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Robert J. Rushakoff, MD Clinical Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu. Hyperglycemia in Hospitalized Patients. Strategies For Implementing Change Nuts and bolts of management. Insulin Administration. Order Written Order Sent to Pharmacy

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slide1
Robert J. Rushakoff, MD

Clinical Professor of Medicine

University of California, San Francisco

robert.rushakoff@ucsf.edu

Hyperglycemia in Hospitalized Patients
  • Strategies For Implementing Change
  • Nuts and bolts of management
insulin administration
Insulin Administration
  • Order Written
  • Order Sent to Pharmacy
  • Order Entry by Pharmacist
  • Drug Preparation by pharmacy
  • Insulin delivery to unit
  • Medication Administration
  • Documentation
slide3

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database

Endocrine Practice 2008. 14:535

slide4

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database

Endocrine Practice 2008. 14:535

slide5

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database

Endocrine Practice 2008. 14:535

slide6

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database

Endocrine Practice 2008. 14:535

slide7

"Each blind man perceived the elephant as something different: a rope, a wall, tree trunks, a fan, a snake, a spear..."

slide8

Patient Assessment of Skills, Education

Diabetes Assessment Form

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Page 1 of 6

Medical Errors

JCAHO

Coordination of Outpatient Care

Home care services

Outpatient diabetes classes

Jargon

CQI

ICU Protocols

slide10

Inpatient Diabetes Goals

Appropriate Glucose Control Based on physiology and outcome studies

Inpatient Diabetes Goals

Normal glucoses for everyone

A high glucose means failure

Sliding Scales are banned

Some hypoglycemia is acceptable

Inpatient Diabetes Goals

Who Cares

Just get patient home

Sliding Scales are fine

Avoid that scary hypoglycemia

benefits of improved diabetes management
Benefits of Improved Diabetes Management
  • Outpatient
    • DCCT
    • UKPDS (United Kingdom Prospective Diabetes Study)
    • Blood pressure control
    • Lipids
  • Inpatient/perioperative - ????????
target glucose levels13
Target Glucose Levels

No DKA or Hyperosmolar Coma

target glucose levels14
Target Glucose Levels

Occasional hypo- and hyperglycemia

target glucose levels15
Target Glucose Levels

No hypo- or hyperglycemia

  • Prevent fluid and electrolyte abnormalities secondary to osmotic diuresis
  • Improve WBC function
  • Improve gastric emptying
  • Decrease surgical complications
  • Earlier hospital dischange
  • Decreased post-MI mortality
  • Decreased post-CABG morbidity and mortality
target glucose levels16
Target Glucose Levels

Normal Glucoses

Decreased Morbidity and Mortality

slide18

Glucose and post-CABG morbidity and mortality

Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and outcomes

Diabetes Care 2003; 26:1518-1524

  • Retrospective Review of 291 patients surviving 24 h post op
  • 40% with retinopathy, nephropathy or neuropathy

Inpatient Complications

For each 1 mmol/l (18 mg/dl) increase in postop day 1 over 6.1 mmol/l (110 mg/dl), a 17% increase risk of complications

slide19

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU

  • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
  • Hyperglycemia was an independent predictor of mortality starting at 111 mg/dl.
  • Effect was greatest with acute myocardial infarction, unstable angina, and stroke
    • heart attack - 1.6-5 time
    • a stroke it raised risk from 3.4 to 15.1 times
    • unstable angina it raised risk from 1.7 to 6.2 times

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

slide20

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU

  • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
  • A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism. Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure.
  • In diabetes patients, the increase in mortality risk was not seen until mean glucose was >146 mg/dl

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

slide21

TPN: Adverse Outcomes

Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition

Cheung et al: Diabetes Care, 28:2367-2371, 2005

Risk of complications in relation to mean daily blood glucose level

slide23

Decreased Infections

Insulin infusion improves neutrophil function in diabetic cardiac surgery patients.

Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999; 88:1011-6.

Perioperative IV insulin infusion

Neutrophil phagocytic activity

% baseline Control 47

Insulin 75

slide24

Decreased Infections

Glucose control lowers the risk of wound infection in diabetics after open heart operations

Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61Furnary et al. Annals of Thoracic Surgery 1999, 67:352-60Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

Perioperative IV insulin infusionProtocol to maintain glucoses <200

Incidence of Deep Wound Infections (%)

19971999 Routine Control 2.4 2.0“Tight” Control 1.5 0.8

slide25

Decreased Infections

Glucose control decreases mortality in diabetics after open heart operations

Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

14.5%

6.0%

4.1%

2.3%

1.3%

0.9%

aace position statement hospital glycemic goals
AACE Position Statement: Hospital Glycemic Goals

Intensive Care Units: 110 mg/dL

Non-Critical Care Units:

Pre-Prandial 110 mg/dL

Max. Glucose 180 mg/dL

how to obtain tight control
How to Obtain “Tight” Control
  • Bedside glucose monitoring
  • IV insulin drips
  • Diabetic Flow sheets
  • Discourage the use of traditional Sliding Scale insulin
slide28

INSULIN

SLIDING

SCALE

slide29

INSULIN

SLIDING

SCALE

slide31

Mr. And Mrs. XXXXX are admitted for spring fever.

Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.”

Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night.

slide32

Fingerstick qid with regular insulin SQ coverage:

FSBG Action

< 50 1 amp D50 iv and call HO

51-80 give juice and repeat in 0.5-1 hr

81-200 no coverage

201-250 3U regular insulin SQ

251-300 6U regular insulin SQ

301-350 8U regular insulin SQ

351-400 10U regular insulin SQ

>400 12U regular insulin SQ, call HO

slide33

INSULIN

SLIDING

SCALE

insulin and glucose patterns
Insulin and Glucose Patterns

Normal

Glucose

Insulin

400

120

100

300

80

mg/dL

U/mL

200

60

40

100

20

0600

1000

1400

1800

2200

0200

0600

0600

1000

1400

1800

2200

0200

0600

B

L

S

B

L

S

Time of Day

Time of Day

Polonsky, et al. N Engl J Med. 1988;318:1231-1239.

slide35

Insulin Regimens

Relative Insulin Level

12pm

Breakfast

Lunch

Dinner

Time

slide36

Insulin Regimens

AM NPH

Relative Insulin Level

12pm

Breakfast

Lunch

Dinner

Time

slide37

Insulin Regimens

BID NPH

Relative Insulin Level

NPH

12pm

Breakfast

Lunch

Dinner

Time

slide38

Insulin Regimens

BID R and NPH

regular

Relative Insulin Level

NPH

12pm

Breakfast

Lunch

Dinner

Time

slide39

Insulin Regimens

PM glargine

Relative Insulin Level

glargine

12pm

Breakfast

Lunch

Dinner

Time

slide40

Insulin Regimens

TID lispro/aspart/glulisine and hs glargine

Relative Insulin Level

Lispro/aspart/glulisine

glargine

12pm

Breakfast

Lunch

Dinner

Time

subcutaneous insulin order sheet bedtime and 2am insulin adjustments
Subcutaneous Insulin Order Sheet : Bedtime and 2am insulin adjustments

Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses.

subcutaneous insulin order sheet q4hour correctional dosing for npo tube feeds or tpn
Subcutaneous Insulin Order Sheet : q4hour correctional dosing for NPO, Tube Feeds or TPN

q4hour correctional insulin options are shown. Here correctional insulin is generally used to add or subtract insulin from the q4hour nutritional insulin ordered in section A. There are times it can be used even if no standing q4hour dose is written.

low glucose reading
Low Glucose Reading

The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose.

  • For BG <70 mg/dl, use Hypoglycemia Protocol below:For patient taking PO, give 20 g of oral fast-acting carbohydrate: 4 glucose tablets (5 grams glucose/tablet)-OR- Give 6 oz. fruit juice Give 25 ml of D50 IV pushIf patient cannot take POCheck fingerstick glucose every15 minutes and repeat above treatment until BG is ≥100 mg/dl.
transition from iv to sq insulin
Transition from IV to SQ Insulin

Take 80% of last 24 h insulin infusion

Basal: ½ of the value

premeal: ½ of the value divided for the meals

Example: 1.5 units per hour = 36U

36 x .8= 29

Basal: 30x.5=15

premeal: 30x.5=15 5 per meal

slide50

Transition from IV to SQ Insulin

Glucose 140 255 180 150

Insulin 5 A(5+0) 8 A(5+3) 6 A(5+1)

15 glargine

Change for next day would be increase in Breakfast and lunch Aspart

patient on diet or oral agents who is eating
Patient on Diet or Oral Agents who is Eating

Depending on which oral agents – may or may not be continuing- - - -

patient on diet alone or oral agents who is eating
Patient on Diet alone or Oral Agents who is Eating

Day 1 – Use Correctional dosing only

Base on BMI, anticipated sensitivity

slide53

Patient on Diet alone or Oral Agents who is Eating

Glucose 140 255 180 190

Insulin 1 A(0+1) 6 A(0+6) 2 A(+2)

0 glargine

  • Change for next day:
  • FBS >130 so start basal insulin at .1 to .3 U/kg
  • Preprandial >130 so start premeal insulin
patient scheduled for npo procedure
Patient Scheduled for NPO Procedure

Patient is scheduled for a CT scan and is NPO tomorrow morning. Glucoses at what would be breakfast time is 240. Orders are as follows. What should be done with the insulin?

slide55

Patient on Insulin who is Eating

Glucose 240

Insulin 6 A(0+6)

65 glargine

glucocorticoids and diabetes
Glucocorticoids and Diabetes

Peripheral Tissues

(Muscle)

postreceptor defect

Insulin

resistance

Glucose

Liver

Increased glucose production

Pancreas

Impaired insulin secretion

glucocorticoids and diabetes57
Glucocorticoids and Diabetes:

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes58
Glucocorticoids and Diabetes:

Typical sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes59
Glucocorticoids and Diabetes:

Typical sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes60
Glucocorticoids and Diabetes:

Revved Up sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes61
Glucocorticoids and Diabetes:

Revved Up sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes62
Glucocorticoids and Diabetes:

NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes63
Glucocorticoids and Diabetes:

NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes64
Glucocorticoids and Diabetes:

Increase NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

slide65

Glucocorticoids and Diabetes

Glucose 151 220 340 350

Insulin 12 A(10+2) 14 A(10+4) 18 A(10+8) 3A(+3)

15 glargine

Change for next day would be increase Aspart

Breakfast: 16units; Lunch 18 units; Dinner 18 units

committee members
Committee Members
  • Physicians: Endocrinologist, Hospitalist
  • Clinical Nurse Specialists: Diabetes, education
  • Nurses: ICU Manager, at least one manager from medical floor (or their representative)
  • Clinical Pharmacist
  • Administration presence – from level of quality assurance or similar title
  • Discharge Coordinator – not required for initial discussions and implementation, but needed later
  • Nutritional services – not required for initial design and implementation of forms.
tasks
TASKS
  • Formulary
    • Clean up insulin
    • Clean up oral agents
  • Nursing Issues
    • Policy on IV insulin use
    • Policy on frequency of glucose monitoring
  • Forms
    • Design forms
      • IV insulin forms
      • SQ insulin forms
      • ?DKA treatment forms
other committees to be conquered
Other Committees To be Conquered
  • Pharmacy and Therapeutics
    • Formulary issues
    • Oral agents
    • Insulins
    • Insulin Forms – iv, sq
  • Forms
    • Insulin forms – iv, sq
  • Quality Improvement
    • Need buy in at this level to achieve administrative support
ucsf implementation
UCSF Implementation
  • Committee: Endocrinologists, Hospitalist, Diabetes Nurse Specialist, Clinical Pharmacists, QA administrators, others
  • Formulary
    • Limited number of insulins now available
  • Forms
      • IV insulin forms – ICU, Floor
      • SQ insulin form
      • DKA treatment forms
ucsf implementation73
UCSF Implementation
  • Nursing Education
    • Diabetes Nurse Specialist
    • Intranet Training
  • Physician Training
    • Small group sessions
    • Internet training
slide82

Improvement in Glucose Management on Medical and Surgical Wards

Limited data from before 2000 showed mean glucose was >200 mg/dl

Mandatory SQ forms and Nursing education began in 2006 (just before sample shown) and then yearly

Physician education mainly after 2006 sample and then yearly

slide83

Improvement in Glucose Management In the ICUs

Limited data from before 2000 showed mean glucose was >200 mg/dl

Mandatory SQ forms and Nursing education began in 2006 (just before sample shown) and then yearly

Physician education mainly after 2006 sample and then yearly

slide84

Improvement in Glucose Management In the ICUs

Limited data from before 2000 showed mean glucose was >200 mg/dl

ICUIV insulin order form in place in 2004

slide85

Using Glucometrics to assess changes in glycemic control during hospital admission: Improvements in glucoses measured during hospitalization

Melissa E. Weinberg and Robert J. Rushakoff

issues at discharge
Issues at Discharge
  • Patient new to diabetes
  • Patient new to insulin or other medications
  • Not metabolically stable (e.g. steroid taper), unclear what any requirement will be
  • Oral agents, Incretins - when, how, why
  • Changing medications (TPN etc) on the day of discharge
  • Inability to perform self management
  • Who follows patient
  • Communication of inpatient care plan to outpatient providers
  • Short term and long term goals