EndoTool IV 1.8.4 Physician User Guide Content Expert: Karen Pritts, MS, RD, CDE; Director, Center for Diabetes & Endocrinology New: August 14, 2017 CME education assigned to all Physicians

Glucommander Replacement The Glucommander insulin drip software has been replaced with EndoTool IV by Monarch Medical. EndoTool IV software system has been reviewed against the medical standards for IV insulin drip protocols; Portland, Yale, and Atlanta protocols. The start date for EndoTool IV was August 16, 2017. CME opportunity is available for all physicians under MVH Link & Applications-MVH Website-Education.

What is EndoTool IV? EndoTool IV is a software program that calculates the initial insulin drip dose taking into account patient specifics: Current body weight Age Type of diabetes Renal function Patient’s insulin sensitivity Steroids EndoTool IV will pull information from Meditech EMR for calculation purposes. The use of insulin drips & EndoTool IV is currently for patients in either ED, ICU, or CCU.

MVH Goals to Treat Hyperglycemia To decrease the rates of hyperglycemia in our patients with or without diabetes, standards of medical care indicate the use of insulin drips for; Steroids Pre-op and Post-op Acute illness with hyperglycemia Our hyperglycemia rates for Fiscal 2017 Q4: 1216 episodes with a 15% attempted treatment rate for patients with diabetes. Our goal is to decrease the number of hyperglycemia episodes with successful treatment.

How Does EndoTool IV Work? EndoTool IV uses 3 modes of therapy to correct elevated BGs due to either DKA, HNS, or Hyperglycemia. DKA Mode calculates insulin drip rates until BG goal range (BG 140-180 mg/dl) is met. It will then prompt change to the ordered Hyperglycemia goal range. HNS Mode calculates insulin drip rates until BG goal range (BG 180-220 mg/dl) is met. It will then prompt change to the ordered Hyperglycemia goal range. Hyperglycemia Mode calculates the insulin drip rates until the ordered BG goal range is met: BGs 110-150 mg/dl or BGs 90-120 mg/dl for CVA or MI. The Hyperglycemia Mode can be used for patients w/o DKA or HNS, but need IV insulin to manage high BGs (i.e. steroids, post-op, undiagnosed diabetes, steroids w/o hx of diabetes …). Dr Tal also included a BG goal range of 90-120 mg/dl for patients experiencing a CVA or MI.

Types of diabetes used in calculations. EndoTool defines diabetes type as: 0 = Non diabetic; patient has no history or undiagnosed. 1 = Type 1 DM (absolute insulin deficiency at dx). 2 = Type 2 DM (insulin resistance & decreased insulin production). Gestational = gestational diabetes dx during pregnancy. Unknown = patient not able to communicate and medical hx for diabetes is unknown.

EndoTool IV Setup Parameters for EndoTool calculations were recommended by Dr Tal, the Medical Director of the Center for Diabetes & Endo. The MD will need to complete the MVH EndoTool IV Insulin Drip orders. Select mode of therapy Hyperglycemia (BG goal range 110-150 mg/dl). Hyperglycemia with CVA or MI (BG goal range 90-120 mg/dl). DKA (BG goal range 140-180 mg/dl). HNS ( BG goal range 180-220 mg/dl). Select the Blood Glucose Goal Range once DKA or HNS resolved. BGs goal: 110-150 mg/ld BGs goal: 90-120 mg/dl (CVA or MI) Select type & rate of continuous IV Dextrose with NSS. D5 ½ NSS at 125 ml/hr. Other fluids equivalent to 6.25 gm CHO/hr: ______ at _______ml/hr. Nursing will enter the parameters ordered into EndoTool IV.

Steroids The EndoTool IV will adjust IV insulin dose calculations based on steroid use. Due to the degree of insulin resistance created by steroids, the insulin drip could be used for patients with hyperglycemia without a history of diabetes.

Hypoglycemia Prevention & Treatment EndoTool IV is setup to prevent hypoglycemia. EREI (Estimated Residual and Extracellular Insulin) is used by EndoTool IV to calculate the Supplemental Carbohydrate treatment. EndoTool IV will prompt use of Supplemental Carbohydrate when the BG result is 70-80 mg/dl. Oral treatment: Dex4 glucose drink or glucose gel IV treatment: D10W specific dose To treat hypoglycemia (BG <70 mg/dl), EndoTool IV will recommend a treatment using D50. EndoTool IV has a hypoglycemia treatment goal of a blood glucose 130 mg/dl.

IV Spreadsheet CDE Special Panel

Transitioning off Insulin Drip Once blood glucose goals are met, EndoTool IV will prompt the nurse to begin transition off the insulin drip. The physician will complete the MVH EndoTool IV Insulin Drip Transition Orders. Initial subcutaneous Lantus insulin dose to be give 2 hours prior to d/c drip. Bedside blood glucose monitoring. Insulin correction scale and type of insulin. Order daily basal insulin dose of Lantus. Hypoglycemia Protocol.

EndoTool IV Operation Questions Our IT staff (x1157) will help with technical issues (log-in/password, network or hardware). EndoTool IV Monarch Medical is also available 24 hours/7days for clinical & application questions (877-349-4582).