A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

Insulin-Focused ADE Webinar Series Part 4: Advancing the Prevention of Hypo- and Hyperglycemic Events

Wednesday, March 19, 2014 1:00 p.m.–2:00 p.m.

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AGENDA

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March 18, 2014 3

Factors to consider in crafting transition regimen

• Outpatient regimen / control • Major changes from recent illness / hospitalization • Inpatient regimen / control • Changing stress levels, weaning prednisone • A1c • Patient preferences • Financial / social / insurance picture • Access to follow up

Transition Guide from Inpatient to Outpatient Regimen

Additional Discharge Orders for Diabetic Patients

The order set is auto-suggested in the Order Sets section of Order Entry and the Rounding Navigator, as well as in the Discharge Order Recon Navigator.

Additional Discharge Orders for Diabetic Patients

Most defaults on these orders are already set in order to save clicks. These are ambulatory orders/prescriptions; they file to the After Visit Summary.

Transitions for patients with hyperglycemia / DM • Incorporate efforts into larger projects for Transitions of

Care

• Identify, mitigate, and communicate interventions and changes to reduce outpatient adverse events and readmission

• Community bridge, social / equipment support, etc

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Questions from Previous Webinar:

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The March 12th webinar focused on measurement and monitoring: o Do you report hypoglycemia as an adverse drug

reaction or do you separately trend hypoglycemic and hyperglycemic occurrences?

o What type of IV solutions are recommended when the Diabetic patient is NPO? o How do you accommodate the insulin needs

with this?

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Questions from Previous Webinar:

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o Do you ever check against the lists of patients in which the Rapid Response Team or with the Fall Prevention Committee when reviewing charts, whether there was hypoglycemia events that occurred prior to these events?

o Do you have any recommendations for hospitals

based on the new rules from the FDA regarding POC glucometers and critical care patients?

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Team Questions

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o Teams have been put forth as a means for managing Insulin Therapy. From you experience, are there benefits to be derived from having an Insulin Management Team? o Who should lead and/or be a part of that team?

o Do you have any recommendations for an Insulin Management Team relative to: o Securing Medical Staff support o Developing the business model

Resources • Patient centered approach to achieving optimal glycemic

control is a multidisciplinary process.

UCSD Team Structure • Inpatient Glycemic Consult Team

– 1.5 Endo’s – 3 APN/CDE’s (2 at 400 bed hospital, 1 at 200 bed hospital)

• Multidisciplinary Glycemic Control Steering Committee

– Representatives from Endo, Hospital Medicine, Nursing, Pharmacy, Surgery, Nutrition Services, IT, Nursing Education, POC Lab

– Meets monthly

• Diabetes Initiative Group (Diabetes Nurse Champions) – 1-2 representatives from each unit – Meets monthly

• We recommend facilitating correct orders for patients via systems

change, order sets, education AND using dedicated team for “just in time” education, consultation, active surveillance.

Getting the docs on board Changing culture as well as practice

• Build the burning platform…and a way to get off of it! • Institutional carrots and sticks • Easy to understand message (marketing) • Influential / high volume champion • Path of least resistance first. • Local data and anecdotes rule. • Just-in-time education and feedback. • Make it easy to do right thing, harder to do wrong thing. • Show that your protocol works. • Address misconceptions / misinterpretations up front

Sutter Sacramento Examples Staff engagement “2 over 200” Campaign

– Modeled after political campaign – 600 providers signed “petition” stating they would address add or

increase insulin for every inpatient with two BG values > 200 mg/dL – Buttons and posters “Our patients may be insulin resistant, but we’re

not!”

“Sugar Stars” – Competition between inpatient units – Star on public board every time high BG values were addressed – Unit with most stars - Pizza Party!

Business Model and ROI • Focus on big picture, continuum of care • Safety issue, costs associated with hypoglycemia • SSI and other complications • Improved administrative coding / capture of co-morbidities • Interventions can improve care / outcomes in outpatient

follow up

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Glycemic Questions

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o The term glycemic target is one that we hear frequently. However, depending on with whom you speak, the glycemic target can be anywhere from 100 to 200. Is there a “rule of thumb” that practitioners can reasonably apply in their practice?

o How is hyperglycemia/DM defined in terms of blood

glucose and A1C for hospitalized patients?

Glycemic Targets – Critical Care When to Initiate Insulin SCCM - BG ≥ 150 mg/dL should trigger initiation of infusion, titrated to keep <150 mg/dL, absolutely < 180 mg/dL. ADA – Initiate at threshold no higher than 180 mg/dL to keep between 140 – 180 mg/dL. Lower targets 110-140 mg/dL may be beneficial in some populations, IF that goal can be achieved with low hypoglycemia rates. Don’t target euglycemia < 110 mg/dL

Glycemic Targets in Non-Critical Care Setting

1. Premeal BG target of <140 mg/dl and random BG <180 mg/dl for the majority of patients.

2. Glycemic targets be modified according to clinical status. – For patients who achieve and maintain glycemic control without

hypoglycemia, a lower target range may be reasonable. – For patients with terminal illness and/or with limited life

expectancy or at high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be reasonable.

3. For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values are 100 mg/dl). Modification of glucose-lowering treatment is usually necessary when BG values are <70 mg/dl.

A1C for Diagnosis of Diabetes in the Hospital

In-hospital hyperglycemia is defined as an admission or inhospital BG > 140 mg/dl.

A1c > 6.5% can be identified as having diabetes, < 5.2% can exclude diabetes.

Implementation of A1C testing can be useful: assist with differentiation of newly diagnosed diabetes

from stress hyperglycemia assess glycemic control prior to admission designing an optimal regimen at the time of discharge

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). Umpierrez et al, Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metabol 97(1):16-38, 2012

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Basal Bolus Questions

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o Is there a classification/type of patients whose glycemic control should always include basal bolus insulin management?

o How is the basal bolus dosage calculated?

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Insulin-Dosing Questions

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o Is there a threshold for when correctional Insulin should not be considered as a routine in the patient’s glycemic management?

o Should Insulin ever be held and if so, when?

Which Patients Need Basal Insulin?

• “Insulin-deficient” patients should always have basal insulin (even NPO): – Type 1 DM or DKA, pancreatic insufficiency – A history of type 2 DM for 10 years or more – On any insulin for 5 years or more – Wide fluctuations of glucose values

• Preprandial glucose > 140 mg/dL consistently

• Random glucose > 180 mg/dL

Calculating Insulin Dosage (Total Daily Dose)

• Calculate from insulin infusion amount – Recent steady state hourly rate x 20, for

example

• Add up insulins taken at home, adjust for glycemic control and other factors

• Calculate from weight, body habitus, other factors

Calculate starting total daily dose (TDD) 0.4 – 0.5 units/kg/day Reduce to 0.3 units/kg/day if hypoglycemia risk increase to 0.5 – 0.6 units/kg/day if overweight / obese

Adjust TDD up or down based on Past response to insulin Presence of hyperglycemia inducing agents, stress

Basal insulin = 50% of TDD Glargine q HS or q AM, detemir in 1 or 2 doses

Starting Basal-Bolus from Scratch

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Insulin-Dosing Questions

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o The relationship between glycemic control and surgical site infection is supported in literature and in the NYSPFP programming, for patients on insulin management, what are the dosing guidelines to maintain glycemic control during operative procedures?

o Frequently patients who are scheduled for testing do not have a meal served until they return from testing/procedure. At times, that meal may be close to the next meal – or the missed meal is skipped because of that timing. How is Insulin dosing adjusted?

Perioperative Standards

• Use intravenous insulin infusions in patients with type 1 or type 2 diabetes treated with insulin and undergoing major surgical procedures, with target glucose between 120 and 180 mg/dL.

• Administer subcutaneous correction dose insulin or an intravenous insulin infusion during minor or short surgical procedures, with target glucose between 140 and 180 mg/dL, and monitoring every 1 – 2 hours, depending on insulin used and type of surgery.

• Post-op SCIP criteria in flux …..not the greatest measure

AACE / ADA guidelines for Perioperative Care: American College of Phyisicians (PIER): Society for Ambulatory Anesthesia Guidelines on Perioperative Management of the Adult Patient with Diabetes.

Give 70 to 100 % of usual dose of glargine or detemir insulin (or 50 to 70 % of NPH insulin)

PLEASE don’t hold basal insulin altogether! Nurses, this means you too!

Reduction in basal dose advisable if patient tightly controlled, or if they take basal insulin to cover nutritional needs as well as basal needs.

Pre-op recommendations for insulin treated patients with diabetes

DiNardo MM et al Endo Pract 17:552 2011

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