1. Glycemic Control In The Hospital Setting

2. LOYOLA UNIVERSITY MEDICAL CENTER Total Number of Beds 580 LOCATION: ICU # OF BEDS MICU 15 CCU 10 Heart Transplant Unit 10 CV Surgery ICU 21 Trauma Units 20 Surgical ICU 18 Neuro ICU 15 Burn ICU 15 Neonatal ICU 50 Pediatric ICU 14

3. Loyola Medical Center LOCATION: Non-ICU # OF BEDS IMC Cardiac & Angioplasty 28 Telemetry Unit 67 Bone Marrow 15 Pediatrics 32 Post partum 30 Labor and Delivery 15 Nursery 25 Rehab Unit 24 General Medicine 60 Hematology/Oncology 30 Orthopedic 19 Neurology, Neurosurgery and ENT 40 Surgery 32 Burn and Surgical Unit 21

4. Glycemic Control In The Hospital Setting  The Evidence For Tight Glycemic Control  The Achievement of Better Control: Strategies and Protocols

5. Insulin In The Hospital Setting Retrospective Studies

6. Hyperglycemia in the Hospital CABG  Tight Control  Hospital Mortality  50% Kalin. Diabetes. 1998;47:a87  Tight Control  Postop Infections  75% Golden SH, Et Al. Diabetes Care. 1999;22:1408-1414  Tight Control  Sternal Wounds  60% Furnary AP, Et Al. Ann Thorac Surg. 1999;67:352-362  Tight Control  Sternal Wounds  60% Zerr KJ, Et Al. Ann Thorac Surg. 1997;63:356-361 General Surgery  Hyperglycemia  Serious Infections  X 6 Pomposelli JJ, Et Al. J Parenter Enteral Nutr. 1998;12:628-652

7. Effect of Continuous Insulin Infusion on Mortality Following CABG 3554 DM Patients Undergoing CABG From Jan. 1987 to Dec. 2001 Treated With: Subcutaneous Injection Group (SQI) (n=942) Received Insulin Q4h to Maintain BG <250 mg/dl Subcutaneous Injection Group (SQI) (n=942) Received Insulin Q4h to Maintain BG <250 mg/dl Continuous Infusion Group (n=2612) Continuous Infusion Group (n=2612) 1987 to 1991 Target BG of 220 mg/dl 1987 to 1991 Target BG of 220 mg/dl 1991 to 1998 Target BG of 150-200 mg/dl 1991 to 1998 Target BG of 150-200 mg/dl In 1999, Target Lowered to 125-175 mg/dl In 1999, Target Lowered to 125-175 mg/dl In 2001, Target Lowered to 100-125 mg/dl In 2001, Target Lowered to 100-125 mg/dl Furnary et al J Thoracic Cardiovasc Surg 2003;125:10073

8. Post-CABG Mortality by Diabetic Status Furnary et al J Thoracic Cardiovasc Surg 2003;125:10073 0% 2% 4% 6% 8% 10% 878889909192939495969798990001 Mortality CII DM Pts. Non-DM

9. Hyperglycemia in the Hospital Stroke  Hyperglycemia  Independent Determinent of Infarct Expansion Baird TA, et al. Stroke. 2003; 34: 2208-14  Hyperglycemia  Hospital Mortality  X 2 Weir CJ, et al. BMJ. 1997; 314:1303-1306 Weir CJ, et al. BMJ. 1997; 314:1303-1306  Hyperglycemia  Hospital Mortality  X 2 Jorgensen H, et al. Stroke. 1994; 25:1977-1984 Jorgensen H, et al. Stroke. 1994; 25:1977-1984

10. Hyperglycemia In Critical Illness Targeting Risk? From The VA Inpatient Evaluation Center  From 177 ICUs In 73 VA Hospitals  216,000 Patients  Glycemia Independent Predictor Of Mortality Starting At 1 mg% Above Normal (Normal = 70-110 mg%)  True In Medical, Surgical & Cardiac ICUs Falciglia, M. et al Annual Meeting of the American Diabetes Association, 2006

11. Hyperglycemia In Critical Illness Targeting Risk? From The VA Inpatient Evaluation Center Different Disease States Variably Affected Condition Risk Of Death* Condition Risk Of Death* Acute MI 1.6-5 Acute MI 1.6-5 Unstable Angina 1.7-6.2 Unstable Angina 1.7-6.2 Stroke 3.4-15.1 Stroke 3.4-15.1 Outcomes Worse In “Non-Diabetics” Falciglia, M. et al Annual Meeting of the American Diabetes Association, 2006 * Fold Increase

12. Insulin In The Hospital Setting Prospective Studies

13. DIGAMI Study 620 Randomized to 2 Groups At 19 Swedish Hospitals Control: Standard Coronary Care for Their Center Control: Standard Coronary Care for Their Center Intensive: Insulin-Glucose Infusion for >24 Hrs Intensive: Insulin-Glucose Infusion for >24 Hrs Target Serum Glucose 126 – 180 mg/dl Target Serum Glucose 126 – 180 mg/dl Multidose (4/day) Insulin for Minimum of 3 Months Following Discharge Multidose (4/day) Insulin for Minimum of 3 Months Following Discharge BMJ 314: 1512-1515, 1997

14. Cardiovascular Risk Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study All Subjects (N = 620) Risk Reduction (28%) P =.011 Standard Treatment 0.3.2.4.7.1.5.6 01 Years of Follow-up 2345 Low-risk; Not Previously on Insulin (N = 272) Risk Reduction (51%) P =.0004 IV Insulin 48 Hours, Then 4 Injections Daily 0.3.2.4.7.1.5.6 01 Years of Follow-up 2345

15. Intensive Insulin Therapy in Critically Ill Patients Van Den Berghe, G et al. NEJM 345: 1359-1367. 2001

16. Intensive Insulin Therapy in Critically Ill Patients 1548 Mechanically Ventilated Patients in SICU 2 Glycemic Treatment Groups: Insulin Infusion to Keep Blood Glucose 80-110 mg/dl Insulin Infusion to Keep Blood Glucose 80-110 mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose 180- 210 mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose 180- 210 mg/dl van den Berghe G. N Engl J Med 2001; 345:1359 Glucose Achieved: Control 153 mg/dl Intensive 103 mg/dl

17. Intensive Insulin Therapy in Critically Ill Patients 87% Diagnosed With DM in the ICU 87% Diagnosed With DM in the ICU 13% Had Previous Dx of Diabetes Mellitus 13% Had Previous Dx of Diabetes Mellitus 5% Had Previous Insulin Treatment 5% Had Previous Insulin Treatment van den Berghe G. N Engl J Med 2001; 345:1359

18. Intensive Insulin Therapy in Critically Ill Patients  34% Decrease in In-Hospital Mortality  46% Decrease in Sepsis  41% Decrease in Renal Replacement Therapy  50% Decrease in Median Number of RBC Transfusions  44% Decrease in Critical Illness Polyneuropathy Van den Berghe G. N Engl J Med 2001; 345:1359

19. 0 5 10 15 20 25 30 >14d in ICU >14d on Ventilator Peak Cr. >2.5 Hyperbilirubinemia ICU Sepsis Antibiotics >10d Polyneuropathy % of Patients Van den Berghe Morbidity Data Glucose 180-200 Glucose 180-200 Glucose 80-110 Glucose 80-110

20. Lazar, H. et al Circulation 109:1997-1502,2004

21. Glucose Achieved: Control 267 mg/dl Intensive 134 mg/dl

22. The Effect of GIK Infusion For CABG in Type 2 Diabetes Lazar, et al: Circulation 109:1497, 2004 0 5 10 15 20 25 30 35 40 45 PacingA. FibInfectionTime on Vent (h) ICU Stay (h) Hospital Stay (Days) GIK n=72 No GIK n=69

23. And Now Van den Berghe -2 Van den Berghe, G. et al NEJM 354: 449-61, 2006

24. Intensive Insulin Therapy in the Medical ICU Greet Van den Berghe, M.D., Ph.D., Alexander Wilmer, M.D., Ph.D., Greet Hermans, M.D., Wouter Meersseman, M.D., Pieter J. Wouters, M.Sc., Ilse Milants, R.N., Eric Van Wijngaerden, M.D., Ph.D., Herman Bobbaers, M.D., Ph.D., and Roger Bouillon, M.D., Ph.D.

25. Intensive Insulin Therapy in Critically Ill Patients: Van den Berghe 2 1200 Patients in MICU 2 Glycemic Treatment Groups: Insulin Infusion to Keep Blood Glucose 80-110 mg/dl Insulin Infusion to Keep Blood Glucose 80-110 mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose 180- 200 mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose 180- 200 mg/dl van den Berghe G. N Engl J Med 2006; 354:449 Glucose Achieved: Control 153 mg/dl Intensive 111 mg/dl

26. With Intensive Insulin Therapy  Reduced Newly Acquired Kidney Disease  Earlier Weaning From Ventilator  Faster Discharge from ICU  Shorter Hospital Length of Stay Van den Berghe, G. et al NEJM 354: 449-61, 2006

27. The Two Van den Berghe Studies 45.9%10.6% % Mort >5 Days I 54.9%20.2% % Mort >5 Days C 37.3%4.6% % Mortality I 40%8% % Mortality C % Mortality C 239 APACHE II 111 mg% 103 mg % Glucose I 153 mg% Glucose C VB 2--MICU VB 1--SICU C- Control Group I- Intensive Group

29. New Trials On The Horizon…  NICE (NormoGlycemia In Intensive Care Evaluation: 4,000 Patients in 20 ICU’s In Australia & New Zealand  SUGAR (Survival Using Glucose Algorithm Regulation): Another 1,000 ICU Patients In Canada NICE + SUGAR = NICE-SUGAR

30. Insulin Therapy for Critically Ill Hospitalized Patients: A Meta-Analysis of Randomized Controlled Trials Pittas et al. Arch Intern med 164: 2005-2011, 2004 Combining Data From All Trials: Insulin Therapy Reduces Short-term Mortality By 15% (RR 0.85, 95% CI: 0.05-0.97) SICU: RR 0.54, 95% CI: 0.58-0.90 AMI: RR 0.84, 95% CI: 0.71-1.00

31. Is It Less Serious If a Patient Has Not Had a Previous Diagnosis of Diabetes?

32. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes Question: Does Hyperglycemia, New or Established, Predict Mortality? Question: Does Hyperglycemia, New or Established, Predict Mortality? 2030 Consecutive Records of Adults Admitted to Georgia Baptist Hospital 2030 Consecutive Records of Adults Admitted to Georgia Baptist Hospital Hyperglycemia: FBG ≥ 126 mg/dl or Random Glucose ≥ 200 mg/dl Hyperglycemia: FBG ≥ 126 mg/dl or Random Glucose ≥ 200 mg/dl New Hyperglycemia 223 Pts. (12%) New Hyperglycemia 223 Pts. (12%) Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978

33. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes 1.7% 3.8% 16.0% 0% 5% 10% 15% 20% NormoglycemiaKnown DiabetesNew Hyperglycemia Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978 Total Mortality

34. A Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes New Hyperglycemia Patients ~3 x’s As Likely to Be Admitted to ICU New Hyperglycemia Patients ~3 x’s As Likely to Be Admitted to ICU New Hyperglycemia Patients Had Twice the Length of Stay New Hyperglycemia Patients Had Twice the Length of Stay Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978

35. There are other benefits…

36. Van den Berghe G. et al N Engl J Med 2001; 345:1359

37. Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: 612-616, 2006

38. Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: 612-616, 2006

39. Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: 612-616, 2006 Euros Conventional 10,569 Intensive 7,931 Savings 2,638

40. Glycemic Control In The Hospital Setting The days of casual glycemic control for critically ill patients should be over!

41. Glycemic Control In The Hospital Setting  The Evidence For Tight Glycemic Control  The Achievement of Better Control: Strategies and Protocols

42. What Are The Treatment Goals?

43. Hospital Glycemic Goals Intensive Care Units: 110 mg/dL Non-Critical Care Units: Non-Critical Care Units: Pre-Prandial 110 mg/dL Pre-Prandial 110 mg/dL Max. Glucose 180 mg/dL Max. Glucose 180 mg/dL Endocrine Practice 10:77-82, 2004 Diabetes Care 27:553-591, 2004 AACE Consensus Conference - 2003

44. Strategies and Protocols for Achieving Inpatient Glycemic Control

45. IV Insulin Infusion Protocols

46. The Ideal IV Insulin Protocol Easily Ordered (Signature Only) Easily Ordered (Signature Only) Effective (Reach Goal Quickly) Effective (Reach Goal Quickly) Safe (Minimal Risk Of Hypoglycemia) Safe (Minimal Risk Of Hypoglycemia) Easily Implemented Easily Implemented

47. IV Insulin Protocol Based On Insulin Sensitivity BGUnits/hrBGUnits/hrBGUnits/hrBGUnits/hr < 60 = Hypoglycemia <80Off<80Off<80Off<80Off 80-1090.280-1090.580-1091 1.5 110-1190.5110-1191 2 3 120-1491 1.5120-1493 5 150-1791.5150-1792 5 7 180-2092 3 6 9 210-2392 4 7 12 240-2693 5 8 16 270-2993 6 10270-29920 300-3294 7 12300-32924 330-3594 8 14>33028 >3606 12>36016 Algorithm 1Algorithm 2Algorithm 3Algorithm 4

48. IV Insulin Protocol Based On Insulin Sensitivity

49. < 70 Off 70-109 0.2 70-109 0.2 110-119 0.5 120-149 1.0 150-179 1.5 180-209 2.0 210-239 2.0 240-269 3.0 270-299 3.0 300-329 4.0 300-329 4.0 Etc. Etc. Suppose The Patient Starts With BG = 254 mg/dl Insulin Drip Algorithm

50. Shifting Between Several Algorithms Makes It Possible To Discover The Insulin Requirement That Maintains Normoglycemia

51. Recommended IV Fluids To Prevent Hypoglycemia, Hypokalemia & Ketosis: Glucose: 5-10 gms/hour Glucose: 5-10 gms/hour Potassium: 20 meq/L Potassium: 20 meq/L The Primary Service Should Choose the Type and the Rate of the Fluid Depending on the Underlying Disease The Primary Service Should Choose the Type and the Rate of the Fluid Depending on the Underlying Disease

52. Other Protocols Exist  DIGAMI (Studied In Acute MI Setting)  Van den Berghe (Critical Care Setting)  Portland Protocol (Surgical Setting)  Markovitz (Postoperative Heart Surgery)  Yale Protocol (Medical Intensive Care Setting)  Glucommander.com; Endotool.com; Medicaldecisions.com (Critical Care & Non- Critical Care)

53. Life After The Drip…. Transition From IV to SQ Insulin In The Adult Patient

54. Physiologic Insulin Secretion : Basal/Bolus Concept Breakfast Lunch Supper Insulin (µU/mL) Glucose (mg/dL) Basal Glucose 150 100 50 0 789101112123456789 A.M.P.M. Time of Day Basal Insulin 50 25 0 Prandial Glucose Prandial Insulin Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule

55. Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

56. Effective OnsetPeakDuration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular 1/2 -1 hr2-3 hr3-6 hr NPH/Lente 2-4 hr7-8 hr10-12 hr Ultralente4 hrVaries18-20 hr Insulin Glargine 1-2 hr Flat/Predictable24 hr Current Insulin Preparations

57. Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular 1/2-1 hr2-3 hr3-6 hr NPH 2-4 hr7-8 hr10-12 hr Insulin Glargine 1-2 hrFlat24 hr Insulin Detemir 0.8-2 hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations * Dose Dependent

58. Insulin Detemir Pharmacokinetics Plank, J et al Diabetes Care 28: 1107-1112, 2005

59. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

60. Glucose Levels after Starting Lantus Lantus Group40%60%80% Glucose when Lantus given (mg/dl) 132.2130.7115.0 Avg Glucose for 24h after Lantus started 146.9157.9140.9 Glucose at time 6 hours 153.4157.7152.5 Glucose at time 12 hours 190.6156.9140.5 Glucose at time 24 hours 145.5152.33143.5 Glucose level – next AM 147.1153.3128.6 Any glucose < 50 mg/dl 1 (4.5%)2 (8.7%)0 Molich M, DeSantis A, 2005

61. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

62. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

63.  Example: Last Drip Dose Is 1.5 Unit/Hour; Give 1.5 X 20 = 30 units Of Glargine SQ; Discontinue Drip Two Hours Later This Is Basal Insulin This Is Basal Insulin

64. Adjust Basal Insulin By FBS: Decrease 4 U if FBS are below 60 mg/dL Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL If FBS Is 80-100mg/dL, At Goal-No Change is Needed If FBS Is 80-100mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Or Adjust Based On Previous Days Correction Factor Doses

65. Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

66. Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular ½ -1 hr 2-3 hr3-6 hr NPH 2- 4 hr 7-8 hr10-12 hr Insulin Glargine 1-2 hrFlat24 hr Insulin Detemir 0.8-2 hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations * Dose Dependent

67. When Patient Is Able To Eat, Add Rapid Acting Insulin For Mealtime Coverage Add Rapid Acting Insulin For Mealtime Coverage Rule Of Thumb: Rule Of Thumb: 50% Basal 50% Basal 50% Prandial, Divided Over 3 Meals 50% Prandial, Divided Over 3 Meals

68. Example: Patient Is On 30 units Glargine Daily; Give 10 units With Each Meal Of Lispro (Humalog), Aspart (Novolog), Or Glulisine (Apidra) This Is Prandial Insulin

69. Basal-Bolus Insulin Therapy: Glargine and Mealtime Rapid Acting SLBB Glulisine Lispro/Aspart/Glulisine HS Glargine Insulin Effect 30 units 10units

70. Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

71. Correction Factor Dose, Added To Prandial Dose Low Dose Total Insulin Dose <40 units/day Medium Dose Total Insulin Dose 40-80 units/day High Dose Total Insulin Dose >80 units/day 5 units >320 4 units271-320 3 units221-270 2 units171-220 1 unit120-170 Additional Insulin Premeal BG 9 units >320 7 units271-320 5 units221-270 3 units171-220 1 units120-170 Additional Insulin Premeal BG 11 units >320 9 units271-320 7 units221-270 5 units171-220 3 units120-170 Additional Insulin Premeal BG

72. What About Patients Admitted With Hyperglycemia On The Floor?

73. Sliding Scale Episodic Bolus Insulin WITHOUT WITHOUT Basal Insulin

74. Pitfalls of Sliding Scale Common Problems With SS Only  Is Reactive Rather Than Proactive  Often Mismatched With Changes In Patient’s Insulin Sensitivity  It Does Not Meet The Physiologic Needs Of The Patient  Leads To Insulin Stacking

75. Calculate Starting Total Daily Dose (TDD) Previous Total Daily Insulin Units Used or Previous Total Daily Insulin Units Used or 0.4 units/kg (Type 1 DM) 0.4 units/kg (Type 1 DM) 0.6 units/kg (New Onset Or Lean Type 2) 0.6 units/kg (New Onset Or Lean Type 2) 0.8 units/kg (Type 2 DM) 0.8 units/kg (Type 2 DM) This Is Very Conservative and Actual Needs May Turn Out to Be Substantially More Starting Basal-Bolus From Scratch

76. NPH or Combination Insulin Discontinue this while an inpatient Disadvantages Insulin peaks Less reliable timing Variation in food intake Often poorer control Conversion Add all doses of insulin total daily dose

77. Starting Basal-Bolus From Scratch Basal Insulin = ½ TDD Give All of Calculated Glargine Dose Q 24h Goal: FBS And Pre-Meal Glucose = 80-110 mg/dl Bolus Doses = ½ TDD Prandial Dose + Correction Factor AFTER THE MEAL Goal: 2h Post-Prandial <180 mg/dl

78. Hypoglycemia: Most Frequent Causes  Not Lowering Insulin Dose For Decreased Caloric Intake  Interrupted Tube Feeding  Unrecognized Renal Insufficiency  Sulfonylurea’s In Addition To Insulin Very Rare:  Adrenal Insufficiency & Drugs

79. A Word About Oral Agents….

80. Therapy of Type 2 Diabetes Mellitus: Hospital Use of Oral Agents Not for Acute Illness With Variable Intake Secretagogues Can Give or Not Glitazones Hold for Acute Illness If Renal, Cardiac, or Liver Function Unstable, or Surgery, or Radiocontrast Metformin Not for Acute Illness With Variable Intake  Glucosidase Inhibitors

81. Common Errors in Glucose Management in Hospital Patients Discontinuing All Diabetes Medicines On Admission (Some Pills Must Be Stopped) Discontinuing All Diabetes Medicines On Admission (Some Pills Must Be Stopped) Setting High Glycemic Targets (>200 mg/dL) Setting High Glycemic Targets (>200 mg/dL) Not Changing Therapy With The Situation Or The Glucose Profile Not Changing Therapy With The Situation Or The Glucose Profile Overutilization Of Sliding Scale Insulin Overutilization Of Sliding Scale Insulin Underutilization Of Insulin Infusions and Basal Insulin Underutilization Of Insulin Infusions and Basal Insulin Metchick LN. Am J Med 2002; 113:317

82. Have A Discharge Plan

83. Admission HbA1C Very Helpful Admission HbA1C Very Helpful Can A Patient Go Back To Oral Agents At Discharge?

84. Admission HbA1C Very Helpful Admission HbA1C Very Helpful If Known Diabetic and Pre-Admission Control Acceptable  YES!!! If Known Diabetic and Pre-Admission Control Acceptable  YES!!! If > 7.5% on Maximum Oral Agents, If > 7.5% on Maximum Oral Agents, Needs Basal Insulin Needs Basal Insulin Can A Patient Go Back To Oral Agents At Discharge?

85. Natural History of Type 2 Diabetes 0 50 100 150 200 250 -10-5051015202530 Years of Diabetes Glucose (mg/dl) Relative Function (%) Insulin Resistance Insulin Level  -Cell Failure *IFG=impaired fasting glucose. 50 100 150 200 250 300 350 Fasting Glucose Post-meal Glucose Obesity IFG * Diabetes Uncontrolled Hyperglycemia

86. Glycemic Management Teams: Review Scheduled Insulin Orders Review Scheduled Insulin Orders Examine Bedside Glucose Levels To Assess Recent Responses To Treatment Examine Bedside Glucose Levels To Assess Recent Responses To Treatment Use These Responses To Revise Insulin Orders Use These Responses To Revise Insulin Orders

87. Glycemic Management Teams: Mild Hypoglycemia  Adjust Downward, Especially Rapid-Acting Analogue Mild Hypoglycemia  Adjust Downward, Especially Rapid-Acting Analogue Review Notes For Unusual Occurrences, i.e., Late Insulin, Decreased Caloric Intake, Physical Activity, Hypoglycemia Treatment Review Notes For Unusual Occurrences, i.e., Late Insulin, Decreased Caloric Intake, Physical Activity, Hypoglycemia Treatment Provide Provide Education/Inservice For Nurses, Pharmacists, Physicians & Physician Assistants Code and Bill Appropriately

88. Inpatient Diabetes Management: Is Cost a Barrier? Use of a Diabetes Management Team:  Reduction in LOS  Cost Reduction of $2353/ Patient  MICU: Annual Savings $40,000/ ICU Bed  SICU: Savings $3,000/Patient Inpatient Diabetes and Glycemic Control: A Call To Action Feb 7, 2006

89. Hospital Diabetic Management: Medical Benefits Unequivocal Medical Benefits Unequivocal Few Studies Address Optimal Method Few Studies Address Optimal Method Principles Borrowed From Outpatient Management Principles Borrowed From Outpatient Management Insulin Strategy Should Be Physiologic Insulin Strategy Should Be Physiologic  All Regimens Must Include Adequate Basal Insulin  Prandial and Correction Factor Team Approach Essential Team Approach Essential Financial Incentives Financial Incentives