1. Disclosures – Anne Brittain, PhD RT(R)(M)(QM), CPHQ I have no disclosures as it pertains to this educational activity.

2. Reduction of Severe Hypoglycemia (<50mg/dL) Goal: Reduce events of severe hypoglycemia 5% by the end of FY12.

3. Baseline Data Out of 407,063 point of care blood glucose checks, there were 2,646 (0.64%) events of severe hypoglycemia as a system. Richland-1,795 Events Baptist-851 Events

9. Project Plan- 1 st Five Weeks Establish cross campus team- Senior Leader, Physician Champion, Nursing Leader, Diabetes Education, CQPS-PIT, Pharmacy, Nutrition, Nursing Education, Endocrinology Select initial pilot units Establish team aim and outcome/process measures Educate team on PI methodologies to be used Complete process mapping Determine opportunities

10. Project Plan- 6 th week and beyond PDSA planning –Begin small, but fast, for initial trials (e.g. 1 pt, 1 day, 1 unit, etc.) –Perfect change (2 weeks max per unit/area) –Expand trials/Spread change Revise Policies & PGR’s, as needed Devise system to monitor hardwiring of improved process

11. Contact Information Anne Brittain-296-2308 Anne.Brittain@palmettohealth.org Anne.Brittain@palmettohealth.org MaryJane Phipps-296-3622 Maryjane.Phipps@palmettohealth.org Maryjane.Phipps@palmettohealth.org Heather Mann-296-3392 Heather.Mann@palmettohealth.org Heather.Mann@palmettohealth.org

12. Disclosures I have no relevant financial relationships with any commercial interests related to the content of this activity – Shahid Aziz, MD Fellow, Endocrinology

13. Inpatient Glucose Management Shahid Aziz, MD Fellow, Endocrinology

14. Hospital-related Hyperglycemia Upon admission: diagnosed diabetes, undiagnosed diabetes, illness-related hyperglycemia (assess for outpatient control: meter readings, HbA1c) Hospital course: glucose targets, adjustment and titration, education and teaching, safety At discharge: planning, self-management skills Follow-up

15. The Increasing Rate of Diabetes in Hospitalized Patients Source: CDC Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Per Capita Healthcare Expenditures Hospital Costs Account for Majority of Total Costs of Diabetes Hogan P, et al. Diabetes Care. 2003;26:917 – 932. Diabetes Doubles the Cost Diabetes listed as a discharge diagnosis more than doubled from 1980 to 2006

16. Subcutaneous Insulin Injection Therapy: Insulin Requirements in Health and Illness Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care. 2004;27:553–591. Reprinted with permission. Units Healthy (outpatient) Sick/Eating (hospitalized) Sick/NPO/TF/TPN Basal Prandial Correction Nutritional NPO, no nutrition A Useful Concept…

17. Strategies and Protocols for Achieving Inpatient Glycemic Control Continuous variable-rate IV insulin drip Regular insulin Subcutaneous basal/bolus therapy Long-acting and rapid- acting insulin Premix / biphasic insulin For selected patients transitioning to outpatient care Protocol Implementation Multidisciplinary team Administration support Pharmacy & Therapeutics Committee approval Forms (orders, flowsheets) Education: nursing, pharmacy, physicians & NP/PA Monitoring/Quality Assessment

18. Glucose Control in the Hospital and Inpatient Outcomes A challenge and an opportunity to favorably impact patient care Open-heart surgery – Portland Diabetic Project 1987-2005 Acute MI – DIGAMI 1 1995-99 DIGAMI 2 Eur Heart J 2005 Surgical ICU – Leuven trial 1 N Engl J Med 2001 Medical ICU – Leuven trial 2 N Engl J Med 2006

19. Indications for IV Insulin Drip Think broad.… DKA Hyperosmolar Hyperglycemic state (HHS) Postoperative period following open-heart surgery Critical care illness (surgical/medical) Myocardial infarction (MI) or cardiogenic shock NPO status in Type 1 diabetes Perioperative care TPN High-dose glucocorticoid therapy Organ transplantation Labor and delivery

20. What should the glucose targets be using IV insulin (insulin drip) in critically ill patients?

21. Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study, New Engl J Med March 2009 6104 ICU pts, IV insulin to achieve a BG target of 81 to 108 (115) in the intensive group and 144 to 180 (144) in the conventional group. 3% increase in primary end point, death at 90 days (27.5%, vs. 24.9%, a 10% higher relative mortality). A significantly higher rate of severe hypoglycemia in the intensive-control group (6.8% vs. 0.5%)

22. Optimal Glucose Targets in Hospital Patients: The ADA-ACE Consensus Statement based on the results of NICE-SUGAR Diabetes Care, May 2009 Critically ill patients Use IV insulin in the majority of patients in the ICU setting Maintain glucose levels between 140 and 180 mg/dL Targets less than 110 mg/dL are NOT recommended Noncritically ill (floor) patients Recommendations are based on “clinical experience and judgment” Premeal glucose targets should generally be <140 mg/dL Random glucose values <180 mg/dL Protocol Implementation: a multidisciplinary effort

23. The Ideal IV Insulin Protocol Easily ordered and implemented Effective (gets to goal quickly) Safe (minimal risk of hypoglycemia)

30. Converting to Subcutaneous Insulin Establish 24-hour insulin requirement Extrapolate from average over last 6–8 hours – if stable Give one-half amount as basal, rest as bolus Transition: stop drip half hour after a small SC dose of short- acting insulin and a SC dose of long-acting (basal) insulin Monitor a.c. (before meal) t.i.d., h.s. Correct all premeal blood glucose > 150 mg/dL

33. Hospitalized patients often require high insulin doses to achieve target glucose Initial dose: Basal insulin  0.15 units / kg; titrate! based on am reading Provide both basal and bolus (prandial or nutritional) coverage Patients often need supplemental or correction insulin for premeal hyperglycemia Use of “Sliding Scale” Insulin Alone is Discouraged! Use of Subcutaneous Insulin

34. Adult Nonpregnant Subcutaneous Insulin Order Set PHR (#6001)

35. What is the Role of ‘Sliding Scale’ Insulin? Sliding scale is retroactive / reactive coverage, treats hyperglycemia after it happens, may lead to glycemic excursions Should not be used as the sole method of insulin administration Quickly add, or adjust, the basal insulin dose and add scheduled bolus insulin if necessary

36. Risk Factors for Hypoglycemia in Inpatients Advanced age Decreased oral intake Chronic renal failure Liver disease Beta-blockers Inadequate glucose monitoring Lack of coordination between dietary, nursing, and transportation; mistiming of insulin and food

37. Key components of hypoglycemia prevention and management protocol Endocrine Society Practice Guideline, Jan 2012 Hospital-wide definitions for hypoglycemia and severe hypoglycemia. Guidance on discontinuation of sulfonylurea therapy and other oral hypoglycemic medications at the time of hospital admission. Directions for adjustments in insulin dose and/or administration of dextrose-containing iv fluids for both planned and sudden changes in nutritional intake. Specific instructions for recognition of hypoglycemia symptoms, treatment, and timing for retesting depending on glucose levels and degree of the patient's neurological impairment and for retesting of glucose levels. Standardized form for documentation and reporting of hypoglycemic events, including severity, potential cause(s), treatment provided, physician notification, and patient outcome.

38. Suggested nurse-initiated strategies for treating hypoglycemia Endocrine Society Practice Guideline, Jan 2012 For treatment of BG below 70 mg/dl in a patient who is alert and able to eat and drink, administer 15–20 g of rapid-acting carbohydrate such as: one–15–30 g tube glucose gel or 4 (4 g) glucose tabs (preferred for patients with end stage renal disease). 4–6 ounces orange or apple juice. 6 ounces “regular” sugar sweetened soda. 8 ounces skim milk. For treatment of BG below 70 mg/dl in an alert and awake patient who is NPO or unable to swallow, administer 20 ml dextrose 50% solution iv and start iv dextrose 5% in water at 100 ml/h. For treatment of BG below 70 mg/dl in a patient with an altered level of consciousness, administer 25 ml dextrose 50% (1/2 amp) and start iv dextrose 5% in water at 100 ml/h. In a patient with an altered level of consciousness and no available iv access, give glucagon 1 mg im. Limit, two times. Recheck BG and repeat treatment every 15 min until glucose level is at least 80 mg/dl.

39. Hypoglycemia Guidelines (PHDOC)

40. What about Oral Agents? Insulin is the preferred medication in hospitalized patients Oral agents may be contraindicated or simply ineffective In general, avoid continuing or starting oral agents in inpatients, except in relatively healthy patients e.g. elective surgery At discharge, inpatient “survival skills” education for pts initiated on insulin; plan in advance!

41. Insulin Drip Non-insulin agents premix/biphasic Dose-finding with correctional rapid- acting insulin Insulin transition and progress towards Discharge Oral food intake, plus Basal and rapid-acting

42. Discharge Planning starts well before discharge! Establish a stable regimen of diet and meds well in advance of anticipated discharge Refresher in self-care issues, monitoring, nutrition, and diabetes teaching (“survival skills”) with inpatient diabetes educator Don’t be afraid to determine a different medication/insulin regimen if necessary discharge Arrange for comprehensive diabetes class and follow up physician visit within 2 weeks of discharge

43. Keys to Euglycemia in the Inpatient Setting Take-home Points Be aware of glucose targets Plan ahead: IV insulin, transition from IV to SC, discharge planning Communicate with patients and other health care professionals

44. South Carolina Guidelines for Diabetes Care – 2011 released September 2011 Available at: http://www.scdhec.gov/health/chcdp/diabetes/clinical.htm http://clinicaldepartments.musc.edu/medicine/divisions/endocrinology/dsc Evidence-based recommendations from: American Diabetes Association American Association of Clinical Endocrinologists American Association of Diabetes Educators