Discharge Issues and Strategies

1. Discharge Issues and Strategies Juli Adelman RD, CDE Cheryl O�Malley, MD Jacqueline Thompson RN,MAS,CDE

2. Objectives How do you determine the best home medication regimen for hospitalized patients with hyperglycemia? What, when and how should you teach them? How can we continue the process with a smooth transition into the community?

3. Using the time in the hospital to improve outpatient therapy for DM Cheryl O�Malley, MD

4. Relationship between inpatient and outpatient diabetes management Sure the economics and volumes of patients mean that this issue affects all of us. However, it is probably most important that an a physician managing ambulatory patients with diabetes, you see that many times, patients receive inconsistent messages about the importance of their DM because their BS were ignored or ineffectively controlled for many different reasons and they return to you, frustrated, confused and having missed an important teaching moment.Sure the economics and volumes of patients mean that this issue affects all of us. However, it is probably most important that an a physician managing ambulatory patients with diabetes, you see that many times, patients receive inconsistent messages about the importance of their DM because their BS were ignored or ineffectively controlled for many different reasons and they return to you, frustrated, confused and having missed an important teaching moment.

5. Hyperglycemia in the hospital: Who�s Who Known Diabetes New hyperglycemia Previously unrecognized diabetes Stress induced hyperglycemia Medical history of diabetes (12-25%) Unrecognized DM (12-30%) Hospital-induced hyperglycemia (13%) One study with 1000 consecutive hospitalized adult patients. Excluding those with known DM, 33% of hyperglycemic pts had undiagnosed DM. 25% of diabetics surveyed had been hospitalized in the last year. Medical history of diabetes (12-25%) Unrecognized DM (12-30%) Hospital-induced hyperglycemia (13%) One study with 1000 consecutive hospitalized adult patients. Excluding those with known DM, 33% of hyperglycemic pts had undiagnosed DM. 25% of diabetics surveyed had been hospitalized in the last year.

6. Obtain a HbA1c level Distinguish stress hyperglycemia from established diabetes Gauge outpatient control on their current regimen Guide educational needs Guide changes in home regimen Obtaining a HbA1c can be quite helpful for several reasons. The ADA recommends obtaining one if there is not one available from the prior month. If the patient has been transfused or has a hemoglobinopathy, this can be unreliable so obtaining it at admission is the best time. Obtaining a HbA1c can be quite helpful for several reasons. The ADA recommends obtaining one if there is not one available from the prior month. If the patient has been transfused or has a hemoglobinopathy, this can be unreliable so obtaining it at admission is the best time.

7. Discharge Planning for New Hyperglycemia Check HgbA1C: >6% highly likely to have DM <5.2% unlikely to have DM 5.2-6% indeterminate Need close follow up Fasting blood glucose or OGTT Consider home blood glucose testing Understand that glycated hemoglobin is NOT a diagnostic criteria for DM at this time. However, it is actually rather specific when >6%. Understand that glycated hemoglobin is NOT a diagnostic criteria for DM at this time. However, it is actually rather specific when >6%.

8. Natural History of Type 2 Diabetes

9. Stress Hyperglycemia: ? Pre-Diabetes Individuals at high risk for developing diabetes need to become aware of the many benefits of modest weight loss and participating in regular physical activity. (A) Patients should be given counseling on weight loss as well as instruction for increasing physical activity. (A for IGT and E for IFG) If pre-diabetes, check for DM every 1�2 years. (E) Because of possible side effects and cost, there is insufficient evidence to support the use of drug therapy. (E) those250 lb (114 kg) were instructed to follow a 2,000 kcal/day diet (55 g fat). On average, 50% of the lifestyle group achieved the goal of 7% weight reduction and 74% maintained at least 150 min/week of moderately intense activity (8). In the Finnish Diabetes Prevention Study, weight loss averaged 9.2 lb at 1 year, 7.7 lb after 2 years, and 4.6 lb after 5 years (9); �moderate exercise,� such as brisk walking, for 30 min/day was suggested. In the Finnish study, there was a direct relationship between adherence with the lifestyle intervention and the reduced incidence of diabetes. those250 lb (114 kg) were instructed to follow a 2,000 kcal/day diet (55 g fat). On average, 50% of the lifestyle group achieved the goal of 7% weight reduction and 74% maintained at least 150 min/week of moderately intense activity (8). In the Finnish Diabetes Prevention Study, weight loss averaged 9.2 lb at 1 year, 7.7 lb after 2 years, and 4.6 lb after 5 years (9); �moderate exercise,� such as brisk walking, for 30 min/day was suggested. In the Finnish study, there was a direct relationship between adherence with the lifestyle intervention and the reduced incidence of diabetes.

10. Case One 47 y.o. HF with DM type 2 X 13 years Admitted for Pyelonephritis HbA1c 9.4% & admission BG 370 Home regimen metformin 500 mg bid Placed on glargine/glulisine doses increased throughout stay Uninsured, admitted from a sliding fee scale clinic where she will continue care She recently changed physicians because she felt the other clinic wasn�t addressing her diabetes

11. Case one inpatient blood sugars The patient was placed on glargine and glulisine per our institutional protocol and had her doses titrated daily so that at discharge, she was on 64 units of glargine qhs and 20 units glulise with meals. Her renal function remained normal The patient was placed on glargine and glulisine per our institutional protocol and had her doses titrated daily so that at discharge, she was on 64 units of glargine qhs and 20 units glulise with meals. Her renal function remained normal

12. What would your regimen be at discharge? Glargine + rapid acting analog tid + metformin Metformin 1000 mg bid+ glipizide + NPH qhs Metformin 1000 mg bid + glipizide Metformin 1000 mg bid Glargine alone at bedtime

13. DO SOMETHING! Clinical inertia is rampant and has a huge impact on diabetes care-delayed diagnosis. It was very intimidating to the residents, hospital physicians and myself to determine what would be the best next steps for patient�s outpatient regimen. Unfortunately, this lack of knowledge frequently led to patients being discharged on their same ineffective home regimen. Again, some patients are going to be extremely complex and some factors will need to be considered. However, this is a great time with resource for education, CM and frequent accuchecks to quickly make a difference. Clinical inertia is rampant and has a huge impact on diabetes care-delayed diagnosis. It was very intimidating to the residents, hospital physicians and myself to determine what would be the best next steps for patient�s outpatient regimen. Unfortunately, this lack of knowledge frequently led to patients being discharged on their same ineffective home regimen. Again, some patients are going to be extremely complex and some factors will need to be considered. However, this is a great time with resource for education, CM and frequent accuchecks to quickly make a difference.

14. Control at home and admission HbA1C Home regimen prior to admission Admission reason: Hypoglycemia, Acute MI, Related to hyperglycemia (DKA, HHS, etc.) Physical limitations New co-morbidities that may limit prior oral therapy Hypoglycemia risk factors Treatment goals (I.e. hospice) Frequency of self monitoring Financial $$$$ Factors Used for Selecting Discharge Therapy for Patients with Known Diabetes It is really easy�One only needs to considerIt is really easy�One only needs to consider

15. Costs of Oral Therapy: Walmart Note that the dose of rosiglitazone is often 8 mg per day. Note that the dose of rosiglitazone is often 8 mg per day.

16. Costs of Insulin (WalMart)

17. Shopping List for Insulin Therapy Blood Glucose meter Testing strips (1-4 per day) Insulin syringes Glucagon kit Scripts for insulin Sharps container

18. Expected decrease in HbA1c Comparison of Basal insulin added to oral agents versus twice daily premixed insulin as initial insulin therapy for type 2 diabetes Janka, Plewe, Riddle (Diabetes Care vol 28, 2, Feb 2005. (70/30 vs OAD + glargine= LAPTOP INITIATE is Novolog 70/30 bid study Treat to target Glargine vs NPH qhs + OADs 4T biphasic, prandial vs basal (detimir) Not as aggressive titration Comparison of Basal insulin added to oral agents versus twice daily premixed insulin as initial insulin therapy for type 2 diabetes Janka, Plewe, Riddle (Diabetes Care vol 28, 2, Feb 2005. (70/30 vs OAD + glargine= LAPTOP INITIATE is Novolog 70/30 bid study Treat to target Glargine vs NPH qhs + OADs 4T biphasic, prandial vs basal (detimir) Not as aggressive titration

19. Adjusting home regimen You will see that exenitide is not on here but clearly has a potential role in those one one (metformin, SU, TZD) or 2 drugs (metformin and TZD) but not reaching control. The advantage seems to be in the weight loss so as clinicians become more familiar with this therapy, we will be seeing it more as an option at step two or three. Home therapy working means an A1C of <7%. Since 2004, the ADA standards of Medical care has the �action threshold� as 7% which corresponds to a BS of 170 mg/dL. There may be some consideration of an action target for hospitalized patients being a little higher but this is arbitrary Please notice that anytime that insulin is used, it is ADDED to oral therapy. The exception is that once you get to step 4 with intensive insulin (I.e. basal/bolus, then SU should be stopped). Some people have suggesting checking an c peptide level to help you determine if the SU are going to work/ are working but this is not widely recommended. As glycemic control approaches normal <7%, more of the excursions are explained by postprandial hyperglycemia. You will see that exenitide is not on here but clearly has a potential role in those one one (metformin, SU, TZD) or 2 drugs (metformin and TZD) but not reaching control. The advantage seems to be in the weight loss so as clinicians become more familiar with this therapy, we will be seeing it more as an option at step two or three. Home therapy working means an A1C of <7%. Since 2004, the ADA standards of Medical care has the �action threshold� as 7% which corresponds to a BS of 170 mg/dL. There may be some consideration of an action target for hospitalized patients being a little higher but this is arbitrary Please notice that anytime that insulin is used, it is ADDED to oral therapy. The exception is that once you get to step 4 with intensive insulin (I.e. basal/bolus, then SU should be stopped). Some people have suggesting checking an c peptide level to help you determine if the SU are going to work/ are working but this is not widely recommended. As glycemic control approaches normal <7%, more of the excursions are explained by postprandial hyperglycemia.

20. Adjusting home regimen using HbA1c You will see that exenitide is not on here but clearly has a potential role in those one one (metformin, SU, TZD) or 2 drugs (metformin and TZD) but not reaching control. The advantage seems to be in the weight loss so as clinicians become more familiar with this therapy, we will be seeing it more as an option at step two or three. Home therapy working means an A1C of <7%. Since 2004, the ADA standards of Medical care has the �action threshold� as 7% which corresponds to a BS of 170 mg/dL. There may be some consideration of an action target for hospitalized patients being a little higher but this is arbitrary Please notice that anytime that insulin is used, it is ADDED to oral therapy. The exception is that once you get to step 4 with intensive insulin (I.e. basal/bolus, then SU should be stopped). Some people have suggesting checking an c peptide level to help you determine if the SU are going to work/ are working but this is not widely recommended. As glycemic control approaches normal <7%, more of the excursions are explained by postprandial hyperglycemia. You will see that exenitide is not on here but clearly has a potential role in those one one (metformin, SU, TZD) or 2 drugs (metformin and TZD) but not reaching control. The advantage seems to be in the weight loss so as clinicians become more familiar with this therapy, we will be seeing it more as an option at step two or three. Home therapy working means an A1C of <7%. Since 2004, the ADA standards of Medical care has the �action threshold� as 7% which corresponds to a BS of 170 mg/dL. There may be some consideration of an action target for hospitalized patients being a little higher but this is arbitrary Please notice that anytime that insulin is used, it is ADDED to oral therapy. The exception is that once you get to step 4 with intensive insulin (I.e. basal/bolus, then SU should be stopped). Some people have suggesting checking an c peptide level to help you determine if the SU are going to work/ are working but this is not widely recommended. As glycemic control approaches normal <7%, more of the excursions are explained by postprandial hyperglycemia.

21. Initiating Insulin Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL If FBS Is 80-100mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Compared with bedtime NPH insulin, insulin glargine is associated with less nocturnal hypoglycemia in patients with type 2 diabetes (28.8% vs. 12.6%, respectively; P�= 0.011) (18, 19). If nocturnal hypoglycemia occurs after evening or bedtime administration of insulin glargine, the timing of the injection should be changed to the morning. Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL If FBS Is 80-100mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Compared with bedtime NPH insulin, insulin glargine is associated with less nocturnal hypoglycemia in patients with type 2 diabetes (28.8% vs. 12.6%, respectively; P�= 0.011) (18, 19). If nocturnal hypoglycemia occurs after evening or bedtime administration of insulin glargine, the timing of the injection should be changed to the morning.

22. So, you are ready to go� How to stop one therapy and start another

23. Caution: Possible Hypoglycemia Ahead Elderly patients with recent hospital discharge are at high risk of developing serious hypoglycemia Using > 5 medications and being the �oldest-old� were also risk factors Glyburide is more likely to cause hypoglycemia than glipizide Shorr, et al: Incidence and risk factors for serious hypoglycmeia in older persons using insulin or sulfonylureas. Arch Intern Med 157: 1681-1686, 1997- The strongest predictor of serious hypoglycemia (<50, with sx and needing to come to the ER or hospital for care in Medicaid patients >65 on SU and/or insulin) was hospitalization within the last 30 days. Other predictors were oldest-old, using >5 medications. Several reasons speculated by the authors=metabolic changes associated with acute illness, hospitalization itself is a marker of underlying frailty, and that monitoring is decreased after d/c. I noticed that there was a large degree of renal insufficiency, it was mostly older 1st generation or early 2nd generation SU Shorr, et al: Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriat Soc 44: 751-755, 1996 Glyburide was the highest (16.6/1000 person years), lowest with tolbutamide Shorr, et al: Incidence and risk factors for serious hypoglycmeia in older persons using insulin or sulfonylureas. Arch Intern Med 157: 1681-1686, 1997- The strongest predictor of serious hypoglycemia (<50, with sx and needing to come to the ER or hospital for care in Medicaid patients >65 on SU and/or insulin) was hospitalization within the last 30 days. Other predictors were oldest-old, using >5 medications. Several reasons speculated by the authors=metabolic changes associated with acute illness, hospitalization itself is a marker of underlying frailty, and that monitoring is decreased after d/c. I noticed that there was a large degree of renal insufficiency, it was mostly older 1st generation or early 2nd generation SU Shorr, et al: Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriat Soc 44: 751-755, 1996 Glyburide was the highest (16.6/1000 person years), lowest with tolbutamide

24. Take Home Messages: Selecting Discharge Therapy Once A1C is >8.5% additional oral agents are unlikely to achieve goals Insulin at bedtime with or without oral agents is a good initial strategy The hospital may be a great place to get started on insulin Cost is heavily dependent on testing frequency Patients with new hyperglycemia need close follow up

25. Inpatient Diabetes Self Management Education Juli Adelman RD, CDE

26. Inpatient CDE � topics overview Educational strategies for the discharging patient Appropriate diabetes education and sample materials Documentation of education and coordination of follow up care Case Study

27. Recommended educational strategies for the discharging patient Initiate Inpatient Diabetes Educator consult as early as possible Education should begin as soon as the patient is appropriate for education based upon patient needs Involve family members in the education if appropriate Ideal for patient to practice new skills early BG monitoring Drawing up administering insulin

28. Education Barriers in the Hospital Illness and fatigue Stress and fear Pain Interruptions Drowsiness from medications Vision impairment Language Lack of important family members present

29. Recommended educational strategies for the discharging patient Nursing to reinforce the education as many times as possible utilizing every opportunity: Medications BG results Consistent Carbohydrate diet Insulin administration

30. Recommended educational strategies for the discharging patient Provide education materials to reinforce the teachings and provide community and web resource lists Continue the education on an Outpatient basis if needed by referring through the appropriate channel

31. Survival Skills Education Blood Glucose Monitoring Provide glucometer if possible Target goals When to notify physician Logbook Prescription for meter, strips, lancets, sharps container

32. Survival Skills Education Medication Use and Safety Drawing up and injecting insulin Hypoglycemia and other side effects Sharps disposal Hypoglycemia � causes, symptoms, treatment Basic Diabetic Diet Information Sick days- especially for patients admitted in DKA Other personalized diabetes concerns- wound healing, exercise, pregnancy, ketone testing, etc. Follow up diabetes education, and follow up with PCP!!!

33. Resources Used at SWMC

34. Resources Used at SWMC

35. Resources Used at SWMC

36. Resources Used at SWMC

37. Resources Used at SWMC

38. Resources Used at SWMC

40. Case Study � Mr. Green 47 year old male with no previous DM history admitted with cellulitis. Admit BG 430 He has been in the hospital 4 days Hospital regimen: Lantus 30 units HS Aspart 10 units with meals CBGs 80-130

41. Case Study continued- Mr. Green Patient to d/c home now Discharge orders include: Self administration of insulin education glucometer education (which he does not yet know how to use) No diabetic education has been requested on this patient up to this point

42. How many potential opportunities has Mr. Green had to self administer insulin? 0-5 5-10 10-20

43. What would you teach Mr. Green? Teach only what is ordered: BG monitoring, insulin adminstration. Expand on the orders: BG monitoring, insulin administration AND cover hypoglycemia, when to call MD, basic diabetic diet, and refer for F/U with CDE. Go even further: BG monitoring, insulin administration, hypoglycemia, exercise, carbohydrate counting, sharps disposal, sick day education, pathophysiology of DM, when to call MD, ketone testing, and refer for F/U with CDE.

44. Take Home Messages: Inpatient DSME Educate patient for a safe discharge home. Provide education as early as possible in the hospitalization. Recognize barriers to education. Do not overwhelm the patient. Give them the basics, support them with minimal written information and provide appropriate follow up diabetes education.

45. Discharge Considerations for Follow Up with Primary Care Physician Jacqueline Thompson RN, MAS, CDE

46. Sunil Kripalani, M.D., M.Sc., of the Emory University School of Medicine, Atlanta Sunil Kripalani, M.D., M.Sc., of the Emory University School of Medicine, Atlanta

47. Deficits in communication to Primary Care Physician Direct communication between hospital physicians and primary care physicians occurred infrequently. Only 3 percent of primary care physicians reported being involved in discussions about discharge Lack of timely important information ~ availability of a discharge summary at the first post discharge visit

48. Timely Information Required For Successful Discharge Diagnostic findings Treatment or hospital course Discharge medications Patient or family counseling Tests pending at discharge Arrangements for post discharge follow-up

49. Communication and discharge planning Can the patient prepare his or her own meals?  Can the patient perform self-monitoring of blood glucose at the prescribed frequency?  Can the patient take his or her diabetes medications or insulin accurately?  Is there a family member who can assist with tasks that the patient cannot perform?  Is a visiting nurse needed to facilitate transition to the home?

50. Physical Limitations � Blindness, Stroke, Amputation Can the patient : Test their own blood sugar Prepare and administer insulin if needed Prepare their own meals Does the Patient: Have Family members to assist Require Home Care/ Long-term Care Assistance Referral to Outpatient DSME program

51. Effective discharge planning for continual care by pt's PCP Reconciliation of medications - If new to insulin, regime discussed with patient prior to discharge. Insulin Instruction Sheet given to patient to take home DME supplies � meter, syringes, lancet, needles etc. Follow-up care with PCP within 15-30 days, or if new to insulin within 7-14 days Referral for OP diabetes Self management If appropriate

52. Diabetes Discharge Prescription

53. Inpatient Subcutaneous Insulin Order Set

54. Insulin Take Home Instructions ~ Mild/Moderate

55. Insulin Take Home Instructions ~ Aggressive/Custom

56. Diabetes General Home Care Instructions

57. Costs of Meter/ Strips (WalMart)

58. Improving Patient and Primary Care Safety with D/C Information Computer-generated discharge summaries Use of standardized formats to highlight the most pertinent information Using patients as couriers

59. Community Resources Partnership for Prescription Assistance www.pparx.org Rx for Californians � www.rxhelpforca.org Wal-Mart Reli on meter ($8), strips $40 for 100 count Active test strips at Target $28.00/50 strips. National Hotline

60. Take Home Messages: Inpatient DSME Educate patient for a safe discharge home. Provide education as early as possible in the hospitalization. Recognize barriers to education. Do not overwhelm the patient. Give them the basics, support them with minimal written information and provide appropriate follow up diabetes education.

61. Questions or Contact Us Juli Adelman RD, CDE Jadelman@swmedctr.com Cheryl O�Malley, MD Cheryl.O�Malley@bannerhealth.com Jacqueline Thompson RN,MAS,CDE Jacqueline.thompson@sharp.com