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Tutorial: How to Use the Glucose Optimizer

Tutorial: How to Use the Glucose Optimizer. Press the arrow  Key on your Keyboard to Proceed. This Tutorial will take about 15 minutes to complete. Press the Forward arrow  Key on your Keyboard to proceed forward or the Back arrow  to go back one step in this tutorial .

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Tutorial: How to Use the Glucose Optimizer

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  1. Tutorial: How to Use the Glucose Optimizer Press the arrow  Key on your Keyboard to Proceed 8.04.09

  2. This Tutorial will take about 15 minutes to complete Press the Forward arrow  Key on your Keyboard to proceed forward or the Back arrow  to go back one step in this tutorial

  3. Open the UMMC Intranet page & click on Patient Care Resources How to Access the Glucose Optimizer Go to Click On

  4. The program may take 20 to 30 seconds to load, during which you may see this image

  5. ALERT ! This program should NOT BE USED for patients with DKA or HHS (Hyperosmolar Hyperglycemic State) • This is the Opening screen of the program • Press the arrow  Key on your Keyboard to Proceed forward NOTE: The buttons that you see during this TUTORIAL are simply screen shots of the actual program. Hence you CANNOT CLICK them using the MOUSE. Instead use the arrow keys  to advance thru’ this tutorial

  6. You can also access the Online Tutorial or Help from here This tutorial will now focus on TITRATE PHASE of GLUCOSE OPTIMIZER! Prescribers may choose to use the INITIATION and TRANSITION PHASES of the GLUCOSE OPTIMIZER OR They may follow their respective UNIT policies for INITITION & TRANSITIONING OFF Insulin drip using UNIT SPECIFIC POWERPLANS built into the CPOE system TheINITIATEbutton is used to begin a NEW patient on Insulin Protocol The TITRATE button is used to adjust Insulin rate for a patient ALREADY on Insulin Protocol The TRANSITION button is used for a patient who is ready to come off Insulin drip- this is only a guideline- Please use Diabetic Management powerplan • The Support button is used for: • Online Tutorial • Phone Support

  7. Lets now access theTITRATE section of the Glucose Optimizerprogramfor a patient WHO IS ALREADY ON INSULIN DRIP

  8. 3 entries are required for the Titration Phase: • Current BG, • Current Insulin Drip rate & • Previous BG Remember, the first Entry Box is always your MOST CURRENT BG level The current BG is graphically displayed here CAUTION ! Do not interchange Current BG with Previous BG ... Current Insulin rate 153 Enter Previous BG Level 4 Next, this button is clicked to see the new recommendations 89

  9. Before the new recommendations are displayed, you are asked to confirm the Current & Previous BG entries

  10. Next your are required to confirm the correct INSULIN dose by re-entering it

  11. RECOMMENDATIONS are then displayed in this area Recommended NEW INSULIN DRIP RATE is shown here In the current example the recommendation is to increase from 4 to 5.5 Units/hour Recommended interval for the next BG level check is shown here Special instructions are shown here

  12. Lets have a look at the Glucose Optimizer recommendations when patient is Hypoglycemic Administer Dextrose 50% STAT IV. The volume of D50W is shown here INSULIN infusion should be STOPPED IMMEDIATELY! A repeat BG MUST BE CHECKED in 15 minutes! Notice: In this example, the Current BG is 30 !

  13. How to Prevent Hypoglycemia • Most importantly: ALWAYS CHECK Blood Glucose level at the CORRECT INTERVAL RECOMMENDED BY THE PROGRAM! • The recommended interval for BG check varies from: • 1 hour (most of the patients on Insulin drip) • 2 hours (if BG and Insulin drip stable for 4 hours) • 15 minutes (if BG is less than 60 mg/dl) • 30 minutes (if BG is decreasing very rapidly or a high insulin dose needs to be decreased rapidly) • (Note, the program indicates when you can go to q2h BG checks) • STAT BG level at ANY time you suspect hypoglycemia • (e.g. Tachycardia, sweating, seizures, altered mental status)

  14. How to Prevent Hypoglycemia • Check Insulin drip to confirm that the concentration is 1 unit/ml, & it has been correctly programmed into the pump • Label the drip & the pump clearly • Be alert for factors that cause BG to drop quickly such as: decrease in TPN or feeds, reduction in steroids dose, reduction in inotrope drips

  15. When these conditions are met, the program automatically alerts you that patient may be ready for q 2h BG checks (button turns GREEN) When Can I do q 2hr FS check? Note: In this example, both the Current & Previous BG values are in target range (80 to 120) & Insulin dose is NOT VERY HIGH (upto 4 units/hr) Let’s now click on this button Note the instructions that appear in this pop-up box CAREFULLY

  16. … Whereas this patient is not ready for q2h BG checks Notice, the Current BG is greater than target range (80 to 150 AND Insulin dose recommended is an increase from 4 to 9 units/hour Clicking on this button ….. Notice, also that the q2h button in NOT GREEN

  17. Lets now look at the -INITIATE Phase of the program

  18. For INITIATING Insulin Drip, simply answer the 4 questions below #1) Insulin Drip is ONLY indicated for patients expected to stay in the ICU for > 12 to 24 hours & are CRITICALLY ILL IMPORTANT ! Your Unit may use different indications to INITIATE a patient on TGC. In that case, please follow your own INITIATION GUIDELINES rather than using the INITIATE section in Gluc Optimizer. In either case INITIATE orders must be entered in powerchart by MD/NP e.g. if the most recent BG was 138, then click the “121-150” range box #2) A recent BG level is required before initiating insulin drip. Once all questions are answered, Recommendations are displayed for initiating Insulin Drip in this box #3) Indicate the most recent BG level, by clicking on the appropriate range box #4) … and if the prior BG was 168 then click the “151-200” range box

  19. Based on the Glucose Optimizer protocol, the program recommends starting Insulin drip if: a) One BG > 200, or b) Two consecutive BG levels > 150 or c) Two consecutiveBG levels > 120 (in a patient who is critically ill eg sepsis, ventilator, inotropes etc) The starting INSULIN drip rate is determined by the current BG level 1 unit/hr (if BG 120 to 150) 2 units/hr (if BG 151 to 200) 3 units/hr (if BG 201 to 300) 4 units/hr (if BG >300) Review the recommendations for INITIATING Insulin Drip in the box below IMPORTANT ! Please advise MD/NP to Enter Order using TGC powerplan (Insulin Drip, Finger sticks, and D50W for hypoglycemia) in Power chart as shown in next slide (see GLYCEMIC CONTROL)

  20. IMPORTANT ! 1) Orders need to be Entered in power chart by MD/NP before initiating insulin infusion

  21. Once you INITIATE a patient on INSULIN DRIP (whether using the INITIATE phase of the GLUCOSE OPTIMIZER, or your own UNIT based Indications), all subsequent Insulin adjustments MUST BE MADE USING THE TITRATE PHASE of the GLUCOSE OPTIMIZER until patient is ready to come off Insulin drip

  22. Lets now look at the -TRANSITION Phase of the program

  23. TRANSITIONING OFF from continuous IV Insulin drip to subcut Intermittent insulin is recommended … WHEN TO TRANSITION OFF INSULIN DRIP? • When transfer out of ICU is expected in next 12 to 24 hours OR • When patient has recovered from critical illness & is stable (e.g. extubated, off inotropes, off CVVH etc)

  24. Answering 5 questions in this section will help generate recommendations & orders for TRANSITIONING off from Continuous Insulin Infusion to Intermittent Subcut Insulin IMPORTANT ! Your Unit may use a different method to TRANSITION OFF Insulin Drip. The TRASITION PHASE of the GLUCOSE OPTIMIZER serves as general guidelines that may be modified as needed Enter current insulin rate & Current BG level (Question 1 & 2) Enter TOTAL Insulin recd in last 4 hours: e.g. If the Insulin drip rate for each of the LAST 4 hours was: 2 units/hr, 1 unit/hr, 2 units/hr, and 2 units/hr, then the TOTAL FOR 4 HOURS= 2+1+2+2 = 7 units. Hence click on the 7 -9 units box Select one of the 3 Sliding scales (low, mid or high) in consultation with MD/NP. Press here for recommendation

  25. TRANSITION Recommendations are displayed in this box Recommendations for Lantus Insulin (Basal, Long-acting) are shown here Recommendations for Prandial Insulin are shown here IMPORTANT ! Transition Orders MUST be entered by MD/NP, in power chart & Sliding scale (Supplemental Insulin) is shown here Transition orders needs to be entered in Power chart.

  26. Follow diabetes Management Power plan as applicable IMPORTANT ! 1) Orders need to be entered by MD/NP, in power chart

  27. If the program fails to load, you will just see a blank grey screen (as shown here) Troubleshooting simply CLOSE ALL open Browser Windows (you can keep PowerChart open) & then reopen the Glucose Optimizer from a new UMMS home page

  28. Remember, Help is only a Click Away ! For IMMEDIATE questions, Call or Page SUGGESTIONS: Your Feedback is VALUABLE You can always access this ONLINE Tutorial from the Help page

  29. TIPS & TRICKS • Have the patient’s flowsheet with you when you access the Glucose Optimizer on the computer • You can then easily refer to the flowsheet, to enter the current BG, the previous BG & the current insulin dose in the Glucose Optimizer • Next, as the Glucose Optimizer recommends a new Insulin drip rate, chart it directly in the flowsheet (so that you don’t have to remember it). • Next change the settings on the infusion pump to the new rate

  30. Where to draw blood for BG checks? • Finger stick is the preferred method • Arterial line may be used • DO NOT USE CENTRAL LINE OR PERIPHERAL LINE that is infusing Dextrose containing IV fluids. • This will give a FALSELY HIGH BG reading • Prompting you to erroneously increase Insulin • Thus causing hypoglycemia

  31. Screen patients for Hyperglycemia!! • Hyperglycemia cannot to treated UNLESS it is first IDENTIFIED! • To detect hyperglycemia all CRITICALLY ILL patients MUST be screened with q 6h BG at • (6am, 12 noon, 6pm 12 midnight) • Remind RESIDENTS (MD/NP) to order q6h BG in PowerChart!

  32. What is the rationale for Tight Glycemic Control? >220 < 40 40-60 180-220 60-80 80-120 120-180 HYPOglycemia HYPERglycemia Normal

  33. Because evidence shows that HYPERGLYCEMIA is bad!

  34. When BG > 300 Mortality =43% Krinsley Hyperglycemia INCREASES Mortality! in Myocardial Infarction patients Even modest increase in BG to 160 doubles the mortality rate! …in Cardiac Surgery patients … and in other ICU patients … in stroke patients If BG < 100 Mortality =10%

  35. …& evidence also shows that NORMOGLYCEMIA is good!

  36. 35% reduced Mortality ! 2001

  37. Morbidity is reduced too! • 30% to 50% reductions in • Bacteremia • Transfusion needs • Need for CVVH • Duration of mechanical ventilation • Length of stay • Polyneuropathy • Ref: NEJM 2001, van den Berghe et al

  38. Your role is crucial!Your efforts are appreciated! • Each time you check a BG level and adjust Insulin drip, you are making a SIGNIFICANT CONTRIBUTION to improving mortality & morbidity • Remember, the aim is to normalize BG in ALL CRITICALLY ILL PATIENTS: DIABETICS AS WELL AS NON-DIABETICS

  39. Explanation of EXPO formula for Glucose Optimizer • The EXPO formula is mathematically designed to aggressively prescribe insulin at high BG, adjust the infusion to achieve a 20% decrease per hour in BG until BG falls below 150 mg/dL, rapidly taper insulin as BG falls, and maintain a BG in the 80-150 mg/dL range. • There are built in safety features including curtailing insulin if the BG falls below 80 mg/dL, limiting hourly increases in the insulin infusion rate to no more than 5 units, and setting a cap on the insulin resistance coefficient at ten times the starting IRC.

  40. EXPO Insulin Dosing Formula • The insulin resistance coefficient (IRC) is adjusted using a correction factor that is based upon the previous IRC (calculated from the previous BG and insulin infusion rate), and the difference between current BG and the fraction (Fx) of previous BG expected from the current insulin infusion rate. This Fx has a sigmoidal relationship where the insulin infusion rate is expected to achieve a BG after one hour that is 80% of previous BG when previous BG is > 150 mg/dL, and 100% of previous BG when previous BG is < 120 mg/dL, the upper limit of our desired BG range. In other words, the IRC is adjusted to achieve a 20% decrease per hour in BG until BG falls below 150 mg/dL, and to keep BG stable when below 120 mg/dL.

  41. Your Suggestions are Valuable • Please to access a short survey & to let your MANAGER know that you have completed this online tutorial. Go to: http://www.surveymonkey.com/s.aspx?sm=aH2Y5kbB46VW4loBJqP_2bpA_3d_3d (Note: It will take a few seconds for the survey webpage to load …)

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