Compile and organize patient-specific diabetes information with the help of a standardized format so that patterns and t

1. Advanced Inpatient Diabetes Program at Community Medical CenterObjectives of Learning: • Compile and organize patient-specific diabetes information with the help of a standardized format so that patterns and trends can be analyzed. • Recognize signs and symptoms of hypoglycemia and treat according to current ADA guidelines. • Calculate carbohydrate content of a meal and apply it to correct dosage administration of medication. • Classify various types of diabetes medications according to mechanism of action, identify medication side effects, and evaluate for appropriate application to individual patients. • Cite reasons and implications for withholding metformin-containing medications 48 hours post contrast administration.

2. Advanced Inpatient Diabetes Program at Community Medical Center Chapter 1: Diabetes Monitoring

3. Why Joint Commission Certification? • To improve compliance with national standards • Clinical practice guidelines are used to improve patient outcomes • Use performance measurement data to improve quality of care and patient satisfaction

4. What does Joint Commission require? • Multidisciplinary team to manage • Staff education • Coordination of meals and insulin • Nutritional assessments • Written protocols for managing insulin infusions, hypo and hyperglycemia treatment • Glucose monitoring protocols • Patient understanding of self management

5. Performance Measures • Percent of patients who receive accurate documentation of glucose, meals and insulin doses • Staff will receive mandatory education • Percent of patients who receive follow up of contrast administration when they use metformin • Percent of patients with A1c results within 60 days.

6. Diabetes management • Carbohydrate intake • glucose monitoring • Insulin dosing • Exercise

7. Teamwork • Patient • Dietitian • Monitor carbohydrate intake • Teach patients • Glucose draw • Nurse • Draw and monitor glucose • Dose insulin • Teach patients • Nurse Technician • If trained can do finger stick glucose • Provider • Monitor trends, change orders

8. 24 hour glucose pattern record

9. 24 hour glucose pattern record

10. Benefits • Fewer episodes of hypo/hyperglycemia • Time savings • More accurate management • Fewer complications • Shorter LOS • More patient satisfaction

13. Primary Care Provider Letter • Dear ________________________; • Your patient _____________________________ was recently admitted to Community Medical Center for _________________________________________. During that visit we noticed that he/she is having problems with blood glucose control. This is detailed on the attached screening form. • Our staff is recommending diabetes education for your patient as there is evidence of improved glucose control when people receive diabetes education. • If you would like him/her to participate, please complete the referral form included with this letter and fax to the Diabetes and Nutrition Center at 327-4790. We will contact the patient and make arrangements from there. • Thank you, • Date___________ Time__________ Nurse Signature__________________________________________ • Community Medical Center • Attachments: □ Referral Form □ Screening Form

14. Nursing Diabetes Screening at OutPatient Contact • Info obtained from: • □ Patient □ Family member(name)__________________________________________________ • □ Other(name)___________________________________________________________________________ • Admitting diagnosis ________________________________________________________________________________ • Which health care professional do you normally see about your diabetes? ___________________ • Present Diabetes Medications: See Medication Reconciliation form • How long have you had diabetes? ________________________________________________________________ • Are you monitoring your own blood glucose? □ Yes □ No • If no, do you have a monitor? □ Yes □ No • Type of monitor? ____________________ Frequency? ______________ Range? __________________ • Any diabetes related Emergency Department visits or admits in the past year? □ Yes □ No □ Unknown • Have you had an HgbA1C greater than 8% in the past year? □ Yes □ No □ Unknown • Do you have any of the following? • □ CAD □ HTN □ Foot problems □ Kidney problems □ Eye problems □ Unknown • LAB RESULTS (if available) • A1C___________/date_____ • Creatinine on admit_______/date________ • eGFR on admit______/date_____ •  Date ________ Time ________ Nurses Signature ______________________________________________________ • Assessment for Diabetes Care Needs as Identified by Patient • □ A1c frequently elevated >7% □ BG frequently <70 or >200 mg/dl • □ Questions about self care □ Education for home care giver • □ Questions about carb counts □ Will need to monitor BG, or other BG monitor problems • □ Medication changes from Admit to Discharge • □ Fax screening form, letter and referral form to Referring Provider _______________________ • Comments _____________________________________________________________________ • ______________________________________________________________________________Date ______Time ______ Nurse Signature ___________________________________________

15. Teaching Results: V= Verbalize Understanding DU= Demonstrates Understanding R= Needs Reinforcement *= Refused (more details in nurses notes) Fax both sides of this form to □PCP □ Diabetes Provider □ Outpatient Diabetes Education (#4728)

16. Living Well with Diabetes topics covered • Monitoring Blood Sugar • Taking Medication • Making Healthy Food Choices • Caring for Your Feet

17. Sick Day Management • Check your blood glucose every 4 hours during the day • To prevent dehydration • If you take a diabetes medication containing metformin • Always take your usual amount of long-acting insulin • If possible, follow your usual meal plan

19. PHYSICIAN ORDERS for Diabetes Patients • □ Dietitian Consult • □ A1c (if not done in past 60 days) • □ Creatinine/ eGFR, if not done in ED • □ Label insulin pen for home use after discharge • □ Referral to diabetes education, Ext. 4323 • Date _________ Time _________ • Physician Signature________________

20. Summary • Increase quality of diabetes care • Eliminate episodes of hypo/hyper-glycemia • Improve patient confidence with their self care • Improve patient satisfaction

21. Questions • If you have any questions about any of the information in this module, please speak with your staff developer, call the Diabetes Education nurse at X4323, or Linda Hightower at X4133.

22. Advanced Inpatient Diabetes Program at Community Medical Center Chapter 2: Carbohydrate Counting

23. Objectives • To increase knowledge of carbohydrate counting skills for those caring for patients with diabetes • Identify the relationship between carbohydrates and blood sugar • Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools • Calculate the total grams of carbohydrate per meal

24. Carbohydrate Counting Defined • A meal-planning approach for all patients with diabetes, based on the following ideas: • Carbohydrate is the main nutrient affecting postprandial glycemic response • Total amount of carbohydrates consumed is more important than the source of carbohydrates • CMC provides a Consistent Carbohydrate meal plan for diabetic management • The movement towards carbohydrate counting means the “ADA Diet” is no longer recognized. The correct diet order is “Consistent Carbohydrate”

25. Benefits of Carbohydrate Counting • More flexible than other meal-planning methods • Allowing a wider array of foods to choose from • All carbohydrate sources are allowed • Complex carbohydrates that break down slowly • Simple sugars that break down almost right away • Focuses attention on the foods that are most likely to make blood glucose levels go up • Provide for tighter control over blood glucose readings

26. Foods That Contain Carbohydrates • Breads, cereals, pasta, and grains • Rice, beans, and legumes • Starchy vegetables-potatoes, corn, and peas • Fruit and fruit juices • Milk, soy milk, and yogurt • Regular soda, fruit and sports drinks • Cakes, cookies, ice cream, candy, and jelly

27. Carbohydrate Servings • One serving of carb is measured as 15 grams • One carbohydrate serving is a food that contains approximately 15 grams of carbohydrate • All carbohydrates affect blood glucose in the same way. It is the amount of carb eaten that is important, not the type of carb. For example, one slice of bread, a small piece of fruit, or ½ cup corn each have around 15 grams of carbohydrate = =

28. Carbohydrates in Food Groups • FOOD GROUPS CONTAINING CARBOHYDRATES: • Starch: 1 serving equals about 15 grams carbohydrate • Fruit: 1 serving equals about 15 grams carbohydrate • Milk: 1 serving equals about 12 grams carbohydrate • Vegetables: 1 serving equals about 5 grams carbohydrate • Starchy Vegetables: 1 serving equals about 15 grams carbohydrate

29. Starches

30. Starch Group • Each amount listed below = 15 g carbohydrate • 1 slice of bread • ¾ c cereal • ½ c cooked cereal • ½ of an English muffin or small bagel • ⅓ c cooked pasta or rice • ½ hamburger or hotdog bun • ½ c mashed potatoes • ½ c corn, beans, chickpeas, peas • 1 small baked potato (3 oz)

31. Fruits and Fruit Juices

32. Fruit Group • Each amount listed below = 15 g carbohydrate • 1 small fresh fruit (4 oz) • ½ c canned fruit (in natural juice) • 2 T raisins or dried fruit • 17 grapes • ½ c fruit juice • 1 c melon or berries • ½ banana

33. Milk and Yogurt

34. Milk Group • Each amount listed below = approximately 12 g carbohydrate • 1 c skim, 1%, 2%, or whole milk • 3/4 c yogurt (6 oz) • 1 cup soy milk

35. Vegetables

36. Vegetable Group • Each amount listed below = 5 g carbohydrate • ½ c cooked vegetables • 1 c raw vegetables • ½ c vegetable juice • Remember - starchy vegetables (corn, peas, and potatoes) count as 15 g carbohydrate per serving

37. Free Foods • Free foods have 5 or fewer grams of carbohydrate • and fewer than 20 calories per serving. • They have no significant effect on blood glucose levels Unlimited Diet soft drinks, Club soda Sugar-free drinks Coffee Hot or iced tea (unsweetened) Sugar-free gelatin Seasonings Sugar substitutes Three or less servings per day Sugar-free jam or jelly, 2 tsp Ketchup, 1 T Mustard, 2 T Dill Pickle, 1 medium Sugar-free popsicle, 1 Salsa, ¼ cup Sugar-free syrup, 2 T

38. Low Carbohydrate Foods • Low carbohydrate foods differ from free foods in that they contain more calories per serving, and when eaten in large amounts can affect blood glucose levels. • For example: A serving of almonds (2 Tbsp) contains approximately 5 g carbohydrate, if you ate 2 servings (or 4 Tbsp) it would total 10 g carb! • Be mindful of serving sizes with low carb foods Examples of carbohydrate-free or low carbohydrate snacks: Cheese, 1 oz Cottage Cheese, ½ cup Tomato juice, ½ c Meats, 1 oz Nuts or seeds, 2 T Raw Vegetables, 1 c Hard boiled egg, 1 Beef jerky, 1 oz Peanut butter, 2 T

39. Tools for Carbohydrate Counting • Carbohydrate grams can be found using various sources: • CMC Menus • Food labels • Clinical diet manual • Dietitian or diet aide

40. Consistent Carbohydrate Menus CMC provides CONSISTENT CARBOHYDRATE menus for diabetes management • The patient’s carb goal is written on the menu, the goal is based on physician orders and/or dietitian recommendations Meal plans are based on individual needs and can range from 30 to over 90 g carb per meal, (the default meal plan is 60 g carb per meal) • The menus list the number of grams in each carbohydrate food item • Foods without carb grams listed contain either no carbohydrates or less than 5 grams per serving • At the end of a meal, total the grams of carb based on the patient’s intake

41. Food Labels • You will find the serving size and grams of carb per serving on food labels • Total Carbohydrates includes all starches, sugars, and dietary fiber • Always start by checking the serving size on the label, if more than 1 serving is eaten, you need to do the math! For example, if a patient ate 6 crackers, how many total grams did they actually eat? What is the serving size on the label: 2 crackers How many grams of Total Carb per serving: 10 g How many servings did they actually eat: 3 servings 3 servings x 10 grams per serving = 30 g carb

42. Clinical Diet Manual • The Clinical Diet Manual includes all diets provided at CMC and can be accessed in two ways: 1. The manuals are located on each unit, look for the large white binders, labeled “Clinical Diet Manual” 2. The manual is also available on CMC’s intranet • From the home page, click Departments, then click Nutrition, then Nutrition Manual • Scroll through to find “Diabetes -Consistent Carbohydrate Diet” • Food lists with carb grams are located on page 7-9

43. Carbohydrate-to-Insulin Ratios • The Carbohydrate-to-Insulin ratio (CHO : INSULIN) is the number of carbohydrate grams that 1 unit of insulin will cover For example, if a patient has a ratio of 15:1, it means that for every 15 grams of Carbohydrates he/she eats, 1 unit of insulin must be injected -- so that blood glucose readings are within normal range two hours later Based on the above ratio, if a patient eats 45 grams of carbohydrate, how many units of insulin do you need to give? 3 units

44. Carb Counting – Putting it all together • The goal is to include a variety of foods as long as the total carbs specified for each meal and snack stay about the same For a patient on a 45 gram per meal plan, here are two different breakfasts that each total around 45 grams carb: BREAKFAST #1 2 slices whole wheat toast 28 g 1 pkt Sugar-free jelly Scrambled Eggs ½ cup Orange Juice 15 g Coffee w/ sugar substitute ____ 43 g BREAKFAST #2 ¾ cup Bran cereal 25 g ½ cup Skim milk 6 g ½ Banana 14 g Coffee w/ sugar substitute ____ 46 g The goal is to come within a 10 gram range of the meal plan

45. Summary • Carb counting allows for improved blood glucose control • Carb counting is more flexible and allows for a greater variety of food choices • Being consistent is the key to successful carb counting • Carb counting increases the quality of diabetes care For further information contact a clinical dietitian

46. Advanced Inpatient Diabetes Program at Community Medical Center Chapter 3: A1C and eGFR

47. Hemoglobin A1c • A1C is a lab test used to assess a patient’s average blood glucose level • The test measures the amount of glucose adherent to the hemoglobin protein in the patient’s red blood cells (RBCs). Since the average lifetime of RBCs is 3 months, A1C reflects the patient’s average blood glucose level during that time period. Conditions which affect RBCs such as profound anemia, recent transfusion, hemoglobinopathies & pregnancy may result in inaccurate results • An A1C below 7% is the target goal to reduce complications from chronically elevated blood glucose • There are tables which correlate A1C to average daily blood sugar

48. Estimated Average Glucose

49. Estimated GFR • eGFR , or estimated glomerular filtration rate, is a measure of kidney function. It is a calculated value based on the patient’s serum Cr (creatinine), age & gender. • Creatinine in the bloodstream comes predominantly from the normal breakdown of muscle. Cr is then removed from the bloodstream by the kidneys. Serum Cr will rise if kidney filtration is below normal. However, patients who are elderly, female or underweight generally have less muscle mass than average males, which will result in a lower serum Cr level. In these populations the Cr level may appear falsely normal even when their kidney function is markedly decreased. • The creatinine level will not be raised above the normal range stated by most laboratories until 60% of normal kidney function is lost. Therefore The National Kidney Foundation recommends the reporting of eGFR when a metabolic profile is ordered, as it is a more accurate reflection of kidney function.

50. Estimated GFR • Currently, the severity of Chronic Kidney Disease, (CKD), is described by 5 stages: • Normal kidney function: GFR> 90ml/min without proteinuria • CKD stage 1: GFR> 90 ml/min WITH proteinuria • CKD stage 2 (mild): GFR 60-89 ml/min • CKD stage 3 (moderate): GFR 30-59 ml/min • CKD stage 4 (severe): GFR 15-29 ml/min • CKD stage 5 (end stage renal disease): GFR<15 ml/min. Some of these patients are on dialysis; many are not. • Diabetes & hypertension are the two most common causes of chronic kidney disease (as well as of cardiovascular disease). Both diabetes and hypertension damage the kidney filtration system. Therefore CKD is an early marker for risk of cardiac disease, stroke and peripheral arterial disease.