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Inpatient Management of Diabetes

Inpatient Management of Diabetes. James T. Lane, MD Associate Professor Department of Internal Medicine UNMC. Hospital Treatment of Diabetes. 2001- Van den Berghe et al. publishes first article on hyperglycemia as marker of in-hospital mortality

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Inpatient Management of Diabetes

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  1. Inpatient Management of Diabetes James T. Lane, MD Associate Professor Department of Internal Medicine UNMC

  2. Hospital Treatment of Diabetes • 2001- Van den Berghe et al. publishes first article on hyperglycemia as marker of in-hospital mortality • 2004- Observational evidence led to a call for recommendations for treatment of inpatient diabetes • 2005- Hyperglycemia treatment in annual ADA clinical guidelines • Tight glycemic control in critical care units • General medicine/surgery patients similar to OP • 2006 • General call to action to treat diabetes in light of systemic barriers to treatment in hospitalized setting • Van den Berghe publishes on intensive insulin therapy in the medical ICU

  3. Timeline - Continued • 2009- NICE-SUGAR study is published; suggests increased mortality with intensive therapy • 2009- Joint consensus statement by American Diabetes Association and American Association of Clinical Endocrinologists related to inpatient glycemic control

  4. Published Data • Observational studies • Patients receiving cardiothoracic surgical procedures had 2-fold increase in surgical wound infections with hyperglycemia (Golden et al., 1999) • Intervention studies with insulin decreased cardiac mortality and surgical wound infections (Sala et al., 2002 and Zerr et al., 1997)

  5. Randomized, Controlled Trials • First Van den Berghe study implemented intensive insulin therapy in a surgical ICU population with a significant decrease in morbidity and mortality • Second Van den Berghe study used identical protocol in a medical ICU patient population resulted in decreased morbidity but not mortality, at the expense of 6-fold increase in hypoglycemia. Hypoglycemia was also identified as a risk factor for mortality

  6. Randomized, Controlled Trials, Continued • Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) study demonstrated no decrease in mortality and higher rates of severe hypoglycemia with intensive insulin treatment in patients with sepsis • Hypoglycemia again identified as independent risk factor for mortality • Similar results from De La Rossa et al., 2008, in mixed med/surg ICU population

  7. Meta- Analyses of RCTs • Wiener et al, 2008, reported on 8,432 patients • Intensive (80 - 110 mg/dl) • Less intensive (150 - 220 mg/dl) • No difference in mortality, 5-fold increase in hypoglycemia, and decrease in septicemia • Griesdale et al., 2009, reported on 13,567 patients • Decreased mortality only in surgical ICU patients • Hypoglycemia 6-fold higher in intensively treated

  8. Glycemic Targets in Hospitalized Patients • NICE-SUGAR, a multicenter, randomized, controlled trial demonstrated 90-day mortality rates in patients with tight glucose control (81-108 mg/dl), compared to those with less tight control (144-180 mg/dl) • 90-day mortality 27.5 vs 24.9% (p = 0.02) • No difference in 30-day mortality • More cardiovascular death in tight control group • More hypoglycemia: 6.6 vs 0.5% (p < 0.001) • NICE-SUGAR in contrast to previous single-center study with improved mortality in tight glucose control group

  9. Summary • Randomized, controlled trials of severely ill patients using intensive insulin treatment to tight glucose control targets resulted in: • More hypoglycemia • Recognition of hypoglycemia as a predictor of mortality • Greater mortality in the largest multicenter study • Only variable improvement in morbidity and questionable benefit in mortality, with surgical patients possibly benefiting more than medical patients

  10. Where Did NICE-SUGAR Leave Us? • What glucose targets do we use? • What treatments do we use to get there? • What do we tell our colleagues?

  11. Glycemic Goals in the Hospital • ICU and critically ill patients: 140-180 mg/dl • Non-critically ill patients on insulin: < 140 mg/dl before meals, but > 70 mg/dl, and random glucose < 180 mg/dl • Basal/bolus insulin recommended • No persistent “sliding scale insulin” as primary insulin regimen • Consider insulin therapy for persistent glucose > 180 mg/dl

  12. Treatment Options • Intravenous insulin infusion • Most centers used one of several algorithms • Requires frequent glucose monitoring • Requires engaged nursing staff • Transition to subcutaneous insulin • Subcutaneous insulin administration • Basal and bolus insulin • No “sliding scale insulin” • Correction or supplemental insulin is preferred • Non-insulin therapies • Not recommended for hospitalized patients

  13. Transition From IV to SubQ Insulin • Can use percentage of IV insulin over 24 hrs • Usually 80-90% of IV dose is used for total dose • Make sure IV insulin dose is increased for meals • Use 50-70% basal insulin and 50-30% bolus insulin • Use weight-based calculation for transition • 0.5 – 1.0 units per kg per day • Subcutaneous bolus insulin should be given prior to stopping IV insulin • Usually stop IV insulin 1-2 hours after subq insulin • Monitor hourly for 1-3 hours after transition • Try to transition around a meal • Try using NPH as basal insulin short-term

  14. The Nebraska Medical Center IV Insulin Protocol • Standard protocols make for greater familiarity • Allows for individualized treatment goals • Relies on making sure results are treated to goal

  15. The Nebraska Medical Center – Subcutaneous insulin order form • Single order form with goal of familiarity by staff and physicians and fewer medication errors • Place for bedside blood sugar testing • Basal and bolus insulin recommended • Prolonged “sliding scale” insulin discouraged • Supplemental insulin order also at bottom of form; used when patient does not meet treatment goals

  16. Notes on Supplemental Insulin • Use rapid-acting insulin • Pre-printed order sheets allow only three levels of supplemental insulin dosing • Orders allow for confirmation of glucose after supplemental insulin • Shy away from use at bedtime or other times when meals not administered to avoid lows • Supplemental level needs to be continuously evaluated for adequacy

  17. Special Populations of Patients • Patients receiving parenteral nutrition • Bias against “insulin in the bag” • Commonly use NPH every 8 hours when feedings given around the clock • Hyperglycemia common with high glucose concentration in feedings • Increases risk of sepsis • Hypoglycemia common when feedings stopped and basal insulin on board

  18. Special Populations • Enteral nutrition concerns similar to TPN • Patients receiving glucocorticoid therapy • Increase insulin resistance • Requires increase in insulin dosing • Insulin to be cut back during steroid taper • Insulin Pump Therapy

  19. Prevention of Hypoglycemia • Hospitalized patients on sulfonylureas commonly require decrease in dose • Metformin commonly stopped for hospitalization and new therapy added • NPH status • Change in clinical status • Prolonged use of “sliding scale” insulin • Poor coordination between glucose testing and meals • Poor communication during patient transfers • Errors in order writing and order perception

  20. Treatment of Hypoglycemia • When an emergent situation is noted, obtain a fingerstick blood glucose immediately • If fingerstick glucose not available, begin treatment while waiting for the test to be done. • Do not wait for lab serum glucose to confirm hypoglycemia • Treatment based on patient’s level of consciousness • Conscious patient with no risk of aspiration • If glucose 50-70 mg/dl • 6 oz juice • 6 oz regular soda • One tube glucose gel • If glucose below 50 mg/dl • 8 oz juice • 12 oz regular soda • Two tubes glucose gel

  21. Hypoglycemia Procedure-Con’t • Unconscious patients, at risk for aspiration • 50 ml 50% dextrose IV over 5 minutes • Stay with patient until you see patient responding • If there is no IV access • Glucagon 1 ml (1 mg/ml) intramuscularly or subcutaneously • Stay with patient until you see them respond • Note: glucagon can cause nausea and vomiting • Notify physician to inform of clinical situation and for further orders or to continue to follow protocol

  22. Hypoglycemia Protocol- Follow-up • Conscious patient, no risk of aspiration • Repeat blood glucose test in 15-30 minutes to evaluate treatment • If blood glucose greater than 70 mg/dl on repeat, no further treatment. Repeat treatment if < 70 mg/dl • Provide the patient with a meal/snack within 1 hour of last carbohydrate treatment • Unconscious patients, at risk for aspiration • Repeat blood glucose test in 15-30 minutes • If glucose less than 70 mg, repeat treatment • Once patient stabilized, notify physician regarding response to treatment, receive further orders/ monitoring parameters

  23. Journey to Excellence – 2004-2005 • Standardized Subcutaneous and Insulin Order Set • After study of insulin errors in the hospital • Part of a Six Sigma project headed by CMO • Established Organization Blood Glucose Goal for non-critical patients 70-180mg/dl; critical patients 70-110mg/dl • Participated in UHC Glycemic Control Benchmarking Project

  24. Journey to Excellence 2006 Accomplishments • Organizational Policy for Detecting Hyperglycemia on Admission • Expanded Diabetes Education content to all licensed nursing staff emphasizing • Standards of Care for inpatients with diagnosis of diabetes • Diabetes Survival Skills • Discharge Planning • Nurse-initiated diabetes education consult capability • Established dedicated Inpatient CDE Coordinator and staff

  25. Journey to Excellence 2007 Accomplishments • Developed Diabetes Clinical Quality Coordinator Position • Organizational representative for diabetes and/or glycemic control quality improvement (QI) • Champions and gains commitment for QI • Develop, implement and maintain glucose metrics • Organize and facilitate multidisciplinary Glucose Management Team (GMT)

  26. Hospital Quality Committee Physician Quality Committee Glucose Management Team, GMT Purpose: To provide excellent, safe glycemic care for all inpatients of The Nebraska Medical Center. Glucose Management Team Summary GMT Membership Internal Med Hospitalist Family Med Endocrine Pedi - Endocrine Surgery Critical Care Emergency Nurses – Manager, clinical specialists, CDE, quality, staff RN Dietitian – CDE Pharmacy Case Management Laboratory Additional resources as needed. Pediatric Quality Committee Nursing Quality Council

  27. Journey to Excellence 2008 Accomplishments • Glucose Metrics developed • % organizational compliance of blood glucose between 70-180mg/dl) – organization / unit and provider • Incidence of Hypoglycemia • ALOS diabetes vs. non-diabetes patients • Diabetes documented on admission • Other metrics • Daily Glucose Report – Patient and Unit Specific • Rate of Glucose Extremes (% >300mg/dl and < 40mg/dl)

  28. Journey to Excellence 2009/10 Accomplishments • Development and refinement of Diabetes Policies and Procedures • Glucose treatment goals in hospitalized patients reevaluated after NICE SUGAR Study • Inpatient Diabetes Education Consult Services structured as formal organizational process • Review and updated of Hypoglycemia Policies for Adults and Pediatrics • Hypoglycemia Audit Process initiated • Diabetes/Hyperglycemia Discharge Summary Sheet (medication reconciliation)

  29. Journey To Excellence 2009/10 Accomplishments • Transition of Subcutaneous Insulin Order Set to more comprehensive Inpatient Glucose Management Order Set • A1c for all patients admitted with diabetes • Hypoglycemia procedure on back for easy access • Development of Continuous Subcutaneous Insulin Infusion (CSII) policy and Order Set • All Glucose Management Order sets – mandatory usage

  30. Outcomes • Findings from Glycemic Control 2005 Benchmarking Project (UHC) • 69% of non-ICU blood glucose levels were greater than 180mg/dL. • 18% of blood glucose levels in all areas (ICU and non-ICU) were greater than 200mg/dL.

  31. Lower Is better

  32. Summary • Targets for inpatient glycemic control may change related to results of ongoing clinical investigation • Likely that hyperglycemia and hypoglycemia have negative clinical effects • Tools need to be in place to help with variety of issues related to patient treatment

  33. Areas of Future Research • Targets for glucose control need to be tested in randomized, controlled clinical trials • Treatment of hyperglycemia in patients without diabetes • Mechanisms for increased morbidity and mortality with hypoglycemia • Role of glucose variability • Role of glucose control in pediatric populations • What is the optimum hospital structure for the treatment of diabetes in the inpatient setting?

  34. Special Thanks • Steven Smith, MD, CMO The Nebraska Medical Center • Beth Pfeffer, RN, BSN, CDE, Director of Diabetes Services at The Nebraska Medical Center • The Nebraska Medical Center Glucose Management Team • Members of the Nebraska Medical Center Diabetes Center

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