1. Spotlight Dropping to New Lows

2. Source and Credits This presentation is based on the April 2016 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available Commentary by: Patricia Juang, MD, and Kristen Kulasa, MD, University of California, San Diego ○ Editor, AHRQ WebM&M: Robert Wachter, MD ○ Spotlight Editor: Bradley A. Sharpe, MD ○ Managing Editor: Erin Hartman, MS 2

3. Objectives At the conclusion of this educational activity, participants should be able to: State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitalized patient Outline goal blood glucoses for patients with diabetes admitted to critical care and noncritical care settings Appreciate the importance of a multidisciplinary diabetes steering committee in guiding glycemic management Describe optimal organizational strategies that can improve inpatient glycemic control Describe electronic health record–based strategies to achieve optimal inpatient glycemic control 3

4. Case: Dropping to New Lows A 62-year-old man with type 1 diabetes was admitted to the hospital with osteomyelitis of the right foot and acute kidney injury. The patient had previously had a stroke. At baseline he had some cognitive deficits and received his nutrition through a percutaneous gastrostomy (feeding) tube. He also received small amounts of soft food by mouth. For his diabetes, at home he was on a complex regimen of twice daily insulin glargine (Lantus, a long-acting insulin), insulin NPH (another long- acting insulin) once in the morning, and regular (short-acting) insulin multiple times a day. 4

5. Case: Dropping to New Lows (2) The patient's blood sugars were difficult to control during the first 3 days of his hospitalization. He had multiple episodes of critical hypoglycemia (blood sugars 300 mg/dL). The hospitalist caring for the patient consulted an endocrinologist to help with the glucose management. 5

6. Background: Inpatient Diabetes Management Diabetes is common in the inpatient setting and is a risk factor for poor outcomes Hospital goals for patients with diabetes are: 1)Prevent hyperglycemia and hypoglycemia 2)Minimize the length of the hospital stay 3)Ensure an effective and safe transition out of hospital 6

7. Management of Diabetes in the Hospital Guidelines support discontinuation of oral diabetes agents and other non-insulin therapies –Patients often have contraindications to their use while hospitalized (NPO status, variable oral intake, acute renal failure, etc.) Insulin is generally the preferred pharmacologic treatment during hospitalization –Easier to adjust in response to changing variables in hospital 7

8. Insulin Use in the Hospital The sole use of the sliding scale is strongly discouraged The preferred route depends on site of care: –Continuous IV insulin infusion should be used in the critical care setting –Scheduled subcutaneous insulin with a basal, nutritional, and correction regimen should be used in the noncritical care setting 8

9. Typical Regimen in Noncritical Care A typical regimen in a noncritical care setting should include: –One long-acting insulin –One short-acting insulin with meals or nutritional intake –The same short-acting insulin with a correctional scale 9

10. Target Blood Sugars in the Hospital Glycemic targets in the inpatient setting have evolved over past 2 decades, moving from "tight" control to more moderate targets The previous "tight" control target of 80–110 mg/dL was based on a large study which showed a lower mortality Subsequent studies and a meta-analysis showed that "tight" control led to increased rates of severe hypoglycemia and increased mortality 10

11. Target Blood Sugars in the Hospital (2) The American Association of Clinical Endocrinologists and the American Diabetes Association guidelines have been updated Guidelines: –Insulin should be initiated for persistent hyperglycemia > 180 mg/dL –Once started, insulin should be used to achieve a target blood sugar of 140–180 mg/dL in critically ill patients –In noncritically ill patients, in general, insulin should be used to achieve a premeal glucose < 140 mg/dL and random glucose < 180 mg/dL 11

12. Target Blood Sugars in the Hospital (3) While those general guidelines should be used, the insulin regimen and goal blood sugar should be assessed daily in the hospital Changes in glycemic trends, nutritional status, and new medications that might impact glucose levels are among the issues that should be considered 12

13. Target Blood Sugars in This Case In this case, given the cognitive deficits, kidney injury, and tube feeding, the goal blood sugar probably should be 140–180 mg/dL This could be achieved with a long-acting insulin (such as glargine), a short-acting insulin (such as regular given every 6 hours), and a correctional scale 13

14. Case: Dropping to New Lows (3) The endocrinologist believed there were multiple reasons for the hard-to-control blood sugars, including an active infection, acute kidney injury, variable oral intake, and tube feeds that were intermittently held. She also recognized multiple system problems that were contributing. The nurses caring for the patient would often "hold" the morning or evening doses of insulin if his blood sugars were less than 200 mg/dL. Because these "holds" were not clearly charted in the electronic health record (EHR), providers were unaware of how much insulin had actually been given. 14

15. Case: Dropping to New Lows (4) In addition, the widely fluctuating sugars were often not immediately entered into the EHR but would only appear at the end of the shift—when the glucometer that was used to measure the blood sugars was "docked" to the EHR and the blood sugar results uploaded into the system. Because of this, the providers were often reacting to old or incomplete data. 15

16. Case: Dropping to New Lows (5) To solve the problem in the short term, a paper tracking system of insulin dosing, blood sugars, and vital signs was developed for the patient. These logs were kept in the (now nearly empty) paper chart and then uploaded into the progress notes in the EHR. The hospital information technology team, aided by a multidisciplinary task force that was convened to improve the overall process and workflow for inpatient diabetes management, began working on modifying the EHR to integrate these improvements. 16

17. Organizational Strategies Building a hospital program to optimally manage patients with diabetes is complex One organizational strategy that has been critical for some hospitals is establishing an interdisciplinary steering committee that meets regularly Order sets and hard-wired systems of care that support safe glycemic control are also essential in building a hospital program Some hospitals have created a frontline "glycemic management team" to monitor glycemic control and directly target individual patients or providers 17

18. Interdisciplinary Steering Committee Should include the following key stakeholders: –Pharmacy –Nursing –Physician groups (hospitalists, intensivists, surgeons, endocrinologists) –Information technology –Diabetes educators –Quality and safety improvement staff –Laboratory services –Dietary/nutrition services –Hospital administration 18

19. Provider Education Provider education is an essential element in achieving glycemic control in the hospital One option is to require providers to successfully complete a competency exam –Exam could be combined with a live lecture or be presented as an online module Education can also include targeted outreach to providers triggered by an event such as: –A reported adverse event –A pharmacist noticing an unusual order –Serious hypoglycemia or hyperglycemia (blood sugar 300 mg/dL) captured in a daily report 19

20. Hyperglycemia Grand Rounds (HGR) Hyperglycemia Grand Rounds (HGR) is a continuing education initiative The HGR is comprised of a four-module seminar of best practices Between 2006 and 2013, the HGR series was presented to more than 12,000 providers at more than 300 institutions Surveys of participants revealed improved knowledge, performance, and outcomes 20

21. Policies, Algorithms, and Protocols In addition to education, policies, algorithms, and protocols are crucial in building an inpatient diabetes management program Protocol-driven and evidence-based order sets for specific clinical scenarios can help standardize insulin prescribing 21

22. Order Sets Order sets can be designed for different scenarios, including: –Transition from intravenous to subcutaneous insulin –Treatment of diabetic ketoacidosis –Treatment of hyperkalemia Order sets can be built with decision support to guide appropriate dosing The following slide shows an example of a subcutaneous order set that matches insulin regimens to different nutritional intake patterns 22

23. Example of an Order Set 23

24. "Holding" of Orders In this case, the patient's tube feeds were intermittently held and nurses were often "holding" doses of insulin if patient's blood glucose was < 200 mg/dL "Holding" orders should be avoided unless absolutely necessary If used, orders that are to be "held" should have clear instructions on when to resume the medication Ideally, the prescribing provider would also be notified anytime a medication is "held" 24

25. Food or Nutritional Intake Patients' food or nutritional intake is often intermittent or interrupted in the hospital If a patient is receiving insulin, stopping nutrition or tube feeding can lead to life- threatening hypoglycemia Some institutions have standard algorithms for the management of insulin if nutrition is stopped 25

26. Electronic Health Record (EHR) EHRs are particularly helpful in achieving optimal glycemic control, especially if information is quickly and easily accessible to providers –For example, a single page that displays all necessary variables together can help Order sets with decision support within the EHR can also guide appropriate insulin ordering and glucose monitoring 26

27. This Case In this case, the fluctuating sugars, coupled with unclear documentation, resulted in a complicated clinical scenario that was difficult for providers to disentangle Glucometer readings need to be transferred to the EHR in real time Insulin administration needs to be clearly documented 27

28. Take-Home Points Target blood glucose for a critically ill patient is 140–180 mg/dL and an insulin infusion should be started for glucose ≥ 180 mg/dL General targets for a noncritically ill patient are premeal glucose < 140 mg/dL and random glucose < 180 mg/dL "Tight" glucose control has been shown to increase mortality among critically ill patients 28

29. Take-Home Points (2) An interdisciplinary glycemic control steering committee that meets regularly has been an essential element for successful programs Electronic health records need to make glucose management information quickly and easily accessible to providers in order to be useful Having extensive clinical decision support built into the electronic health record order sets is a way to guide providers to order appropriate insulin regimens 29