Download 2008 inpatient dm - LA talk

Hyperglycemia in Hospitalized
Patients
•Strategies For Implementing Change
•Nuts and bolts of management
Robert J. Rushakoff, MD
Clinical Professor of Medicine
University of California, San Francisco
[email protected]
Insulin Administration







Order Written
Order Sent to Pharmacy
Order Entry by Pharmacist
Drug Preparation by pharmacy
Insulin delivery to unit
Medication Administration
Documentation
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
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
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
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
"Each blind man perceived the elephant as something
different: a rope, a wall, tree trunks, a fan, a snake, a
spear..."
Patient Assessment of Skills, Education
Diabetes
Assessment Form
Coordination of
Outpatient Care
Medical
Jargon
ICU
Errors
Protocols
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CQI
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Home care services
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JCAHO
Outpatient diabetes
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classes
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Page 1 of 6
What is inpatient diabetes
care?
Diabetes as a
Secondary
Diagnosis
Inpatient Diabetes
Goals
Inpatient Diabetes
Goals
Who Cares
Normal glucoses for
everyone
Just get patient home
Sliding Scales are fine
A high glucose means
failure
Avoid that scary
hypoglycemia
Sliding Scales are banned
Some hypoglycemia is
acceptable
Inpatient Diabetes
Goals
Appropriate Glucose
Control Based on
physiology and outcome
studies
Benefits of Improved Diabetes
Management

Outpatient
DCCT
 UKPDS (United Kingdom Prospective
Diabetes Study)
 Blood pressure control
 Lipids


Inpatient/perioperative - ????????
Target Glucose Levels
Alive
Target Glucose Levels
No DKA or
Hyperosmolar
Coma
Target Glucose Levels
Occasional
hypo- and
hyperglycemia
Target Glucose Levels
No hypo- or
hyperglycemia
•Prevent fluid and electrolyte
•Decreased
post-MI
mortality
abnormalities
secondary
to
osmotic diuresis
•Decreased
post-CABG
•Improveand
WBC
function
morbidity
mortality
•Improve gastric emptying
•Decrease surgical complications
•Earlier hospital dischange
Target Glucose Levels
Normal
Glucoses
Decreased Morbidity and
Mortality
Problems
With High
Glucoses
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
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
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
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
OR (95% CI)
P
Any infection
1.40 (1.08–1.82)
0.01
Septicemia
1.36 (1.00–1.86)
0.05
Acute renal failure
1.47 (1.00–2.17)
0.05
Cardiac complications
1.61 (1.09–2.37)
0.02
Death
1.77 (1.23–2.52)
<0.01
Any complication
1.58 (1.20–2.07)
<0.01
Intervention
Studies
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; 88:10116.
Perioperative IV insulin infusion
Neutrophil phagocytic activity
Control
% baseline
47
Insulin
75
Decreased Infections
Glucose control lowers the risk of wound infection in diabetics
after open heart operations
Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61
Furnary et al. Annals of Thoracic Surgery 1999, 67:352-60
Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021
Perioperative IV insulin infusion
Protocol to maintain glucoses <200
Incidence of Deep Wound Infections (%)
Routine Control
“Tight” Control
1997
2.4
1.5
1999
2.0
0.8
Decreased Infections
Glucose control decreases mortality in diabetics after open heart
operations
Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021
16
14.5%
Mortality (%)
14
12
Cardiac-related
mortality
10
8
6.0%
6
4
2
Noncardiacrelated Mortality
4.1%
2.3%
0.9%
1.3%
0
<150
150-175
175-200
200-225
225-250
>250
AACE Position Statement:
Hospital Glycemic Goals
Intensive Care Units:
110 mg/dL
Non-Critical Care Units:
Pre-Prandial
Max. Glucose
110 mg/dL
180 mg/dL
How to Obtain “Tight” Control




Bedside glucose monitoring
IV insulin drips
Diabetic Flow sheets
Discourage the use of traditional Sliding
Scale insulin
INSULIN
SLIDING
SCALE
INSULIN
SLIDING
SCALE
Roller Coaster Effect of Insulin
Sliding Scale
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.
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
INSULIN
SLIDING
SCALE
Insulin and Glucose Patterns
Normal
Glucose
Insulin
400
120
100
mg/dL
U/mL
300
200
80
60
40
100
20
0600 1000 1400 1800 2200 0200 0600
B
L
S
Time of Day
Polonsky, et al. N Engl J Med. 1988;318:1231-1239.
0600 1000 1400 1800 2200 0200 0600
B
L
S
Time of Day
Insulin Regimens
Relative
Insulin
Level
12pm
Breakfast
Lunch
Time
Dinner
Insulin Regimens
AM NPH
Relative
Insulin
Level
12pm
Breakfast
Lunch
Time
Dinner
Insulin Regimens
BID NPH
Relative
Insulin
Level
NPH
12pm
Breakfast
Lunch
Time
Dinner
Insulin Regimens
BID R and NPH
regular
Relative
Insulin
Level
NPH
12pm
Breakfast
Lunch
Time
Dinner
Insulin Regimens
Relative
Insulin
Level
PM glargine
glargine
12pm
Breakfast
Lunch
Time
Dinner
Insulin Regimens
TID lispro/aspart/glulisine and hs glargine
Relative
Insulin
Level
Lispro/aspart/
glulisine
glargine
12pm
Breakfast
Lunch
Time
Dinner
Subcutaneous Insulin Order Sheet
Introduction
Subcutaneous Insulin Order Sheet :
- PATIENT EATING
Check blood glucose and give insulin before meals, bedtime, and 2 A.M.
1.Discontinue previous SQ insulin order.
2.If patient becomes NPO for procedure/stops eating:
•HOLD nutritional dose of Aspart
•Give correctional dose of Aspart if BG >130 mg/dL
•Give Glargine dose. If BG has been <70 mg/dL in last 24 hours, call MD to consider adjusting Glargine
dose
•Call MD for SQ insulin NPO orders if patient on 70/30, NPH insulin or has been NPO for >12 hours.
BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS)
Patient Eating TIME
Aspart (Novolog)
Nutritional Dose
NPH
Glargine (Lantus)
Novolog Mix 70/30
Breakfast
Lunch
Dinner
Bedtime
Subcutaneous Insulin Order Sheet : Meal time insulin adjustments
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from
nutritional dose of aspart
Blood Glucose Range
<70 mg/dl
Once BG≥100mg/dl give
 Sensitive
 Average
 Resistant
BMI less than 25 and/or <50
units per day
BMI 25-30 and/or 50-90 units
per day
BMI >30 and/or >90
units per day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following
change when patient eats.
2 units less
3 units less
4 units less
_____units less
70-100 mg/dl
2 units less
2 units less
3 units less
_____units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
131-150 mg/dl
+0 unit
+1 units
+2 units
+_______units
151-200 mg/dl
+1 units
+2 units
+3 units
+_______units
201-250 mg/dl
+2 units
+4 units
+6 units
+_______units
251-300 mg/dl
+3 units
+6 units
+9 units
+_______units
301-350 mg/dl
+4 units
+8 units
+12 units
+_______units
351-400 mg/dl
+5 units
+10 units
+15 units
+_______units
Over 400 mg/dl
+6 units
+12 units
+18 units
+_______units
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.
C. BEDTIME AND 2AM BLOOD GLUCOSE CORRECTIONAL INSULIN WITH ASPART IF BG ≥ 200mg/dl
BG Range:
Default Value
200-250 mg/dL
1 unit
251-300 mg/dL
2 units
>300 mg/dL
3 units
Or Custom
Subcutaneous Insulin Order Sheet :
- NPO, Tube Feeds or TPN
1. NPO _____________________ (start date / time)
TPN continuous cycle _______________
TUBE FEED continuous cycle ______________
1.Check blood glucose and give insulin every 4 hours.
2.Discontinue previous SQ insulin order.
3.If patient becomes NPO for procedure/stops eating:
•
Hold nutritional does of Aspart
•
Give correctional dose of Aspart if BG>130 mg/dl
•
Give Glargine dose. If BG has been less than 70 mg/dl in last 24 hours, call MD to consider adjusting
glargine dose.
4.If TPN/Tube Feed interrupted >30 minutes, hand D10W at rate of Tube Feed/TPN
A. BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS)
6:00
10:00
14:00
18:00
22:00
02:00
Aspart (Novolog)
Nutritional Dose
5
5
5
5
5
5
Glargine (Lantus)
24
BLOOD GLUCOSE TIME
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.
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract
from nutritional dose of aspart
 Sensitive
 Average
 Resistant
Blood Glucose Range
BMI less than 25 and/or
BMI 25-30 and/or 50-90 units
BMI >30 and/or >90
Custom
<50 units per day
<70 mg/dl
Once BG≥100mg/dl give
70-100 mg/dl
101-130 mg/dl
131-150 mg/dl
151-200 mg/dl
201-250 mg/dl
251-300 mg/dl
301-350 mg/dl
351-400 mg/dl
Over 400 mg/dl
per day
units per day
Treat for hypoglycemia per protocol (see order #6). Once BG ≥100 mg/dl, give Aspart with
following change when patient eats.
2 units less
3 units less
2 units less
2 units less
Give nutritional dose of Aspart as in # 4A above
+0 unit
+1 units
+1 units
+2 units
+2 units
+4 units
+3 units
+6 units
+4 units
+8 units
+5 units
+10 units
+6 units
+12 units
4 units less
3 units less
_____units less
_____units less
+2 units
+3 units
+6 units
+9 units
+12 units
+15 units
+18 units
+_______units
+_______units
+_______units
+_______units
+_______units
+_______units
+_______units
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.
3.
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 push If 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
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
A.
Transition from IV to SQ
Insulin
BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
•
•
If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl
If patient is NPO >4 hours call MD for IV Dextrose order
Patient Eating TIME
Aspart (Novolog)
Nutritional Dose
Breakfast
Lunch
Dinner
5
5
5
Bedtime
15
Glargine (Lantus)
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart
Blood Glucose Range
 Sensitive
BMI less than 25 and/or <50 units
per day
<70 mg/dl
Once BG≥100mg/dl give
 Average
BMI 25-30 and/or 50-90 units per day
 Resistant
BMI >30 and/or >90 units per
day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
2 units less
3 units less
4 units less
_____units less
70-100 mg/dl
2 units less
2 units less
3 units less
_____units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
131-150 mg/dl
+0 unit
+1 units
+2 units
+_______units
151-200 mg/dl
+1 units
+2 units
+3 units
+_______units
201-250 mg/dl
+2 units
+4 units
+6 units
+_______units
251-300 mg/dl
+3 units
+6 units
+9 units
+_______units
301-350 mg/dl
+4 units
+8 units
+12 units
+_______units
351-400 mg/dl
+5 units
+10 units
+15 units
+_______units
Over 400 mg/dl
+6 units
+12 units
+18 units
+_______units
Transition
from IV180
to SQ
255
Insulin 6 A(5+1)
5 A(5+0)
8 A(5+3)
Glucose
Insulin
140
A.
150
BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
•
•
If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl
If patient is NPO >4 hours call MD for IV Dextrose order
Patient Eating TIME
Aspart (Novolog)
Nutritional Dose
Breakfast
Lunch
Dinner
5
5
5
15 glargine
Bedtime
15
Glargine (Lantus)
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart
Blood Glucose Range
 Sensitive
BMI less than 25 and/or <50 units
per day
<70 mg/dl
Once BG≥100mg/dl give
 Average
BMI 25-30 and/or 50-90 units per day
 Resistant
BMI >30 and/or >90 units per
day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
2 units less
3 units less
4 units less
_____units less
70-100 mg/dl
2 units less
2 units less
3 units less
_____units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
131-150 mg/dl
+0 unit
+1 units
+2 units
+_______units
151-200 mg/dl
+1 units
+2 units
+3 units
+_______units
201-250 mg/dl
+2 units
+4 units
+6 units
+_______units
251-300 mg/dl
301-350 mg/dl
351-400 mg/dl
Over 400 mg/dl
+3 units
+6 units
+9 units
Change
for
next
day
would
be
increase
in
+4 units
+8 units
+12 units
+5 unitsBreakfast and
+10 units lunch Aspart
+15 units
+6 units
+12 units
+18 units
+_______units
+_______units
+_______units
+_______units
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
Day 1 – Use Correctional
dosing only
Base on BMI, anticipated
sensitivity
Patient on Diet alone or Oral Agents who is Eating
Glucose
140
A.
Insulin
255
180
190
BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
1 A(0+1)
•
•
6 A(0+6)
2 A(+2)
If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl
If patient is NPO >4 hours call MD for IV Dextrose order
Patient Eating TIME
0 glargine
Breakfast
Lunch
Dinner
Bedtime
Aspart (Novolog)
Nutritional Dose
Glargine (Lantus)
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart
Blood Glucose Range
 Sensitive
BMI less than 25 and/or <50 units
per day
<70 mg/dl
 Average
BMI 25-30 and/or 50-90 units per day
2 units less
less
Change32 units
for
next day:
units less
70-100 mg/dl
2 units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
151-200 mg/dl
201-250 mg/dl
251-300 mg/dl
301-350 mg/dl
BMI >30 and/or >90 units per
day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
Once BG≥100mg/dl give
131-150 mg/dl
 Resistant
4 units less
_____units less
3 units less
_____units less
•FBS >130
so start basal
insulin at .1
to .3
+0 unit
+1 units
+2 units
+2 units
+3 units
U/kg +1+2 units
units
+4 units
+6 units
•Preprandial
>130 so+8 units
start premeal insulin
+4 units
+12 units
+3 units
+6 units
+9 units
+_______units
+_______units
+_______units
+_______units
+_______units
351-400 mg/dl
+5 units
+10 units
+15 units
+_______units
Over 400 mg/dl
+6 units
+12 units
+18 units
+_______units
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?
Glucose Patient
240
A.
Insulin
on Insulin who is Eating
6 A(0+6)
BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
•
•
If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl
If patient is NPO >4 hours call MD for IV Dextrose order
65 glargine
Patient Eating TIME
Aspart (Novolog)
Nutritional Dose
Glargine (Lantus)
Breakfast
Lunch
Dinner
21
65
14
19
Bedtime
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart
Blood Glucose Range
 Sensitive
BMI less than 25 and/or <50 units
per day
<70 mg/dl
Once BG≥100mg/dl give
 Average
BMI 25-30 and/or 50-90 units per day
 Resistant
BMI >30 and/or >90 units per
day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
2 units less
3 units less
4 units less
_____units less
70-100 mg/dl
2 units less
2 units less
3 units less
_____units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
131-150 mg/dl
+0 unit
+1 units
+2 units
+_______units
151-200 mg/dl
+1 units
+2 units
+3 units
+_______units
201-250 mg/dl
+2 units
+4 units
+6 units
+_______units
251-300 mg/dl
+3 units
+6 units
+9 units
+_______units
301-350 mg/dl
+4 units
+8 units
+12 units
+_______units
351-400 mg/dl
+5 units
+10 units
+15 units
+_______units
Over 400 mg/dl
+6 units
+12 units
+18 units
+_______units
Glucocorticoids and Diabetes
Peripheral
Tissues
postreceptor (Muscle)
defect
Glucose
Liver
Increased glucose
production
Pancreas
Impaired insulin
secretion
Insulin
resistance
Glucocorticoids and
Diabetes:
Glucose
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Typical sliding
scale insulin
Glucose
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Typical sliding
scale insulin
Glucose
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Revved Up sliding
scale insulin
Glucose
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Revved Up sliding
scale insulin
Glucose
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Glucose
NPH
and
Regular
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Glucose
NPH
and
Regular
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids and
Diabetes:
Glucose
Increase NPH
and
Regular
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Glucocorticoids
and 340
Diabetes350
151
220
Glucose
A.
Insulin
BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
•
•
12 A(10+2)
14 A(10+4)
18 A(10+8)
If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl
If patient is NPO >4 hours call MD for IV Dextrose order
Patient Eating TIME
15 glargine
Breakfast
Lunch
Dinner
Aspart (Novolog)
Nutritional Dose
10
10
10
Glargine (Lantus)
30
3A(+3)
Bedtime
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart
Blood Glucose Range
 Sensitive
BMI less than 25 and/or <50 units
per day
<70 mg/dl
 Average
BMI 25-30 and/or 50-90 units per day
 Resistant
BMI >30 and/or >90 units per
day
Custom
Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
Once BG≥100mg/dl give
2 units less
3 units less
4 units less
_____units less
70-100 mg/dl
2 units less
2 units less
3 units less
_____units less
101-130 mg/dl
Give nutritional dose of Aspart as in # 1A above
131-150 mg/dl
151-200 mg/dl
+0 unit
+1 units
+2 units
Change for
next
day
would
be
increase
Aspart
+1 units
+2 units
+3 units
+_______units
+_______units
201-250 mg/dl
+2 units
+4 units
+6 units
+_______units
301-350 mg/dl
+4 units
+8 units
+12 units
+_______units
351-400 mg/dl
+5 units
+10 units
+15 units
+_______units
Over 400 mg/dl
+6 units
+12 units
+18 units
+_______units
Breakfast: 16units;
Lunch
18 units; Dinner
18 units +_______units
+3 units
+6 units
+9 units
251-300 mg/dl
What does it take to
Implement Change?
Physicians
Administration
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

Formulary



Nursing Issues



Clean up insulin
Clean up oral agents
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

Pharmacy and Therapeutics





Forms


Formulary issues
Oral agents
Insulins
Insulin Forms – iv, sq
Insulin forms – iv, sq
Quality Improvement

Need buy in at this level to achieve administrative
support
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 Implementation

Nursing Education



Diabetes Nurse Specialist
Intranet Training
Physician Training


Small group sessions
Internet training
Pediatric Nursing Training
Preimplementation
N=24
127
Postimplementation
N=22
17
Total possible
errors
882
1107
Mean # errors/pt
5.29
0.77
2-tailed t,
independent
samples with
unequal
variance p.=.004
Error rate
Denominator =
possible errors
0.14
0.02
Z-test, 2-tail
p=0.02
Total errors
Test of significance
Improvement in Glucose Management on Medical and
Surgical Wards
2. Mandatory SQ forms
and Nursing
education began in
2006 (just before
sample shown) and
then yearly
Adult Med/Surg Units
Mean Blood Glucose
180
Mean BG mg/dL
1. Limited data from
before 2000 showed
mean glucose was
>200 mg/dl
Trendline
165
150
135
120
2005
2006
Jan '08
Feb '08
Mar '08
Apr '08
Adult Med/Surg Units
Hypoglycemic Glucose Results: BG <60mg/dL
4.0
3.6
% BG <60mg/dL
3. Physician education
mainly after 2006
sample and then
yearly
3.2
2.8
Goal = <2%
2.4
2.0
1.6
1.2
0.8
0.4
0.0
2005
2006
Dec '07
Jan '08
Feb '08
Mar '08
Apr '08
Improvement in Glucose Management In the ICUs
2. Mandatory SQ forms
and Nursing
education began in
2006 (just before
sample shown) and
then yearly
Mean BG mg/dL
1. Limited data from
before 2000 showed
mean glucose was
>200 mg/dl
Adult ICU's
Mean Blood Glucose for SQ Insulin
260
245
230
215
200
185
170
155
140
125
110
2000
2004
2006
Jan '08
Feb '08
Mar '08
Apr '08
Adult ICU's : SQ Ins ulin
Hypoglyce m ic Glucos e Re s ults : BG <60m g/dL
3. Physician education
mainly after 2006
sample and then
yearly
% BG <60mg/dL
2.0
1.5
1.0
0.5
0.0
Nov '07
Dec '07
Jan '08
Feb '08
Mar '08
Apr '08
Improvement in Glucose Management In the ICUs
Adult ICU's
Mean Blood Glucose for IV Insulin
2. ICUIV insulin
order form in
place in 2004
195
180
165
150
135
120
2000
2004
2006
Jan '08
Feb '08
Mar '08
Apr '08
Adult ICU's: IV Insulin
Hypoglycemic Glucose Results: BG <40mg/dL
1.0
%BG <40mg/dL
1. Limited data
from before
2000 showed
mean
glucose was
>200 mg/dl
Mean BG mg/dL
210
Goal = <1%
0.8
0.6
0.4
0.2
0.0
Nov '07
Dec '07
Jan '08
Feb '08
Mar '08
Apr '08
Using Glucometrics to assess changes in glycemic
control during hospital admission: Improvements
in glucoses measured during hospitalization
Melissa E. Weinberg and Robert J. Rushakoff
Metric: By patient-day
Day 1
Day 2
Day 3
Day 4
Days 5-14
Mean BG (SD) (mg/dL)
188.6
(64.6)
183.2
(60.4)
176.1
(49.4)
172.3
(47.7)
163.4
(50.9)
Median BG (mg/dL)
174.5
169.5
168.3
165
154
% outside range (80150)
71.2%
64.4%
63.7%
62.3%
54.1%
% hypoglycemia (<60)
2.9%
0%
1.6%
1.7%
1.1%
% hyperglycemia
(>350)
9.1%
10.4%
6.8%
5.1%
3.8%
Hospital accused of
'dumping' homeless patient
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