Presented by : CAPT Christine Chamberlain, PharmD, BCPS, CDE

1. Multidisciplinary Approach to Inpatient Blood Glucose Management Presented by: CAPT Christine Chamberlain, PharmD, BCPS, CDE

2. NIH Clinical Research Center

3. Introduction • 1,500 studies currently in progress. Most Phase 1 & 2 trials. • 240 inpatient beds, 82 day hospital stations, and outpatient clinics.

4. Objectives • List important factors that were considered in the design of blood glucose management service (BGMS) • Explain the design of electronic medical record to support the service • Implement new strategies for managing inpatients requiring insulin efficiently in similar environments

5. Introduction • All patients seen at NIH are on a clinical research protocol • Some investigational drugs may affect glucose or insulin action • Some research protocols require steroids • Minimizing serious adverse events of glycemia related to protocol

6. Introduction • Patients come from all 50 states and other countries as often we are studying rare diseases • Many foreign languages • Many without insurance

7. Perils of Hyperglycemia n engl j med 355;18 www.nejm.org november 2, 2006

8. Reasons for Formation of Blood Glucose Management Service • No consistency • Changing management guidelines • New drugs to use in controlling blood glucose • Late endocrine consults • Delay in implementing consult recommendations • Discharge planning • Disjointed patient education

9. Blood Glucose Management Service • Members • Attending • Fellows • Pharmacist • Dietitian • Nurse Practitioner • Nurse • Social Worker as needed

10. BGMS Roles • Attending Physician • Champion • Expert • Training • Liaison

11. BGMS Roles • Fellow • Initial visit and history • Orders • On-call

12. BGMS Roles • Dietitian • Patient teaching • Participation in daily rounds • Determination of diet/TPN

13. BGMS Roles • Nurse • Ambassador • Daily visits with patient • Participate in daily meetings, report • Documentation in electronic record • Discharge teaching with patients • Staff training • Back up on call Fellow

14. BGMS Roles • Nurse Practitioner • Ambassador • Daily visits with patient • Participate in daily meetings, report • Documentation in electronic record • Discharge teaching with patients • Staff training • Back up on call Fellow • Facilitate order entry

15. BGMS Roles • Pharmacist • Ambassador • Daily visits with patient • Participate in daily meetings, report • Documentation in electronic record • Discharge teaching with patients • Staff training • Back up on call Fellow • Medication Profile review

16. Mission Statement • Multidisciplinary team consult service • Provide around the clock responsibility for blood glucose management for referred patients. • Manage only inpatients receiving insulin • Team will participate in multidisciplinary rounds each working day and a fellow during weekends • Team interdisciplinary notes will be recorded daily in the EMR • Insulin orders will be entered in the EMR rather than a recommendation in a note • Resources: laptops, pager, conference room, supervisor support

17. BGMS Meeting • Report • Discussion • Orders • Discharge planning

18. Birth of BGMS • January 8, 2007 • Piloted on one unit initially • Medical executive committee endorsement • Hospital wide at 7 months

19. Tracking • Census form • Occurrences • Daily Rounds log • Monthly on-call schedule

20. Selling the Concept

21. Bumps in the Road • Selling the concept • Finding the data • Primary team physicians changing orders • Communication between BGMS and primary team • Transfers to the ICU (transition of care) • Misinterpretation of insulin order • No resources for diabetes supplies (glucometer, strips)

22. Documentation • Flowsheet (Eclipsys electronic medical record)

23. Flowsheet continued

24. Checklist for Expansion • BGMS team pager • Appropriate education for each patient care unit • Sufficient “beta-testing” of the EMR systems, including: • The BG flowsheet- worklist link and • System for recording daily BGMS progress notes • “Stamp” for the BGMS fellow to place a note in each patient’s medical record indicating the service is following that patient, and where progress notes can be found (On service note)

25. Documentation • Consult Note (structured note)

26. Documentation • Consult Note (structured note)

27. Bumps in the Road • Selling the concept • Finding the data • Primary team physicians changing orders or putting them in hold status • Communication between BGMS and primary team • Transfers to the ICU • Misinterpretation of insulin order • No meter when discharged

28. Documentation • Consult Note (structured note)

29. Documentation • Consult Note (structured note)

30. Documentation • Consult Note (structured note)

31. Documentation • Consult Note (structured note)

32. BGMS Meeting - Efficiency • Report • Discussion • Orders • Discharge planning

33. Standardized Script for Rounds •   “We are following Mr/Mrs ________ whose primary diagnosis underlying their hospitalization is _______.   •  Our present blood glucose management orders for him/her are ________.    •  Issues today that may have influenced the BGs you can see on the flowsheet include _____ (and examples may be infections, alterations in his/her diet, procedures, new medications like glucocorticoids).   • Upcoming plans for his/her hospitalization that may effect his/her blood glucose control include ____ (and examples may include alterations in his/her diet, procedures, new medications like glucocorticoids, plans for discharge).” • State pertinent lab values for that day

34. Quote for the Day Quoting Lennon and McCartney, “I have to admit its getting better, a little better all the time.”

35. Discharge planning • Prepare for home regimen • Prepare for insulin pump or adjust setting if admitted on pump • Transition to outpatient

36. Discharge planning – patient education

37. Trials and Tribulations

38. Bumps in the Road • Selling the concept • Finding data • Primary team physicians changing orders or putting them in hold status • Communication between BGMS and primary team • Transfers to the ICU • Misinterpretation of insulin order • No meter when discharged

39. Medication Occurrences

40. Insulin Basic Concepts • Established rules for initial insulin dosing • Created treatment plans specific to glycemia issue • Created Standard operating procedures • Created insulin ordering templates • Insulin drip • High concentration insulin • Insulin subcutaneous pump

41. Inpatient Glycemia Goals • Pre-meal goal • Critically ill 140-180 mg/dl • Non critically ill pre-meal <140 mg/dl and random <180 mg/dl • Individualize per patient condition • Issues with hgb A1C, low hematocrit, blood glucose level data

42. U-100 Insulin RegimenInitial dose • Weight based regular insulin • Regular insulin 0.2-0.5 units/kg/day divided four times daily with meals or every 6 hr if not eating • 30%-25%-25%-20% for breakfast, lunch, dinner and bedtime snack plus correction regular insulin based on BG level • Basal/ bolus • Continue home regimen or weight based • Insulin glargine or detemir 50% TDD • Lispro insulin with meals 50% of TDD • Correction with lispro

44. Regular insulin QID schedule will have overlap

45. Insulin Pump

46. Nursing SOP • On admission obtain insulin pump program settings • Patient must have an order that includes specific pump settings, self administer, and using own supplies • If patient needs MR,I pump needs to be suspended (MD to order a bolus) • Nurse assess patient’s competence for insulin pump use – self administration • Monitor labs, and blood glucose pre-meal and bedtime • Review with patients s/s of hypoglycemia to report • Validate emergency medications available – glucagon, 50% dextrose • Site, tubing and cartridge are changed every 3 days • Patient to communicate with nurse bolus amount and time

47. Documentation on Flowsheet Specific for insulin pump

48. U-100 Insulin Regimen with Corticosteroids • Oral Corticosteroids • prednisone, dexamethasone, methylprednisolone, hydrocortisone • Budesonide (drug interaction/systemic effect) • NPH insulin single dose in morning and correction with regular insulin • Regular insulin 4 times/day (30%-25%-25%-20%)

49. U-100 Insulin Dose Adjustment • Add in correction amount given over past 24 hr • Increase dose by 10-15% if not at target • Reduce dose by 50% if episode of hypoglycemia • Reduce dose by 15-20% for below target blood glucose levels

50. Insulin Regimens • NPO guidelines • Reduce insulin dose by 50% if on regular insulin regimen • Basal bolus regimen – • stop mealtime insulin • Give basal insulin or decrease dose by 20% • Prevention of hypoglycemia due to good communication and quickly adjusted medication orders