Managing Diabetes and Hyperglycemia Safely in the Complex Hospital - - PowerPoint PPT Presentation

Managing Diabetes and Hyperglycemia Safely in the Complex Hospital Setting

Greg Maynard MD, MSc Clinical Professor of Medicine and CQO, UC Davis Medical Center Sacramento, CA

Greg Maynard – Disclosure SHM Glycemic Control Tools

No personal financial interest

21 million in US with dx of DM 8.1 million with undiagnosed DM

Why Glycemic Control?

(It’s about more than infusion insulin glycemic targets!)

• DM / Hyperglycemia Very Common
• Opportunity to identify and intervene

– poorly controlled DM, previously undiagnosed DM, stress hyperglycemia (pre-diabetes)

• Hypoglycemia and extreme hyperglycemia

– Safety problem and a Quality problem

• Inpatient Care - Complex w/ unique challenges

– Education alone insufficient, need systems change

• Huge Implementation Gap - Chaotic baseline
• Public reporting, regulatory guidelines etc.

Society of Hospital Medicine. http://www.hospitalmedicine.org/ResourceRoomRedesign/ pdf/GC_Workbook.pdf.

Focus on the Wards:

• > 1/3 with mean glucose > 180 mg/dL
• 60%-70% of insulin regimens sliding scale only
• >15% with hypoglycemic episodes during their stay
• >6% of patient-days hypoglycemic
• 40% of patients with hypoglycemia suffer recurrence
• Uneven training / performance amongst staff
• Poor coordination of nutrition, monitoring, and insulin
• Inconsistent transitions
• Patients often confused or angry
• Readmissions and return to ED common

Implementation Gap

Achieving good glycemic control AND low hypoglycemia

• Institutional / system support

– Will to standardize, goals, help with metrics

• Empowered centralized steering team
• Local teams addressing barriers
• Protocols / order sets
• Common approach for special populations and

failure modes

• Metrics (balanced approach)
• Active surveillance (aka measure-vention)
• EHR tools
• Automation / closed loop algorithms /

computerized glucose management

Best practices to reinforce

• Actionable glycemic target
• Consistent carbohydrate / dietary / consult
• A1c
• Patient education plan
• Hypoglycemia protocol
• Guidance for transitions (linked protocols)
• Coordinated monitoring / nutrition / insulin
• DC oral agents, insulin preferred
• Insulin regimens for different conditions
• Dosing guidance

Algorithms

Glycemic Targets in Non-ICU 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.

Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metabol 97(1):16-38, 2012

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 Endocr Pract. 2009;15(4). Umpierrez et al,. J Clin Endocrinol Metabol 97(1):16-38, 2012

Antihyperglycemic Therapy SC Insulin Recommended for most medical- surgical patients OADs Not Generally Recommended

Pharmacological Treatment of Hyperglycemia in Non-ICU Setting

1.ACE/ADA Task Force on Inpatient Diabetes. 2.Diabetes Care. 2006 & 2009 3.Umpierrez et al,. J Clin Endocrinol Metabol 97: January 2012

Continuous IV Infusion Selected medical-surgical patients

Algorithmic guidance based on four simple factors

Johns Hopkins example

• Give 70 to 100% of usual dose of glargine
• r detemir insulin or 50 to 70 % of NPH

insulin

• PLEASE don’t hold basal insulin altogether!
• Nurses, this means you too!
• For patients undergoing prolonged

procedures (e.g. CABG) hold SQ insulin and start IV insulin infusion Pre-op recommendations for insulin treated patients with diabetes

DiNardo MM et al Endo Pract 17:552 2011

Guidance for Scheduled Temporary NPO Example UC San Diego

• Basal / Nutritional / Correction insulin terms reinforced

across orders, MAR, documentation venues

• New orders not required for temporary NPO

Insulin glargine (LANTUS) injection: “basal glargine insulin should still be administered even if the patient is temporarily NPO for a procedure, or has temporary interruption of procedure” Nutritional RAA-I guidance for eating patients: “Give with first bite of food (or up to 30 minutes after first bite

• f food if patient is nauseated or has poor appetite).

Give 0% if patient ate less than 50%, half if patient eats 50%, and full dose if they eat all / almost all of meal.”

Anesthesia and Analgesia 2017. 124:1041 Traditional “NPO after Midnight” still common, but should it be?

Carb loading: Not just because it tastes good! Cochrane Collaboration review March 2014

ASHP Foundation Recommendation

Every hospital should prospectively monitor/measure:

– rates of hypoglycemia and hyperglycemia – Insulin use patterns – Coordination of insulin administration, glucose testing, and nutrition delivery Real-time, institution-wide glucose reports should be provided to health care team members to ensure appropriate surveillance and management of patients with unexpected hypoglycemia and hyperglycemia

Cobaugh D, Maynard G, et al. Am J Health-Syst Pharm 2013;70:1404-13.

“Glucometrics” – Unit of measure Operational definitions

• Unit of analysis –

– the individual reading (not recommended) – the patient-day – the patient-stay

• No consensus on best methods yet, but SHM
• ffers a variety of measures
• Hypoglycemia:< 70 mg/dL
• Severe hypoglycemia: < 40 mg/dL
• DWM ≥ 180 mg/dl
• Percent patient-days with BG > 299 mg/dL
• Recurrent hypoglycemia: > 1 hypoglycemic day

Society of Hospital Medicine: https://www.studydata.net/qgen/LoginSecure.php Data / Reporting for Glucometrics, Community, and More

Benchmarking Ranking Bar Chart Hypoglycemia Rates

Scatterplot Hypoglycemia (x axis) Uncontrolled Hyperglycemia (y axis) SHM Benchmarking How do these hospitals get low hypoglycemia AND good glycemic control?

Iatrogenic Hypoglycemia

A Top Source of Inpatient Adverse Drug Events (ADEs)

Classen DC et al. Health Aff (Millwood) 2011;30:581–9. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109. Classen DC et al. JAMA 997;277:301–6. Bates DW et al. JAMA 1997;277:307–11. Classen et al. Jt Comm J Qual Patient Saf. 2010;36:12-21

• ADEs: most common cause of inpatient complications

– affecting 1.9 million stays annually – costing $4.2 billion / year – responsible for 1/3 of hospital acquired conditions (HACs).

• 50-60% of ADEs are preventable
• 57% of ADEs are from hypoglycemic agents
• > 10% of those on a hypoglycemic agent suffer at

least one hypoglycemic ADE

Hypoglycemia Risk Factors - Different Flavors

Inherent

Low BMI / cachexia / Advanced Malignancy / Age Liver / Kidney disease / CHF

Iatrogenic

Insulin / oral agents Some risk with appropriate use. Risk magnified with inappropriate use or failure to react / anticipate preventable problems. Overly aggressive targets, inappropriate prescribing Hypoglycemic (< 70 mg/dL) events - 50% preventable Severe Hypoglycemic events ( < 40 mg/dL) - 50-80% preventable

Improved Glycemic Control AND Reduced Hypoglycemia possible.

Iatrogenic Hypoglycemia from Insulin Most common failures and strategies to address them

• Inappropriate prescribing

– Standardized orders with embedded CDS – mandatory use – Ongoing monitoring for inappropriate prescribing, just in time intervention

• Failure to respond to unexpected nutritional interruption

– Protocols and Education – Methods to reduce interruptions in tube feeding

• Poor coordination of nutrition delivery, monitoring, and insulin delivery

– Clear directions in protocols and order sets – Regular education / competency training – Redesign process

• Failure to respond to a prior hypoglycemic day

– Make sure ASSESSMENT is part of hypoglycemia protocol – Competency and case based-training – Monitor recurrent hypoglycemia rates

Cobaugh DJ et al. Am J Health Syst Pharm;70(16):1404-13. Hellman R. Endocr Pract 2004;10 Suppl 2:100-8. Maynard GA, et. Diabetes Spectr 2008;21 241-247.

RR 2013 vs 2009-10 baseline

hypoglycemic stay 0.71 (0.65,0.79) severe hypoglycemic stay 0.44 (0.34, 0.58) recurrent hypoglycemia 0.78 (0.64,0.94) hypoglycemic day 0.73 (0.66,0.79) severe hypoglycemic day 0.48 (0.37,0.62) Days with BG > 299 mg/dL 0.76 (0.73,0.80)

New BPA for Tube Feedings on hold + Insulin

• Appears for pt’s w/ “0” charted for TF rate + “on

insulin”

• Potential Problems

– RNs don’t consistently chart TF interruptions in I/O – Charting, if done, not always timely

STROKE CODE - June 10

Recurrent hypoglycemia on same insulin doses for several days preceding stroke code

Proposed CDS Display for hypoglycemia evaluation – Federal Interagency Workgroup to prevent ADE

Why was patient Hypoglycemic? Critical Thinking to prevent next episode!

Active Surveillance

• Identify patients with a potential deficit in care,

who are in the hospital right now.

• Triage tools to quickly determine if the patient is

truly uncontrolled or “off protocol”.

• Intervene to bring onto protocol, reduce risk of

glycemic excursions and continued deficits in care, provide ‘just in time’ education. aka “measure-vention”

Urgent re-evaluation is required: At least one episode of frank hypoglycemia (BG<70) or severe hyperglycemia (BG>299) has

• ccurred.

Modify the regimen as needed and consider requesting assistance from the Endocrine Consult or Glycemic Management Services.

Glucose Rounding Report Dashboard

RED: Any POC Glucose result in the past 24 hours > 299 OR Any POC Glucose result in the past 24 hours < 70 YELLOW: Any POC Glucose result in the past 24 hours between 181 – 299 Or Any POC Glucose result in the past 24 hours between 70 – 100 GREEN: All POC Glucose result in the past 24 hours between 100 – 180

At least one BG is in the caution range of 70-100 or 181-299. Re-evaluate the current glycemic regimen and modify as needed.

Glucose Rounding Report Dashboard

RED: Any POC Glucose result in the past 24 hours > 299 OR Any POC Glucose result in the past 24 hours < 70 YELLOW: Any POC Glucose result in the past 24 hours between 181 – 299 Or Any POC Glucose result in the past 24 hours between 70 – 100 GREEN: All POC Glucose result in the past 24 hours between 100 – 180

All BGs are in range (80-180). Additional regimen escalation to maintain BGs in the range

• f 80-140, may be appropriate

for well selected patients for whom the risk of hypoglycemia remains low.

Glucose Dashboard for Rounding Report

RED: Any POC Glucose result in the past 24 hours > 299 OR Any POC Glucose result in the past 24 hours < 70 YELLOW: Any POC Glucose result in the past 24 hours between 181 – 299 Or Any POC Glucose result in the past 24 hours between 70 – 100 GREEN: All POC Glucose result in the past 24 hours between 100 – 180

Hypoglycemia Reduction with Simultaneous Improvement in Glycemic Control

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
• Patients with poor health literacy, new insulin, and

advanced age at highest risk of transitional problems

Transition Guide

Inpatient to Outpatient Regimen

A1c <7% A1c 7- 10%* A1c >10%*

Return to same regimen as prior to admission (oral agents and/or insulin) Restart outpatient oral agents, optimize orals, consider adding basal insulin once daily at 50% inpt dose Restart outpatient oral agents, optimize orals, add basal insulin once daily at 75% inpt dose Alternative: stop orals and start 70/30 or basal/bolus at same inpt dose

Adapted with permission from algorithm by Umpierrez, G.,Emory University School of Medicine, 2011.

*Ensure compliance with home regimen, maximize lifestyle changes,

• ptimize orals and add insulin according to funding, compliance and

lifestyle on individual basis

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.

Computerized Glucose Management

• Now available for IV, SubQ, and Transitions
• Timely adjustment of dosing
• Adjusts for variable carbohydrate intake
• Embedded glucometrics
• Improved glycemic control with low hypoglycemia

rates in research and real world settings

CV Surgery J Diabetes Sci Technol 2(3);370-375 Basal bolus J Diabetes Sci Technol 11(1) CABG J Diabetes Complications 2017 31(4):742-747 CABG Diabetes Care. 2015 38(9):1665-1672. BMT Bone Marrow Transplant 2016 S1, 973-979

Now Available at the Society of Hospital Medicine Glycemic Control Website

www.hospitalmedicine.org/gc

• Best Practice Review
• Assess Current State
• Metrics and Data Collection
• High Performing Teams
• SC Insulin Orders / Protocols
• Insulin infusion protocols
• DKA protocols / order sets
• Perioperative DM management
• Transitions and Reliability
• Education programs
• Hypoglycemia reduction bundle
• Coordination of nutrition / insulin
• Insulin pens
• Insulin pumps
• Example order sets and tools

Questions and Comments?

Thank you!