Hyperglycemia in Hospitalized Patients

Hyperglycemia in Hospitalized Patients
Strategies For Implementing Change Nuts and bolts of management Robert J. Rushakoff, MD Clinical Professor of Medicine University of California, San Francisco

Insulin Administration
Order Written Order Sent to Pharmacy Order Entry by Pharmacist Drug Preparation by pharmacy Insulin delivery to unit Medication Administration Documentation

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database Endocrine Practice :535

"Each blind man perceived the elephant as something different: a rope, a wall, tree trunks, a fan, a snake, a spear..."

Coordination of Outpatient Care
Patient Assessment of Skills, Education Diabetes Assessment Form Page 1 of 6 Medical Errors JCAHO Coordination of Outpatient Care Home care services Outpatient diabetes classes Jargon CQI ICU Protocols

What is inpatient diabetes care?
Diabetes as a Secondary Diagnosis

Inpatient Diabetes Goals Inpatient Diabetes Goals
Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable Inpatient Diabetes Goals Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia Inpatient Diabetes Goals Appropriate Glucose Control Based on physiology and outcome studies

Benefits of Improved Diabetes Management
Outpatient DCCT UKPDS (United Kingdom Prospective Diabetes Study) Blood pressure control Lipids Inpatient/perioperative - ????????

Target Glucose Levels Alive

Target Glucose Levels No DKA or Hyperosmolar Coma

Target Glucose Levels Occasional hypo- and hyperglycemia

No hypo- or hyperglycemia
Target Glucose Levels No hypo- or hyperglycemia Prevent fluid and electrolyte abnormalities secondary to osmotic diuresis Improve WBC function Improve gastric emptying Decrease surgical complications Earlier hospital dischange Decreased post-MI mortality Decreased post-CABG morbidity and mortality

Decreased Morbidity and Mortality
Target Glucose Levels Normal Glucoses Decreased Morbidity and Mortality

Problems With High Glucoses

Glucose and post-CABG morbidity and mortality
Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and outcomes Diabetes Care 2003; 26: Retrospective Review of 291 patients surviving 24 h post op 40% with retinopathy, nephropathy or neuropathy Inpatient Complications For each 1 mmol/l (18 mg/dl) increase in postop day 1 over 6.1 mmol/l (110 mg/dl), a 17% increase risk of complications

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU
Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati Hyperglycemia was an independent predictor of mortality starting at 111 mg/dl. Effect was greatest with acute myocardial infarction, unstable angina, and stroke heart attack time a stroke it raised risk from 3.4 to 15.1 times unstable angina it raised risk from 1.7 to 6.2 times Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU
Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism. Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure. In diabetes patients, the increase in mortality risk was not seen until mean glucose was >146 mg/dl Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

Cheung et al: Diabetes Care, 28:2367-2371, 2005
TPN: Adverse Outcomes Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition Cheung et al: Diabetes Care, 28: , 2005 Risk of complications in relation to mean daily blood glucose level OR (95% CI) P Any infection 1.40 (1.08–1.82) 0.01 Septicemia 1.36 (1.00–1.86) 0.05 Acute renal failure 1.47 (1.00–2.17) Cardiac complications 1.61 (1.09–2.37) 0.02 Death 1.77 (1.23–2.52) <0.01 Any complication 1.58 (1.20–2.07)

Intervention Studies

Decreased Infections Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999; 88: Perioperative IV insulin infusion Neutrophil phagocytic activity % baseline Control 47 Insulin 75

Decreased Infections Glucose control lowers the risk of wound infection in diabetics after open heart operations Zerr et al: Ann Thoracic Surgery, 1997, 63: Furnary et al. Annals of Thoracic Surgery 1999, 67: Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: Perioperative IV insulin infusion Protocol to maintain glucoses <200 Incidence of Deep Wound Infections (%) Routine Control “Tight” Control

Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021
Decreased Infections Glucose control decreases mortality in diabetics after open heart operations Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 14.5% 6.0% 4.1% 2.3% 1.3% 0.9%

AACE Position Statement: Hospital Glycemic Goals
Intensive Care Units: mg/dL Non-Critical Care Units: Pre-Prandial mg/dL Max. Glucose mg/dL

How to Obtain “Tight” Control
Bedside glucose monitoring IV insulin drips Diabetic Flow sheets Discourage the use of traditional Sliding Scale insulin

INSULIN SLIDING SCALE

Roller Coaster Effect of Insulin Sliding Scale

Mr. And Mrs. XXXXX are admitted for spring fever.
Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.” Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night.

Fingerstick qid with regular insulin SQ coverage:
FSBG Action < 50 1 amp D50 iv and call HO 51-80 give juice and repeat in hr no coverage U regular insulin SQ U regular insulin SQ U regular insulin SQ U regular insulin SQ >400 12U regular insulin SQ, call HO

INSULIN SLIDING SCALE

Insulin and Glucose Patterns
Normal Glucose Insulin 400 120 100 300 80 mg/dL U/mL 200 60 40 100 Slide 6-17 MIMICKING NATURE WITH INSULIN THERAPY Insulin and Glucose Patterns Normal and Type 2 Diabetes This figure compares the normal 24-hour profiles of glucose and insulin concentrations in plasma with those typical of type 2 diabetes. Polonsky et al studied 16 patients with untreated type 2 diabetes and 14 matched controls. Plasma glucose levels were considerably higher in the diabetic patients both under fasting conditions and in response to meals, as expected. The main abnormality was a prominent increase of fasting and 24-hour mean glucose levels. The rise of glucose after meals was proportionately less abnormal than the fasting elevations. The basal and 24-hour mean levels of insulin and C-peptide, however, did not differ greatly from those in the control group. Still, compared to normal subjects, diabetic patients did show significantly lower incremental responses of insulin secretion to meals, and the increases of insulin secretion after meals were more sluggish. These patterns suggest that, in type 2 diabetes, much higher fasting glucose is required to stimulate the b-cells to secrete enough insulin to suppress overnight glucose production by the liver and kidney. The authors of this paper studied other aspects of insulin secretion in these patients and found several kinds of abnormalities. Polonsky KS, Bruce D, Given MD, et al. Abnormal patterns of insulin secretion in non- insulin-dependent diabetes mellitus. N Engl J Med. 1988;318: 20 0600 1000 1400 1800 2200 0200 0600 0600 1000 1400 1800 2200 0200 0600 B L S B L S Time of Day Time of Day Polonsky, et al. N Engl J Med. 1988;318:

Relative Insulin Level
Insulin Regimens Relative Insulin Level 12pm Breakfast Lunch Dinner Time

Insulin Regimens AM NPH Relative Insulin Level 12pm Breakfast Lunch Dinner Time

Insulin Regimens BID NPH Relative Insulin Level NPH 12pm Breakfast Lunch Dinner Time

Insulin Regimens BID R and NPH regular Relative Insulin Level NPH 12pm Breakfast Lunch Dinner Time

Insulin Regimens PM glargine Relative Insulin Level glargine 12pm Breakfast Lunch Dinner Time

Insulin Regimens TID lispro/aspart/glulisine and hs glargine
Relative Insulin Level Lispro/aspart/glulisine glargine 12pm Breakfast Lunch Dinner Time

Subcutaneous Insulin Order Sheet
Introduction

Subcutaneous Insulin Order Sheet : - PATIENT EATING
Check blood glucose and give insulin before meals, bedtime, and 2 A.M. Discontinue previous SQ insulin order. If patient becomes NPO for procedure/stops eating: HOLD nutritional dose of Aspart Give correctional dose of Aspart if BG >130 mg/dL Give Glargine dose. If BG has been <70 mg/dL in last 24 hours, call MD to consider adjusting Glargine dose Call MD for SQ insulin NPO orders if patient on 70/30, NPH insulin or has been NPO for >12 hours. BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS) Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose NPH Glargine (Lantus) Novolog Mix 70/30

Subcutaneous Insulin Order Sheet : Meal time insulin adjustments
B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units

Subcutaneous Insulin Order Sheet : Bedtime and 2am insulin adjustments
Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses. C. BEDTIME AND 2AM BLOOD GLUCOSE CORRECTIONAL INSULIN WITH ASPART IF BG ≥ 200mg/dl BG Range: Default Value Or Custom mg/dL 1 unit mg/dL 2 units >300 mg/dL 3 units

Subcutaneous Insulin Order Sheet : - NPO, Tube Feeds or TPN
1. NPO _____________________ (start date / time) TPN continuous cycle _______________ TUBE FEED continuous cycle ______________ Check blood glucose and give insulin every 4 hours. Discontinue previous SQ insulin order. If patient becomes NPO for procedure/stops eating: Hold nutritional does of Aspart Give correctional dose of Aspart if BG>130 mg/dl Give Glargine dose. If BG has been less than 70 mg/dl in last 24 hours, call MD to consider adjusting glargine dose. If TPN/Tube Feed interrupted >30 minutes, hand D10W at rate of Tube Feed/TPN A. BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS) BLOOD GLUCOSE TIME 6:00 10:00 14:00 18:00 22:00 02:00 Aspart (Novolog) Nutritional Dose 5 Glargine (Lantus) 24

Subcutaneous Insulin Order Sheet : q4hour correctional dosing for NPO, Tube Feeds or TPN
q4hour correctional insulin options are shown. Here correctional insulin is generally used to add or subtract insulin from the q4hour nutritional insulin ordered in section A. There are times it can be used even if no standing q4hour dose is written. B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #6). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 4A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units

Low Glucose Reading The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose. For BG <70 mg/dl, use Hypoglycemia Protocol below: For patient taking PO, give 20 g of oral fast-acting carbohydrate:  4 glucose tablets (5 grams glucose/tablet) OR  Give 6 oz. fruit juice  Give 25 ml of D50 IV push If patient cannot take PO  Check fingerstick glucose every15 minutes and repeat above treatment until BG is ≥100 mg/dl.

Transition from IV to SQ Insulin
Take 80% of last 24 h insulin infusion Basal: ½ of the value premeal: ½ of the value divided for the meals Example: 1.5 units per hour = 36U 36 x .8= 29 Basal: 30x.5=15 premeal: 30x.5= per meal

BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl If patient is NPO >4 hours call MD for IV Dextrose order Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose 5 Glargine (Lantus) 15 B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units

Glucose Insulin 5 A(5+0) 8 A(5+3) 6 A(5+1) 15 glargine BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl If patient is NPO >4 hours call MD for IV Dextrose order Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose 5 Glargine (Lantus) 15 B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units Change for next day would be increase in Breakfast and lunch Aspart

Patient on Diet or Oral Agents who is Eating
Depending on which oral agents – may or may not be continuing

Patient on Diet alone or Oral Agents who is Eating
Day 1 – Use Correctional dosing only Base on BMI, anticipated sensitivity

Patient on Diet alone or Oral Agents who is Eating
Glucose Insulin 1 A(0+1) 6 A(0+6) 2 A(+2) 0 glargine BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl If patient is NPO >4 hours call MD for IV Dextrose order Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose Glargine (Lantus) B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units Change for next day: FBS >130 so start basal insulin at .1 to .3 U/kg Preprandial >130 so start premeal insulin

Patient Scheduled for NPO Procedure
Patient is scheduled for a CT scan and is NPO tomorrow morning. Glucoses at what would be breakfast time is Orders are as follows. What should be done with the insulin?

Patient on Insulin who is Eating
Glucose 240 Insulin 6 A(0+6) 65 glargine BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl If patient is NPO >4 hours call MD for IV Dextrose order Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose 21 14 19 Glargine (Lantus) 65 B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units

Glucocorticoids and Diabetes
Peripheral Tissues (Muscle) postreceptor defect Insulin resistance Glucose Liver Increased glucose production Pancreas Impaired insulin secretion

Glucocorticoids and Diabetes:
Glucose Breakfast Lunch Dinner Bedtime Breakfast

Typical sliding scale insulin Glucose Breakfast Lunch Dinner Bedtime Breakfast

Revved Up sliding scale insulin Glucose Breakfast Lunch Dinner Bedtime Breakfast

NPH and Regular Glucose Breakfast Lunch Dinner Bedtime Breakfast

Increase NPH and Regular Glucose Breakfast Lunch Dinner Bedtime Breakfast

Glucocorticoids and Diabetes
Glucose Insulin 12 A(10+2) 14 A(10+4) 18 A(10+8) 3A(+3) 15 glargine BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl If patient is NPO >4 hours call MD for IV Dextrose order Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose 10 Glargine (Lantus) 30 B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart Blood Glucose Range  Sensitive BMI less than 25 and/or <50 units per day  Average BMI and/or units per day  Resistant BMI >30 and/or >90 units per day  Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less mg/dl mg/dl Give nutritional dose of Aspart as in # 1A above mg/dl +0 unit +1 units +2 units +_______units mg/dl +3 units mg/dl +4 units +6 units mg/dl +9 units mg/dl +8 units +12 units mg/dl +5 units +10 units +15 units Over 400 mg/dl +18 units Change for next day would be increase Aspart Breakfast: 16units; Lunch 18 units; Dinner 18 units

What does it take to Implement Change?
Physicians Administration

Size Matters

Committee Members Physicians: Endocrinologist, Hospitalist
Clinical Nurse Specialists: Diabetes, education Nurses: ICU Manager, at least one manager from medical floor (or their representative) Clinical Pharmacist Administration presence – from level of quality assurance or similar title Discharge Coordinator – not required for initial discussions and implementation, but needed later Nutritional services – not required for initial design and implementation of forms.

TASKS Formulary Nursing Issues Forms Clean up insulin
Clean up oral agents Nursing Issues Policy on IV insulin use Policy on frequency of glucose monitoring Forms Design forms IV insulin forms SQ insulin forms ?DKA treatment forms

Other Committees To be Conquered
Pharmacy and Therapeutics Formulary issues Oral agents Insulins Insulin Forms – iv, sq Forms Insulin forms – iv, sq Quality Improvement Need buy in at this level to achieve administrative support

UCSF Implementation Committee: Endocrinologists, Hospitalist, Diabetes Nurse Specialist, Clinical Pharmacists, QA administrators, others Formulary Limited number of insulins now available Forms IV insulin forms – ICU, Floor SQ insulin form DKA treatment forms

UCSF Implementation Nursing Education Physician Training
Diabetes Nurse Specialist Intranet Training Physician Training Small group sessions Internet training

Pediatric Nursing Training
Pre-implementation N=24 Post-implementation N=22 Test of significance Total errors 127 17 Total possible errors 882 1107 Mean # errors/pt 5.29 0.77 2-tailed t, independent samples with unequal variance p.=.004 Error rate Denominator = possible errors 0.14 0.02 Z-test, 2-tail p=0.02

Improvement in Glucose Management on Medical and Surgical Wards
Limited data from before 2000 showed mean glucose was >200 mg/dl Mandatory SQ forms and Nursing education began in 2006 (just before sample shown) and then yearly Physician education mainly after 2006 sample and then yearly

Improvement in Glucose Management In the ICUs
Limited data from before 2000 showed mean glucose was >200 mg/dl Mandatory SQ forms and Nursing education began in 2006 (just before sample shown) and then yearly Physician education mainly after 2006 sample and then yearly

Improvement in Glucose Management In the ICUs
Limited data from before 2000 showed mean glucose was >200 mg/dl ICUIV insulin order form in place in 2004

Melissa E. Weinberg and Robert J. Rushakoff
Using Glucometrics to assess changes in glycemic control during hospital admission: Improvements in glucoses measured during hospitalization Melissa E. Weinberg and Robert J. Rushakoff Metric: By patient-day Day 1 Day 2 Day 3 Day 4 Days 5-14 Mean BG (SD) (mg/dL) 188.6 (64.6) 183.2 (60.4) 176.1 (49.4) 172.3 (47.7) 163.4 (50.9) Median BG (mg/dL) 174.5 169.5 168.3 165 154 % outside range (80-150) 71.2% 64.4% 63.7% 62.3% 54.1% % hypoglycemia (<60) 2.9% 0% 1.6% 1.7% 1.1% % hyperglycemia (>350) 9.1% 10.4% 6.8% 5.1% 3.8%

Hospital accused of 'dumping' homeless patient

Issues at Discharge Patient new to diabetes
Patient new to insulin or other medications Not metabolically stable (e.g. steroid taper), unclear what any requirement will be Oral agents, Incretins - when, how, why Changing medications (TPN etc) on the day of discharge Inability to perform self management Who follows patient Communication of inpatient care plan to outpatient providers Short term and long term goals

Hyperglycemia in Hospitalized Patients

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