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

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4. 1,500 studies currently in progress. Most Phase 1 & 2 trials. 240 inpatient beds, 82 day hospital stations, and outpatient clinics. 3

5. 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 4

6. 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 5

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

8. 7 n engl j med 355;18 www.nejm.org november 2, 2006

9. 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 8

10. Members Attending Fellows Pharmacist Dietitian Nurse Practitioner Nurse Social Worker as needed 9

11. Attending Physician Champion Expert Training Liaison 10

12. Fellow Initial visit and history Orders On-call 11

13. Dietitian Patient teaching Participation in daily rounds Determination of diet/TPN 12

14. 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 13

15. 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 14

16. 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 15

17. 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 16

18. Report Discussion Orders Discharge planning 17

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

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

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23. Flowsheet ( Eclipsys electronic medical record) 22

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25. 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 patients medical record indicating the service is following that patient, and where progress notes can be found (On service note) 24

26. Consult Note (structured note) 25

27. Consult Note (structured note) 26

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29. Consult Note (structured note) 28

30. Consult Note (structured note) 29

31. Consult Note (structured note) 30

32. Consult Note (structured note) 31

33. Report Discussion Orders Discharge planning 32

34. 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 33

35. Quoting Lennon and McCartney, I have to admit its getting better, a little better all the time. 34

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

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41. 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 40

42. 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 41

43. 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 42

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45. 44 Regular insulin QID schedule will have overlap

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47. 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 patients 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 46

48. 47 Documentation on Flowsheet Specific for insulin pump

49. 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%) 48

50. 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 49

51. 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 50

52. Laboratory Postprandial Nursing orders Insulin Stat orders Nutrition Medications (insulin orders, ID bracelet) OGTT orders

55. Gradually increase dextrose content in TPN Initiate 0.1 units of regular insulin per gm of dextrose in TPN infusion Our maximum insulin dose in TPN is 0.3 units/gm of dextrose in TPN Correction dose of short acting insulin based on blood glucose level every 6 hours Continuous insulin infusion if cannot achieve goal 54

56. Computerized order set Four algorithms per insulin sensitivity Blood glucose monitoring required hourly initially Medical floor with adequate staffing ICU if hemodynamically unstable Transition to subcutaneous insulin when the event resolves 55

57. Regular insulin 100 units in a total volume of 100ml of sodium chloride 0.9% for final concentration of 1 unit/ml Additional instructions: See ORDER DETAILS for dosing algorithm. Notify BGMS on call physician (102-12200) when blood glucose result is above 180mg/dL and glucose does not decrease by at least 60mg/dL within 1 hour of a rate change. Page 102-12200 for all blood glucose/insulin related issues.

61. Patients requiring more than 200u/day-severe insulin resistance More than 100U/day by insulin pump is also high dose requirement Pediatrics-more than 2-3U/kg/day Typically seen in patients with severe forms of insulin resistance Increased incidence of high dose insulin requirements related to obesity epidemic Other forms of diabetes: Genetic defects in insulin secretion or action Autoantibodies to insulin receptor Endocrinopathies-Cushings and Acromegaly Most common- corticosteroid induced diabetes 60

62. What is influencing insulin requirements… Influenced by type of diabetes Influenced by energy intake - Insulin requirements when fasting - Insulin requirements after bariatric surgery Influenced by device/mechanical issues: -Pumps with bolus rate limits of 1 unit per 40 seconds, maximum bolus of 25-30 units, and cartridge that holds 180-300 units - Pens with maximum amount of 60 unit or 80 unit bolus - Cost and insurance

63. Use of U-500 Insulin inpatient setting Hospital Policy For use

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66. Multidisciplinary approach Consistent plan of care Continuous endocrinology input Quick response to medication errors Training for staff Discharge instructions for patients Electronic communication Data-driven blood glucose targets 65

67. David Harlan, MD Rana Malek, MD Kathryn Feigenbaum, RN, CDE Elaine Cochran, CRNP, BC-ADM Pamela Brooks, CNP Mahfuzul Khan, MD Christine Salaita, RD Allison McLean- Adams, RN Ann McNemar RN, IT specialist NIDDK Diabetes Branch Support Staff NIDDK and NICHD Endocrine Fellows Clinical Center Nursing Staff 66

68. Mean bg prior to our consult Median BG with range prior to consult Fasting BG on discharge % days at goal 67