4-06 change is good: the basal bolus insulin concept management of hyperglycemia in the adult...

4-06

CHANGE IS GOOD: THE BASAL BOLUS INSULIN CONCEPT

Management of Hyperglycemia in the Adult Hospitalized PatientTEAM MEMBERS:Physicians: Maryann Emanuele, William Barron, Fadi Nabhan and Stephanie Painter Nurses: Rita Vercruysse MPH, Terse Bertucci APN/CNP,CDEDonna Murphy APN/CNS,CDE, Theresa Pavone MSN, Barb Rumick CCRN, Barb Pudelek,ACNP, Rose Lach PhD, Pam Clementi, MSN, Camille Robinson (EPIC), Diabetes LiaisonsPharmacists: Barb Murphy and Alison SchrieverDietician: Jill Whitney RD/LDCenter for Clinical Effectiveness: Michael Wall PharmD, Sr. Clinical Quality Improvement Analyst and Jan JandristisMultidisciplinary ICU Committee

4-06


Project Aim Statement:

Create a consistent state of the art evidenced based

approach to achieve normal blood glucose levels and

standardize the management of hyperglycemia in

hospitalized patients.

Measurement Goal and Target: Implemented insulin protocols to achieve tight glycemic

control: ICU 80-120mgdL; Patient care units less than

110mg/dL pre prandial and random less than 180mg/dL.

(7/04)

No increased episodes of hypoglycemia.

PLAN

4-06


Solutions Implemented:• Reviewed scientific literature and established a multidisciplinary ICU

committee and consensus for insulin protocols and guidelines.• Developed protocols and guidelines for Intravenous Insulin Infusion

and Transition from IV to Subcutaneous Insulin in Adult Patient. 10/03-12/03 - Protocols implemented. 4/04

• Initiated hospital wide nursing and physician education for protocols and the Basal Bolus insulin concept. 12/03

• Implemented protocol changes based on medical staff feedback and clinical outcomes. 7/04 & 9/04

• Changed nursing practice by adjusting blood glucose levels before meals and adjusting the prandial dose based on post meals. 7/04

DO

4-06


Solutions Implemented:• Changed Food and Nutrition practice, ordering evening snacks for

patients on the insulin protocols were not routinely ordered.• Implemented Non-ICU Hyperglycemia Insulin Therapy in

Adults Patients who are eating. 9/04• Removed sliding scale regular insulin from LUCI for better

physiologic hyperglycemia control. 10/04• Formed a Diabetes QI Steering committee 1/05 and unit based

nurse “Train the Trainer” program. 5/05• Developed RN and MD fact sheets on insulin protocols. 10/05• Changed hypoglycemia treatment targets from 60mg//dL to

70mg/dL.• Added A1c lab order to all insulin protocols for patients with an

admission glucose above 180mg/dL if not drawn in the last month. 11/05

DO

4-06


Analysis:• Graph 1: The control chart indicates a statistically significant

improvement change in blood glucose levels beginning in 2004. Beginning in July 2004, there is a statistical significance at 99.7% (3 standard deviations) as compared to period prior to the insulin

protocols. 2/03 through 3/04• Graph 2: The median inpatient glucose value, which was previously

stable with a median of 158mgd/L, has decreased and continues to decrease, with the implementation of inpatient insulin protocols.

• Graph 3: The percent of inpatients with diabetes who experienced a day of hypoglycemia is not stable, the mean went from 10.43% to 11.74 % with the implementation of the insulin protocols.

• Graph 4: The incidence of rescue therapy in patients receiving insulin has increased since 2003.

STUDY

Glu

cose

(m

g/dL

)MEDIAN INPATIENT GLUCOSE

These data are confidential and to be used for quality improvement purposes only.Month of Glucose Result (number of results)

02/2

003

n=(1

0075

)

03/2

003

n=(1

1843

)

04/2

003

n=(8

696)

05/2

003

n=(1

0097

)

06/2

003

n=(1

0798

)

07/2

003

n=(1

1428

)

08/2

003

n=(1

1247

)

09/2

003

n=(9

667)

10/2

003

n=(1

1303

)

11/2

003

n=(9

368)

12/2

003

n=(9

686)

01/2

004

n=(1

1160

)

02/2

004

n=(1

1169

)

03/2

004

n=(1

1664

)

04/2

004

n=(1

1205

)

05/2

004

n=(1

2951

)

06/2

004

n=(1

1580

)

07/2

004

n=(1

1625

)

08/2

004

n=(1

0543

)

09/2

004

n=(1

1296

)

10/2

004

n=(1

1574

)

11/2

004

n=(1

1130

)

12/2

004

n=(1

2078

)

01/2

005

n=(1

1246

)

02/2

005

n=(8

702)

03/2

005

n=(1

1868

)

04/2

005

n=(9

044)

05/2

005

n=(9

541)

06/2

005

n=(8

490)

07/2

005

n=(8

357)

08/2

005

n=(1

1776

)

09/2

005

n=(1

0822

)

10/2

005

n=(8

921)

11/2

005

n=(9

774)

12/2

005

n=(1

2110

)

01/2

006

n=(9

572)

02/2

006

n=(4

044)

135

140

145

150

155

160

UCL = 163.54

Mean = 156.79

LCL = 150.03

UCL = 151.72

Mean = 142.93

LCL = 134.15

Definition: Median inpatient glucose levels in patients with diabetes. Glucose readings below 40mg/dL and above 400mg/dL were excluded.

Data Source: Clarity database, FORCE database.

Analysis: The median inpatient glucose value, which was previously stable with a median of 158mg/dL, has decreased, and continues to decrease, with the implementation of inpatient insulin protocols.

Transition from IV to SubQ protocol and ICU insulin infusion released into LUCI

Non-ICU hyperglycemia management protocol releasedinto LUCI EPIC Inpatient Go-live

Per

cent

HYPERGLYCEMIA IN DIABETIC INPATIENTS

These information are confidential and to be used for quality improvement purposes onlyMonth (number of patient days)

02/2

003

(n=2

149)

03/2

003

(n=2

525)

04/2

003

(n=2

005)

05/2

003

(n=2

278)

06/2

003

(n=2

296)

07/2

003

(n=2

452)

08/2

003

(n=2

321)

09/2

003

(n=2

155)

10/2

003

(n=2

405)

11/2

003

(n=2

066)

12/2

003

(n=2

162)

01/2

004

(n=2

545)

02/2

004

(n=2

369)

03/2

004

(n=2

523)

04/2

004

(n=2

450)

05/2

004

(n=2

625)

06/2

004

(n=2

395)

07/2

004

(n=2

345)

08/2

004

(n=2

069)

09/2

004

(n=2

174)

10/2

004

(n=2

267)

11/2

004

(n=2

118)

12/2

004

(n=2

248)

01/2

005

(n=2

236)

02/2

005

(n=1

859)

03/2

005

(n=2

114)

04/2

005

(n=1

893)

05/2

005

(n=1

844)

06/2

005

(n=1

494)

07/2

005

(n=1

727)

08/2

005

(n=2

132)

09/2

005

(n=1

999)

10/2

005

(n=1

863)

11/2

005

(n=1

850)

12/2

005

(n=1

874)

01/2

006

(n=1

755)

56

58

60

62

64

66

68UCL = 67.60

Mean = 64.61

LCL = 61.62

UCL = 63.48

Mean = 60.25

LCL = 57.02

Definition: Number of diabetic inpatients who experience a day with a glucose measurement above 180mg/dL / Number of diabetic inpatient days with any glucose measurement. Glucose readings below 40mg/dL and above 400mg/dL were excluded.


Analysis: Hyperglycemia in inpatients with diabetes, which was previously unstable, has decreased, and continues to decrease, with the implementation of inpatient insulin protocols.


Non-ICU hyperglycemia management protocol releasedinto LUCI

EPIC Inpatient Go-live

Per

cent

HYPOGLYCEMIA IN DIABETIC INPATIENTS

These information are confidential and to be used for quality improvement purposes onlyMonth (number of patient days)

02/2

003

(n=2

149)

03/2

003

(n=2

525)

04/2

003

(n=2

005)

05/2

003

(n=2

278)

06/2

003

(n=2

296)

07/2

003

(n=2

452)

08/2

003

(n=2

321)

09/2

003

(n=2

155)

10/2

003

(n=2

405)

11/2

003

(n=2

066)

12/2

003

(n=2

162)

01/2

004

(n=2

545)

02/2

004

(n=2

369)

03/2

004

(n=2

523)

04/2

004

(n=2

450)

05/2

004

(n=2

625)

06/2

004

(n=2

395)

07/2

004

(n=2

345)

08/2

004

(n=2

069)

09/2

004

(n=2

174)

10/2

004

(n=2

267)

11/2

004

(n=2

118)

12/2

004

(n=2

248)

01/2

005

(n=2

236)

02/2

005

(n=1

859)

03/2

005

(n=2

114)

04/2

005

(n=1

893)

05/2

005

(n=1

844)

06/2

005

(n=1

494)

07/2

005

(n=1

727)

08/2

005

(n=2

132)

09/2

005

(n=1

999)

10/2

005

(n=1

863)

11/2

005

(n=1

850)

12/2

005

(n=1

874)

01/2

006

(n=1

755)

9

10

11

12

13

14

15

UCL = 12.34

Mean = 10.43

LCL = 8.52

UCL = 13.87

Mean = 11.74

LCL = 9.61

Definition: Number of diabetic inpatients who experience a day with a glucose measurement below 70mg/dL / Number of diabetic inpatient days with any glucose measurement. Glucose readings below 40mg/dL and above 400mg/dL were excluded.


Analysis: The percent of inpatients with diabetes who experience a day with a glucose measurement below 70mg/dL increased from 10.43-11.74% with the implementation of inpatient insulin protocols, and is not currently stable. Additional analyses are being performed to determine the source of the increased hypoglycemia.




Definition: The percent of patients receiving rescue treatment (glucagon, dextrose 50%) following insulin therapy.

Data Source: UHC Pharmacy database

Analysis: The incidence of rescue therapy in patients receiving insulin has increased since 2003.

Per

cent

of p

atie

nts

rece

ivin

g re

scue

trea

tmen

t fol

low

ing

insu

linUSE OF RESCUE TREATMENT (glucagon or dextrose 50%) IN PATIENTS RECEIVING INSULIN

These data are confidential and to be used for quality improvement purposes onlyMonth (total patients receiving insulin)

02/2

003

(354

)

03/2

003

(404

)

04/2

003

(348

)

05/2

003

(396

)

06/2

003

(356

)

07/2

003

(401

)

08/2

003

(402

)

09/2

003

(391

)

10/2

003

(402

)

11/2

003

(367

)

12/2

003

(398

)

01/2

004

(416

)

02/2

004

(382

)

03/2

004

(452

)

04/2

004

(447

)

05/2

004

(488

)

06/2

004

(509

)

07/2

004

(459

)

08/2

004

(462

)

09/2

004

(506

)

10/2

004

(456

)

11/2

004

(476

)

12/2

004

(492

)

01/2

005

(459

)

02/2

005

(452

)

03/2

005

(451

)

04/2

005

(449

)

05/2

005

(420

)

06/2

005

(395

)

07/2

005

(433

)

08/2

005

(453

)

09/2

005

(457

)

10/2

005

(451

)

11/2

005

(472

)

12/2

005

(472

)

10

12

14

16

18

20UCL = 19.59

Mean = 14.51

LCL = 9.43




4-06


Next Steps: • Develop Continuous Tube Feed Protocols.

• Develop protocols for steroid use and protocols for cyclic tube feeds.

• Mandate annual nursing competency test on e-learning for insulin protocols.

• Develop nursing competency test on e-learning for hypoglycemia treatment. (2006)

• Analyze cause for increase in hypoglycemia with the implementation of the insulin protocols. Consider treatment guidelines that address the severity of the hypoglycemia.

• Monitor protocol effectiveness, staff compliance and protocol violations through outcome data collection.

• Share protocol outcome data and experience in appropriate physician, nursing and pharmacy publications.

• Plan an all day seminar on insulin protocols for Loyola staff and outside hospitals.

ACT

4-06 change is good: the basal bolus insulin concept management of hyperglycemia in the adult...

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