mg/dl in a patient who is alert and able to eat and drink, administer 15–20 g of rapid-acting carbohydrate such as:

    one–15–30 g tube glucose gel or 4 (4 g) glucose tabs (preferred for patients with end stage renal disease).

    4–6 ounces orange or apple juice.

    6 ounces “regular” sugar sweetened soda.

    8 ounces skim milk.

• For treatment of BG below 70 mg/dl in an alert and awake patient who is NPO or unable to swallow, administer 20 ml dextrose 50% solution iv and start iv dextrose 5% in water at 100 ml/h.

• For treatment of BG below 70 mg/dl in a patient with an altered level of consciousness, administer 25 ml dextrose 50% (1/2 amp) and start iv dextrose 5% in water at 100 ml/h.

• In a patient with an altered level of consciousness and no available iv access, give glucagon 1 mg im. Limit, two times.

• Recheck BG and repeat treatment every 15 min until glucose level is at least 80 mg/dl.

Hypoglycemia Guidelines (PHDOC)

What about Oral Agents?• Insulin is the preferred medication in hospitalized

patients

• Oral agents may be contraindicated or simply ineffective

• In general, avoid continuing or starting oral agents in inpatients, except in relatively healthy patients e.g. elective surgery

• At discharge, inpatient “survival skills” education for pts initiated on insulin; plan in advance!

Insulin Drip

Non-insulin agents

premix/biphasic

Dose-finding with correctional rapid-

acting insulin

Insulin transition and progress towards Discharge

Oral food intake, plus

Basal and rapid-acting

Discharge Planning starts well before discharge!

• Establish a stable regimen of diet and meds well in advance of anticipated discharge

• Refresher in self-care issues, monitoring, nutrition, and diabetes teaching (“survival skills”) with inpatient diabetes educator

• Don’t be afraid to determine a different medication/insulin regimen if necessary discharge

• Arrange for comprehensive diabetes class and follow up physician visit within 2 weeks of discharge

Keys to Euglycemia in the Inpatient Setting

Take-home Points• Be aware of glucose targets

• Plan ahead: IV insulin, transition from IV to SC, discharge planning

• Communicate with patients and other health care professionals

South Carolina Guidelines for Diabetes Care – 2011

released September 2011

Available at:•http://www.scdhec.gov/health/chcdp/diabetes/clinical.htm  •http://clinicaldepartments.musc.edu/medicine/divisions/endocrinology/dsc 

Evidence-based recommendations from:•American Diabetes Association•American Association of Clinical Endocrinologists•American Association of Diabetes Educators