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Current Practices and Experiences of Tight Glycemic Control in Hospital Settings

Current Practices and Experiences of Tight Glycemic Control in Hospital Settings. Irl B. Hirsch, M.D. University of Washington Seattle, WA. What We Are Really Addressing. Current practices of INSULIN Use in the Hospital. Please keep in mind

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Current Practices and Experiences of Tight Glycemic Control in Hospital Settings

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  1. Current Practices and Experiences of Tight Glycemic Control in Hospital Settings Irl B. Hirsch, M.D. University of Washington Seattle, WA

  2. What We Are Really Addressing Current practices of INSULIN Use in the Hospital • Please keep in mind • Little interest in this topic until the publication of Van den Berghe’s NEJM SICU study in 2001 • Little teaching about insulin use for both inpatients AND outpatients due to lack of consensus prior to the insulin analogue era • Minimal randomized studies addressing best practices for insulin use, particularly in non-research settings where systems are not ideal for insulin management

  3. With That In Mind, How Do We Do? “Organized Chaos”

  4. How Do We Do? • N=2916 patients with known diabetes or diagnosed hyperglycemia during a 3-year review at a tertiary care hospital • Age = 69 years, LOS = 5.7 days J Hosp Med 2007;2:203-211

  5. How Do We Do? In first 24 hours, 25% of patients had mean glucose > 200 mg/dL For entire hospitalization, 20% with sustained mean hyperglycemia > 200 mg/dL In 24 hrs before discharge, 21% with mean sustained hyperglycemia > 200 mg/dL with some with average > 300 mg/dL J Hosp Med 2007;2:203-211

  6. How Do We Do? • Hypoglycemia < 60 mg/dL: < 1% of bedside measurements • < 40 mg/dL: < 0.2% of bedside measurements J Hosp Med 2007;2:203-211

  7. How Do “We” Do? • 37 academic med centers in 2004 • N=1700 eligible adults with 79% with known Dx of DM (51% on outpt insulin Rx) • ICU target in 2004 was < 110 mg/dL J Hosp Med 2009;4:35-44

  8. How Do We Do? • First 3 days of glycemia assessed • On day 1, 23% were ICU patients • By day 3, 14% were ICU patients J Hosp Med 2009;4:35-44

  9. ICU GLYCEMIC CONTROL “Target” is < 110 mg/dL % within target J Hosp Med 2009;4:35-44

  10. HYPERGLYCEMIA (> 180 mg/dL) % ICU Patients Hyperglycemic * * * * p<0.001 J Hosp Med 2009;4:35-44

  11. HYPERGLYCEMIA (> 180 mg/dL) % Non-ICU Patients Hyperglycemic p=0.015 * J Hosp Med 2009;4:35-44

  12. Other Measures • Severe hypoglycemia (< 50 mg/dL) only 2.8% of all patient days • A1C assessment for diabetic patients (or < 30 days prior to admission): 34% • Glucose measurement within 8 hours of admission: 77% • Recommended physiologic insulin therapy (or IV insulin for NPO patients): 45% (range 12-77%) J Hosp Med 2009;4:35-44

  13. Summary of These Data • Persistent hyperglycemia with rare hypoglycemia in this large population • IV insulin underutilized (< half of ICU patients) and associated with improved control • Wide variation in hospital performance of recommended diabetes care measures

  14. At Least We Don’t Order “Sliding Scale” Insulin in the Hospital Any Longer…Right?

  15. Wrong • Review of insulin management in large Boston teaching hospital • 43% basal insulin ordered • 4% scheduled mealtime insulin • 90% sliding scale insulin • 47% with basal insulin, 39% oral agents, 23% no other therapy • Sliding scale alone associated 20 mg/dL more hyperglycemia J Hosp Med 2006;1:145-150

  16. Reviewing the Literature: What is Clear • Prior to NICE-SUGAR, the problem was not hypoglycemia, but non-aggressive treatment of hyperglycemia (recommended targets have made for great academic debates, but do not represent real-world experience) • The problem has never been we’ve been over-aggressive with our insulin protocols, but rather as a medical community we’ve been nonchalant with treating the severe hyperglycemia that is pervasive in our hospitals

  17. Reviewing the Literature • Despite the fact we’ve used insulin for almost 90 years, we don’t use it intelligently in the hospital

  18. Is It Even Possible To Improve Glucose Control in the Hospital? • There are many possible strategies to have a successful glycemic management program • Numerous IV and SC protocols have been published with reasonable to good levels of success • There is no “right way” or “wrong way” to use insulin in the hospital if the protocol is efficacious and safe • Example: inpatient insulin use at UWMC

  19. Keys To Success • Agreement between all clinicians and stake-holders to glycemic targets and general philosophies of insulin use • Education with staff, communication between staff, examination for staff for continued improvement • A “champion” for each specialty to address questions and concerns • An appropriate culture to prioritize and standardize glycemic control

  20. The Culture of Inpatient Diabetes Management At The U of WA UW Medical Center Surgeon Parking

  21. UWMC: Our Story • 1992: initiation of IV insulin protocols throughout the hospital due to several “near-misses” with use of SC insulin • Consider • Before any controversy of TGC in the hospital • Before the introduction of insulin analogues • This more than anything else changed our culture of insulin Rx in the hospital

  22. More History • 2001-2002 • Since over six IV protocols and NO SC protocols, decided to standardize all insulin orders • Van den Berghe SICU targets from 2001 seemed too ambitious for us, especially in non-ICU areas • Target: 100-180 mg/dL with implementation of IV 2002-2003, SC 2003-2004

  23. What We Did and What We Learned • Our new IV protocol had to take into account RATE OF CHANGE of blood glucose, particularly to reduce hypoglycemia

  24. Suppose a patient had a glucose of 180 1 hour later the glucose is 110? The rapid glucose reduction (> 60 mg/dl/h) suggests a more conservative column is required

  25. How Well Did We Do? • N= 105 subjects (8% type 1) admitted to hospital, all mostly NPO, both medical and surgical • 50 subjects on new column-type protocol, 55 on standard protocol • Populations identical Ku SY, et al. Jt Comm J Qual Safety March, 2005

  26. % Time Hyperglycemic 56  2.3* 33  2.6* 18  2.4 15  2.3 *p<0.001 Ku SY, et al. Jt Comm J Qual Safety March, 2005

  27. % Time BG<60 mg/dL. Normalized for Duration of Time on IV Insulin Drip Ku SY, et al. Jt Comm J Qual Safety March, 2005

  28. What About SC Insulin • Much more difficult problem, especially outside of the ICU setting • Little data in terms of efficacy, safety, or outcome • Philosophies of insulin therapy disparate, even amongst “experts” • What allowed us to standardize our approach and thinking BASAL INSULIN ANALOGUES

  29. 2004 UWMC Subcutaneous Insulin Order Form ac & hs q6h if NPO BG Monitoring: __ hrs pc 2–3 am X Goal Range Premeal BG = 80-130mg/dl or Goal Range Bedtime BG = 90-150 mg/dl or

  30. Correction Dose Insulin for Premeal Hyperglycemia: 2004 Algorithms for Hyperglycemia: Lispro (Humalog®) Aspart (NovoLog®) Low-Dose Algorithm (For pts requiring < 40 units of insulin/day) Medium-Dose Algorithm (For pts requiring 40–80 units of insulin/day)

  31. Correction Dose Insulin for Premeal Hyperglycemia: 2004 Algorithms for Hyperglycemia (Continued): Lispro (Humalog®) Aspart (NovoLog®) High-Dose Algorithms (For pts requiring > 80 units of insulin/day) Individualized Algorithms

  32. Strengths Effective/safe control Standardized protocols ensure best practices for all Teaches all involved in patient care how to THINK about insulin therapy Weaknesses Difficult to keep on-going teaching/momentum about TGC once Diabetes Clinic moved off-site Not particularly effective with high-dose IV steroids 3 teaching hospitals at UW: 3 cultures, 3 messages to residents/students As good as computerized algorithm? Strengths and Weaknesses of UWMC’s Insulin Protocol 2003-2009

  33. Results: Computer vs Standard (Glucommander) vs (Column) % of Glucoses Maintained within Target Achieved Glucommander= 68.7% Standard = 47.5%* Diabetes 57 (Suppl. 1) 136A, 2008 Mean glucose maintained once at goal: 117±17vs103±9 mg/dL* Time to achieve a glucose 80-120mg/dL: 8.4±9vs4.9±3hours† * p < 0.0001 † p < 0.05

  34. Hypoglycemia & Hyperglycemia After Target Achieved (patients) p = NS p = 0.02 p = NS Newton CA et al. Diabetes 57 (Suppl. 1) 136A, 2008.

  35. My Take • UWMC is unique-we had a 10 year “head start” all because of several “near misses” • Our small successes need to be tempered by the realities of the need to educate a constant turn-over of physicians and nurses • What we do not necessarily do well • High-dose steroids in patients eating on the floor • Transition off of IV insulin • Discharge patients new-to-insulin into the community

  36. More of My Take • Computerized algorithms should do better than paper algorithms in most settings. The key is the frequency of glucose testing and knowledge of the nurse operating the insulin drip

  37. What We Are Doing Now • 2009-changed IV protocol so that all 3 teaching hospitals use the same algorithms • Standardizes patient care • Standardizes philosophy and culture of insulin use (esp. with residents) • ICU targets: 100-140 or 100-180 (physician checks which one on the protocol) • Non-ICU targets: 100-180 • Separate OR and high-dose protocols

  38. Summary: Current Practices of TGC in the Hospital • Despite the concerns about hypoglycemia, the real problem in the hospital remains untreated hyperglycemia both in the ICU and on the floors • Despite controversy about actual targets, the real enemy is lack of attention to glycemia in general and intimidation of insulin use due to lack of training and new concerns about hypoglycemia

  39. THANK YOU!

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