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Managing the Highs and Lows of Inpatient Diabetes Management: A Nursing Perspective Rita McCarthy, ANP, CDE October 22,

Managing the Highs and Lows of Inpatient Diabetes Management: A Nursing Perspective Rita McCarthy, ANP, CDE October 22, 2008. Increased costs and length of stay Increased morbidity and mortality Quality of care issue Patient safety issue Patients demanding it

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Managing the Highs and Lows of Inpatient Diabetes Management: A Nursing Perspective Rita McCarthy, ANP, CDE October 22,

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  1. Managing the Highs and Lows of Inpatient Diabetes Management: A Nursing PerspectiveRita McCarthy, ANP, CDEOctober 22, 2008

  2. Increased costs and length of stay Increased morbidity and mortality Quality of care issue Patient safety issue Patients demanding it Increased evidence about importance of managing it Compelling Reasons to Address Hyperglycemia in the Hospital

  3. Implementation Issues Lots of literature about the why and the what Less literature about the how

  4. Optimal Glycemic Management in Hospitalized Patients • Establish a team approach to diabetes management • Identify a system to recognize elevated BG levels • Implement protocols for control of blood glucose in ICU’s as well as non-ICU settings • Create educational programs for personnel taking care of patients with diabetes • Establish programs to ensure appropriate transition from inpatient to outpatient diabetes management. ACE/ADA Task Force on Inpatient Diabetes. Endo Prac 2006; 12(4) 458-468

  5. Joint Commission Expectations • Blood Glucose Targets • Preventing hypoglycemia • Diabetes Care Providers • Diabetes self-management education • Medical nutrition therapy • Blood glucose monitoring

  6. What are the Institutional Supports to Help Change the Culture? • Management teams/champions • Protocols/order sets • Policies and Procedures • Staff education programs • Quality management programs

  7. Order Sets and Clinical Guidelines Supporting Intensive Inpatient Diabetes Management • IV insulin protocols • ICU • Step-down units • Order templates for sc insulin • Basal, bolus and correctional • Hypoglycemia - policy and order set • Glucose monitoring • Insulin pump use in the hospital – policy and order set • Self diabetes management policy

  8. Major Perceived Barriers to Management of Inpatient Hyperglycemia by Medical Residents and Midlevel Practitioners • Knowing what insulin type or regimen works best (58%) • Risk of causing hypoglycemia (38%) • Knowing best options to treat hyperglycemia (38%) • Knowing how to adjust insulin (36%) • Unpredictable changes in patient diet and mealtime (34%) • Unpredictable time of patient procedures (34%) Cook, et al, Diabetes Educator (34), 2008,75-83

  9. Nurses’ Barriers • 41% believed they had access to adequate education about diabetes • 28% reported no continuing education on diabetes in past 2-15 years • 37% had practice guidelines • 84% of these found them helpful • McDonald, J Adv Nursing, 1999

  10. Nursing • Largest segment of HCPs in US • Carry out majority of care for hospitalized patients • Implement protocols • Oversee patients 24/7/365

  11. Education Programs • MD’s, NP’s, PA’s • RN’s • Allied health • Dietitians • Pharmacists • PCA’s

  12. Nursing Education Programs • Healthstream – hospital-wide annual competency program • Monthly noon conference –case-based • Unit posters • NGR

  13. Nursing Education Programs Educational blitzes • ICU • Step-down units ICU • Case study approach • Focus • Insulin management • Hypoglycemia • Discharge planning

  14. SC Insulin: Three Components Programmed/Scheduled Supplemental

  15. Insulin Glargine +Fast Acting Insulin Analogue Fast acting insulin Glargine Insulin Effect B L S HS B 6-56

  16. NPH Twice Daily Premeal Fast-acting Analogue Lispro Lispro Lispro Insulin Effect NPH Meals Brk Lunch Dinner Bed

  17. Quality Studies • Help ID positive trends • Help ID problem areas

  18. DSWI rates for Cardiac Surgery:BWH experience Percent of patients

  19. Hypoglycemia on BHIPEvaluation of 20 episode of BG below 50 mg/dl Contributing factors noted (more than one could occur) • SC insulin concurrently used 15% • IV fluids or TF stopped 10% • Multiple lows; BHIP cont’ 5% • Protocol violations 40% • Missed BG 30% • Late on rate change 10%

  20. Hypoglycemia on BHIPEvaluation of 20 episode of BG below 50 mg/dl • No identified cause found in 40% • Average drip rate at time of episode = 16 u/hr • Average BG before low = 122 mg/dl • Bottom Line: • Do not miss scheduled glucose checks • Check more frequently when TF stopped • Vigilance at high drip rates

  21. But even with the best laid plans, there are obstacles…..

  22. Case 1 Mr. C is a 50 year old man with type 2 diabetes on glipizide and metformin at home. He underwent a CABG yesterday. He is extubated and starting to eat. He is on 1-2 units of insulin/hour with glucose values 110-150 mg/dl. Glucose after breakfast was 200

  23. Case 1 cont.

  24. Case 1 - Issues • Can sc insulin be used in addition to drip?

  25. Case 1 • Patients who are eating while on drip protocols may benefit from addition of sc insulin prior to meals • Meal time dose may be calculated based on drip rate or weight of patient • To assist in transition from IV to sc, basal insulin may be started the day prior to anticipated d/c of insulin drip.

  26. Case 1 • Cardiac surg patients stay on insulin drip until POD #3 • On POD #2, Mr C was eating so was started on aspart 6 units ac. • In the pm of POD #2, glargine 20 units started • POD #3 FBS 142 – drip d/c’d.

  27. Case 2 Mr T is a 55 year old homeless male admitted after being found “down”. He is unresponsive. A1C is 8.9%. He is started on insulin drip and tube feeds. Total insulin dose yesterday was 150 units. Team wants to transition to sc and transfer to floor. What doses and which types of insulin are reasonable?

  28. Case 2 - Issues • Transitioning from IV to SC insulin • Tube feed issues

  29. Case 2 • Calculations begin with assessment of basal and nutritional needs. • If insulin drip rate is stable, can use drip requirements to help determine starting sc insulin doses • In patients on tube feeds over 50% of insulin needs are nutritional. • SC dosing is purposely calculated at 60-80% of IV dosing so as to not overtreat patient.

  30. Case 2 • 60%-80% of 150 equals 90-120 units a day • 40% of that is 36-48 for basal insulin • 60% of that is 54-72 for nutritional • Sample orders: • NPH 20 units q 12 hours • Regular 15 units q 6 hours • Sliding scale regular (high scale) q 6 hours

  31. Case 2 • Transferred to step-down • Tube feeds continue until pt pulls tube out early am on 9/28 • BG’s: • 9/27 182-191-205- 102 • 9/28 196- 45- 72- 251 • What happened?

  32. Issues • Tube feeds held or stopped • Tube feeds cycled

  33. Case 2 Preventing hypoglycemia when tube feeds are cycled or stopped -Hold regular insulin -Run D10 at tube feed rate -If tube feeds are cycled may need only NPH qd and regular insulin q6h during the cycled feeds

  34. NPO, Continuous Tube Feeds Continuous Tube Feeds Insulin Effect NPH Reg 0 6 12 18 24 Time (hours)

  35. Case 3 • Miss J is a 40 yr old woman with a 23 year history of type 1 diabetes. Her diabetes has never been in good control • Neuropathy, PVD, ESRD. • Admitted with foot infection – going to the OR for BKA

  36. Case 3 • Insulin doses at home: • NPH 20 units bid • Lispro 6-4-4 • Hospital insulin orders: same

  37. Case 3 The day prior to surgery pt off floor to dialysis, and NPH was not given in the am The night prior to surgery ½ NPH dose given – “Pt NPO” Novolog sliding scale held – pt “NPO”

  38. Case 3 12a (night prior to surgery) pt c/o thirst, headache, nausea. BG 462 –aspart scale given 2a BG 562 – no AG, bicarb nl 4a BG 476 – NPH 10 units, aspart 10 6a BG 423 – additional 10 units arpart given 8a BG 362 – NPH 10 units given

  39. Issues • Type 1 diabetes • Holding or decreasing insulin for surgery • Use of sliding scale insulin

  40. Issues • Type 1 diabetes – need exogenous insulin at all times. • If patient is off unit, special care to send insulin with pt or give as soon as back to the unit • Holding or decreasing insulin for surgery • NPH night prior to NPO – same dose • DOS - give 50-100% of basal dose • Use of sliding scale insulin • Insulin is correctional – should not be held because “NPO”. The only insulin that should be held for NPO is nutritional insulin.

  41. Case Study 4 -Mr. R • 65yo man with 14 yr history of type 2 diabetes. • Admitted for CABG • A1c 8.2, creat 1.2 • DM treatment at home: • Insulin: • Glyburide 10 mg bid, metformin 1000 mg bid, actos 30 mg qd • Blood glucose monitoring: tests 2-3x/day and runs “100-180”

  42. Case Study 4 -Mr. R • Remains on insulin drip until POD #3 • Transitioned to glargine and aspart sc. • Eating but doesn’t like to get up early for breakfast

  43. Case Study 4 Issues • When meal times don’t match BG testing times • Patient education issues

  44. Case Study 4 – Nutritional Issues Menu-ordering – carb consistent • Menus have number of carbs – pt instructed to order consistent number • Nutrition consult PCA education Timing of BG testing, insulin to meals • “Controlling Diabetes While in the Hospital” • Posters on dry erase board in pt room • Dietary to notify staff when tray delivered if “carb-consistent” menu

  45. Case Study 4 – Pt Education A1c on admission 8.2 Won’t be d/c’d on actos So what will the patient need to learn before discharge? What are the tools to help educate the patient?

  46. Significant Hospital Hyperglycemia Requires Potential Change in Diabetes Medication(s) on Discharge Previously diagnosed diabetes and medically stable : • A1c below 7 – no change in home medical regimen • A1c 7-8 – consider adjustment to doses of current home medical treatment • A1c >8 – consider adding or changing medical therapy

  47. Patient Education • Begins with patient assessment on admission • Type of diabetes • Home treatment plan • Self-management skills • Level of control - A1c • Current treatment(s), ie steroids, TPN • Comorbidities • Dietary status

  48. Patient Education Tools • Teaching tool • CCTV • Blood glucose meters • Insulin starter kits

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