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					Presenter Disclosure Information
  In compliance with the accrediting board policies, the
   American Diabetes Association requires the following
              disclosure to the participants:

                  NAME OF PRESENTER:
                Charles Reed, MSN, RN, CNRN

Speaker’s Bureau: Indiana University
Consultant: Roche Diagnostics
        Inpatient Management


Charles Reed MSN, RN, CNRN
Patient Care Coordinator
Surgical Trauma Intensive Care Unit
University Hospital
San Antonio, Texas
Objectives
• Identify metrics for measuring a glycemic
  control program
• Understand the importance of data in
  effectively managing a glycemic
• Identify barriers related to glycemic
  control
 Background
 •   24 Million people diagnosed with diabetes
 •   57 Million with pre-diabetes
 •   $58 Billion in hospital costs
 •   20-40% Longer LOS




CDC Press Release 6/24/2008 ADA Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care,
2008;31(3):596-615
Background
Diabetes & Hyperglycemia
 – Increased complications
 – Reduction in productivity
     • EC
     • PACU
     • OR
 – EC Diversion / Canceled elective cases
 – Increased LOS PACU / ORs on hold
 – Ill-will between physician & hospital
 – Increased LOS due to bounce back
 – Increased healthcare costs
San Antonio Express News 9/9/07
• “University's cramped ER
  illustrates the problem. It
  was expanded in the mid-
  1980s to handle 35,000
  patients a year. Today, it
  sees 70,000 in the same 44
  beds.”
   What can Healthcare
Institutions do to maximize
    current resources?
 Past
 • Historically little attention paid to glucose control
      – Lack of benchmarks, guidelines, & evidence1

 • Sliding scale insulin protocols
      –     Glucose control started at >200 mg/dl
      –     Minimal insulin used
      –     Insulin drips rare
      –     Fear of hypoglycemia



1ACE/ADA   Consensus Statement, Endocrine Practice.2006:12(4)459-468
  Present
  • Van den Berghe (2001)
         – Reduced Mortality 34%, sepsis 46%, renal failure, blood
           transfusions, polyneuropathy


  • Van den Berghe (2006)
         – Reduced Mortality in those w/ LOS>3 days




Van den Berghe et al. Intensive Insulin Therapy in the Critically Ill Patients. N Engl J Med.
2001;345:1359-1367
Van den Berghe et al. Intensive Insulin therapy in the medical ICU. N Engl J Med.
2006;354:449-461
 Present
 • Krinsley (2004) decreased mean blood glucose
   152.3-130.7
        – 29% reduction in mortality, 75% reduction in new renal
          insufficiency
 • Pittas (2004) Meta-analysis 35 clinical trials
        – Insulin therapy in the ICU decreased short-term
          mortality by 15%




Krinsley J. Effect of Intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc.
2004;79(8):992-1000                ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
 Present
 • AMI and hyperglycemia
       – Predictor of mortality
       – Elevated infarct segments


 • Cardiac Surgery and hyperglycemia
       – Independent predictor of infection
       – Reduction in mortality
       – Reduction in deep sternal wound infections


ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
Present
• Yendamuri (2003) Hyperglycemia in trauma
  patients
       – Higher: LOS, Complications: UTI, Pneumonia, Wound
         Infection, Bacteremia, and Mortality


• Frontera (2006) Hyperglycemia after SAH
       – Associated with serious complications, increased LOS,
         and an increased risk of death or disability



Yendamuri S. et al. Admission Hyperglycemia as a prognostic indicator in Trauma. J Trauma. 2003;555:33-38
Frontera J et al. Hyperglycemia After SAH Predictors, Associated Complications, and Impact on Outcomes. Stroke. 2006;37:199-203
Benefits of TGC
• Patient:
   –   Sepsis
   –   Wound Infection
   –   Dialysis
   –   Blood Transfusions
   –   Polyneuropathy
   –   Ischemic Brain Injury
   –   Respiratory Failure
   –   Pneumonia
   –   Infarct Size of AMI & Stroke
Hyperglycemia
• Causes:
  –   Pre-existing Diabetes
  –   Medications
  –   Nutrition
  –   Surgery
  –   Dialysis Solutions
  –   Hypothermia
  –   Anesthesia
  –   Stress Induced Hyperglycemia
Implementing Tight Glycemic
          Control
STICU Timeline
• 2001 - 2002 Research published
• 2003 Implementation of TGC
• 2004 Multi-disciplinary development of TGC
       protocol
• 2005 Implementation of TGC Protocol, with
             titration grid
• 2006 Implementation of TGCM
• 2007 Implementation of TGC in all Adult ICUs
Strategies for Success
• Administrative support
• Multidisciplinary team
• Assessment of current
  practices
• Development of intervention
  –   Order sets
  –   Protocols
  –   Algorithms
  –   Education
• Metrics          ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
Implementing TGC Support
• Identify Champions:

  – Administration
                               – Dietary
  – Physician

  – Nursing                    – Case management

  – Laboratory                 – Information Systems

  – Pharmacy                   – Quality Dept.


                        1ACE/ADA   Consensus Statement, Endocrine Practice.2006:12(4)459-468
                                                                   Tight Glycemic Control Process Improvement Team



Current Practice                                  AS IS Process for Getting Patients on Protocol and into Target Range
                                                                         Physician Perspective
                                                                                     as of April 20, 2007



                                    Start. Patient is admitted to unit


(Physician)                                Physician reviews
                                           original/initial labs



     Defining
     Hyperglycemia                           Is the patient
                                            hyperglycemic?
                                                                               No
                                                                                               End. Patient not on
                                                                                                    protocol.

                                                                     Hyperglycemia
                                                                     defined by
                                                                     individual physician
                                                   Yes



      Clarify Clinical                       Is the glucose

      Triggers                                level greater
                                               than 170 or
                                                   so?
                                                                                Yes                   Order insulin drip


                                                                     Cut-point defined
                                                                     by individual
                                                                     physician
                                                                                                       Nurse follows
                                                                                                       protocol/orders
                                                   No
      Automate the                                                                                                                No


      Orders                               Order sliding scale                Yes
                                                                                                       Is it time to stop
                                                                                                        the drip and go
                                                                                                       to sliding scale?
                                                                                                                             Reasons include:
                                                                     May happen at
                                                                                                                               drip at 1-2 units per hour
                                                                     rounds, not
                                                                                                                               for extended time
                                                                     admission
                                                                                                                               patient is going to the floor
                                                                                                                               patient will start regular diet

    Clarifying Transition                 Nurse follows orders              Patient transferred out

    Between Drip and
                                                                             End. Protocol stops.
    S/S                         All proceedings and records of the Quality/Risk Management Committee are confidential and all professional review actions and
                            communications made to the Quality/Risk Management Committee are privileged under Texas and federal law. TEX. OCC. CODE ANN. CHPS
                                                    151 and 160; TEX HEALTH AND SAFETY CODE § 161.032; and 42 U.S.C. 11101 § et seq.
                                                                   Tight Glycemic Control Process Improvement Team
                                              AS IS Process for Getting Patients on Protocol and into Target Range
                                                                                                             as of April 13, 2007



Current Practice                             Start


                                  Patient admitted to unit                                                          Did the MD
                                                                                                                    write orders
                                                                                                                    for an insulin
                                                                                                                                                No
                                                                                                                                                            Initiate sliding
                                                                                                                                                                 scale


(Nurse)                         Nurse draws Rainbow and
                                Accu-check (on some units
                                for all patients, on others only
                                if indicated by health history)
                                                                                                                        drip?



                                                                                                                         Yes
                                                                                                                                                      Recheck glucose level by
                                                                                                                                                           Accu-check

                                                                                                                                                                                  every 2,
                                                                                                                                                                                   4, 8 or
                                  Evaluate glucose level.                                                            Initiate drip                                                ? hours
  Physician                       Nurse approaches MD
                                      about protocol
                                       (on some units)                                                                                                       Is the patient      No
  Initiating Insulin                                                                                                 Recheck
                                                                                                                  glucose level by
                                                                                                                                                            hyperglycemic?

                                                                                                                    Accu-check
  Drip                                                                                                                                                            Yes




                                                                             No, follow protocol or orders
                                        Did the MD
                                       decide to place                                                             Nurse titrates
                                                                     Yes                                             the drip
                                         patient on
                                         protocol?                                                                 (per T GC protocol
                                                                                                                     on some units)                          Did the MD

  Physician Order                                                                                                                             Yes          choose to start a
                                                                                                                                                                drip?
                                              No
  Entry                                                                                                                                                           No
                                                                                                                      Is patient
                                                                                                                     ready to be
                                                                                                                     transferred
                                                                                                                         out?

  Nurses Titrating                                                                                                                      Yes            Did MD write
                                               Does the Nurse                                                                                         transfer orders?
  Insulin Drips           Yes
                                              choose to approach
                                                  next MD in
                                                                                                                         Yes
                                                                                                                                                          No
                                              hierarchy (resident,
                                                fellow, attending)
                                                about protocol?
                                                                                                                                                     Did MD make any
  Continuing                                                                                                                                         changes (tighten the
                                                                                                                                                      scale, send STAT
                                                                                                                                                                                  No

                                                                                                                                                     glucose to the lab)?

  Insulin Drip Once                                     No                                                             Patient
                                                                                                                   transferred out
                                              End. Patient not on                                                                                         Yes
  on Regular Diet                                  protocol.
                                                                                                                End. Protocol stops.                 Initiate new orders

                           All proceedings and records of the Quality/Risk Management Committee are confidential and all professional review actions and
                       communications made to the Quality/Risk Management Committee are privileged under Texas and federal law. TEX. OCC. CODE ANN. CHPS
                                               151 and 160; TEX HEALTH AND SAFETY CODE § 161.032; and 42 U.S.C. 11101 § et seq.
                                                                     TGC-Barriers to Protocol and to Achieving Target


                               Nurse
                                Nurse
                                                                 Fear                                                               Fearful
                                                                                                                                              Doctor
                                                                                                                                              Doctors

     No algorithm                                                                                                                                                           Driven by different triggers
                                                          Hypoglycemia                                                    Hypoglycemia
        Gets thrown away                               Pump programming errors                                                                                        Hold different opinions
   Removed from binder                                                                                        If on protocol, MD takes off
              1. Fear HypoglycemiaassertivenessMD
Can’t get to look right in SR
         Not readily accessible
                               Lack of
                                 Reluctant to call
                                                                                                                                                      Different protocols,
                                                                                                                               1. Putsbeliefs Hypoglycemia TX, target ranges
                                                                                                                               Personal Fear
                                                                                                                                         off doing it                Too many chiefs
                                 In target range                Lack of experience                                                                                       Different interpretations
    Don’t believe due to education                                                                                         Lack of time
                                                                                                                                                                             Faculty vs. residents vs. interns
              2. Lack of Value TGC
       Diff in pts; in diabetic, 150 is normal
         Difference in believes
                                                                     Fear
                                                                          MD puts off ordering
                                                                                                                               2.
                                                                                                                                Too busy
                                                                                                                        MD doesn’t order
                                                                                                                                         Personal Beliefs in treatment
                                                                                                                                                      Interruptions
                                                                              Lowers priority for nurses                             Personal beliefs
                     Not up on literature                                     Frustrates nurses                                                                                Orders wrong SS or drip
                 Standards have changed
              3. Nurse Avoids Drip
                             In standards
                                                                                Not all nurses value TGC
                                                                               Don’t understand
                                                                                                                               3.        Different ClinicalPersonal preference
                                                                                                                          Avoids protocols
                                                                                                               Doesn’t think protocol works for everyone    Triggers
                             Don’t think protocols work                                                                                                                          Lack of training
                                                                             Don’t understand                             Thinks will have to increase SS
                        Not enough pumps for drips                                   Doesn’t know when to switch
                                                                                                                               4.        Lack of time/ too busy
                                                                                                                                         Admitted without orders
                                                                                                                                                                             Computer order entry issue

              More Reluctant
              4. frequent avoids dripsto call MDblood
                   Nurse
                          accuchecks
                                                                                           from SS to drip
                                                                                      Lack of protocol                                   Doesn’t answer page
                                                                                                                                                  know
                                                                                                                               5. Don’t forgets about
                                        Wasting too much                            Lack of standardization
   Not enough techs to do accuchecks
                       More work               Too many sticks                                                                  Getting admission orders
                                                                                                    Goes off protocol
                                 Follow
              5. Does Not of protocol
                          Sympathy for the patient
                    Delays start
                                                                                                Fear of hypoglycemia
                                                                                                                                        Too busy;
                                                                                                                                                   MD not available

                 Protocol   Other priorities
                                                                 Too busy
                                                                                                  Too busy
                                                                                            Personal belief                              protocol                                            Barriers to Protocol
                                                                                                                                                         MD doesn’t order                     & Meeting Target
                       Lack of insulin syringes
                                           On back order
                                                                                1. Dialysis  Develops sepsis
                                                                                       Started on Steroids
                                                                                                                            For procedure
                                                                                                                           Protocol not followed
                                                                                                                                                   Won’t break chain
                                                                                                                                                     of command
  No standardized way of dispensing                                                                                              off floor              Accucheck not
            Unit to unit                           Unit of measure to bill
               PYXIS versus 446                     versus unit to treat        2. Bolus Feeds
                                                                                Dialysis patient
                                                                                                                         Leaves floor     Protocols only
                                                                                                                                                        always ordered
                   Lack of insulin                                                                                                        on some units
                                                                                                                     Level may be
1. Delay in receiving drip
                                                                   3. Feeds Held Patient preference MD won’t order protocol
                                                                             Insulin increased                                                  Not every patient gets it
                                                                    Stays elevated after dialysis       1. Different depts
                                                                                                                  considered abnormal

                                                                               Dextrose in dialysate
                                                                                            Level may be     do things differently
2. Delayed deliver ofreal time value
     Lack of drip
      from Pharmacy                                                     for procedureon TPN normal Inconsistent units have a vs.
                                                                                        considered
                                                                                  Started               2. Not all
                                                                                                                                   Parm/Units (PYXIS
                                                                                                                                         floor stock)
  Nurse has to do                         Lack of real-time lab values                                                                     Nurse doesn’t
                                                                                  Patient started on feeds    results
                                            Have to call for lab values
3. Reactive Instead ofReactive instead of proactive Regular Diet to gauge intake some stick pt.
                                                                   4.             Difficult                 protocol
                                                                                                           Some use A line;                   make drip
                                                                                                                                         Not suppose to, only in emergency
                                                                                 Non continuous bolus       Drawn differently      Difficult to get buy-in from MD
     Proactive
     MD not aware they have to do
                                  That’s the standard                                                                                Differ Policy
                                                                                                        3. No Standardized on f/u, how often, etc.
               No comment in Sunrise                                                                       SS from floor has different triggers
                                                                                        Patient               Not every unit has protocol                                Different believes
                                               STAT glucose takes an hour           Patient                       Different MD buy in
                                                                                                       Different trigger floor to unit
                                                                                                                                                                       Personal preference


    Facility /                                     More expensive

                                             Glucose not considered “super-STAT”
                                                                                                                                         Policy /
                                                                                                              Driven by different protocols
                                                                                                                   Handled differently on floors
                                                                                                                                                                   No standardized policy
                                                                                                                                                                    Too busy to sit and discuss

    Facility/Equipment                                                                                                                                                No agreement from MDs

   Equipment                                                                                                                             Protocol
                                                                                                                                         Policy/Protocol
                                                                                                                                                                                                       IBM
                                                                                                                                                                                                     QPI/UHS
                       All proceedings and records of the QRM Committee are confidential under Texas and Federal law. Tex. Occ. Code Ann. Chps151 and 160; Tex. Health and Safety Code
                                                                                                                                                                                                     04/2007
                                                                                    § 161.032; and 42 USC § 11101 et seq
                                 Patient                                                                    Physicians

                                                                          MDs feel guilty about                                Depends on service
                                                                          nurse's increased work load
All ICU patients don't                                                                                                                        No consensus
                                                                 Diabetic treatment      Not a focus
necessarily have to be in ICU                                                                                                                                        Preferences and beliefs
                                                                 for hyperglycemia                            ue                          No
    skewing numbers?                                                                                       iss                               righ
                                                                or Type 2 Diabetes                     ta
                                                                                                         n                                  to a t/wron                      No
                                                                                                  No                                            chi
                                                                                                                                                   eve g way
                                                                                                                                                                                stu

                            tie on
                                                                                                                                                                                   dy
                                                                                                                                                                                      tha

                                  ?
                          pa ed                                      tre D                  Lack of standard                                           TG
                               nts
                                                                                                                                                          C                               t
                                                                        atm iff                                                                                               dec TGC says
                        se eed
                                                                           en eren          operating procedure                                                                   rea the if o
                     the C n


                                                                             ts t                                                                                                    se             n
                                                                           or on         Residents don't tell                                                                           in Mre is a
                       TG




                                                                             als                                                                    Admitted in middle of night             &M
                                                                                         interns
                                                                                                                                                     Not
                                                                                                                                                         prio




                                                                                                              re of
          Sick patients not on insulin                                        Type 1 Diabetic,                                                               rity




                                                                                                            du e
                                                                                                       pro owl of
                                                                                                          ce edg
                                                                              insulin only option                                                                 at th
                                                  enc e




                                                                                                         kn ack
                                              r                                                                                                                        at ti
                                      Pr ef e                                                                                                                               me




                                                                                                           L
           Different standard on floor than ICU                                                          Intern's lackadaisical attitude                     Barriers to instituting tight
                                                                                                                                                              glycemic control protocol
                                                          it
                                                      s if ce in                                                                                               and to keeping TGC on
                                                 now en                                                                                                                patients
                                              y k iffer                         Patients in ICU with transfer orders
                                           bod d ts                             for floor placement skew numbers
                                         No kes a atien                                                                          ea                           No study for when drip
                                          ma se p                                                                              ak
                                           tho                                                                             it m e?                            starts from sliding scale
                                                                                                                        es renc
   Nurses complain about patient                                                                                      Do ffe
                                                                                                                       di                                          TGC fairly new
   taking diet on insulin drip                                        Patients in ICU who are
                                                                      eating regular diet
                                      d
                                   loa
                               work                             Nurses complain hard to keep on TGC                                                                         Not with sliding scale or
                           ses                                                                                ep                                                            insulin sensitizers
                        rea                                                                               o ke
                     Inc                                                                                dt
                                                                                                                                                                     On
                                                                                                                                                                       ly
                                                                                                      ar rip
                                                                                                     H d                                                                  stu
                                                                                                       on                                                                    dy
                                                          No protocol (pre-set) for TGC                                                                                         wi
                                                          sliding scale from MD to choose                                                                                         th
                                                                                                                                                                                     dri
                                                                                                                                                                                        p
                                 Staff                                                                        Procedure


      All proceedings and records of the Quality/Risk Management Committee are confidential and all professional review actions and communications made to the Quality/Risk Management Committee are
Barriers Current Practice
• Cost            Reduction in LOS
                  Reduction in blood
                  Reduction in dialysis
                  Reduction in diversions
                  Reduction in antibiotics
                  Decrease in wait times
                  Increased patient function
Barriers Current Practice
• Hypoglycemia   NPO/Feeds held/Regular Diet
                 IVF changed
                 Dialysis
                 Failure to change Insulin dosing
                 Medication Error
                 Infrequent blood glucose
                 monitoring
                 Orders not clearly written
Barriers Current Practice
• Organizational
  –   Culture/Training
  –   Workflow habits
  –   Nursing time
  –   Skepticism about benefits
  –   Fear of hypoglycemia
  –   Lack of knowledge
  –   Lack of integration technology
  –   Lack of ownership

                     ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
Survey Barriers Current Practice
                                                 •   Protocol not followed at all
•   No algorithm available to follow
                                                 •   Protocols differ per unit and per service
•   Difference in RN/MD belief for appropriate
    accucheck levels
                                                 •   Glycemic control driven by different
                                                     trigger values
•   RN/MD fear of hypoglycemia
                                                 •   Too many chiefs/no consensus on how to
•   Pump programming errors                          treat
•   Reluctance to call MD regarding              •   Order wrong/inadequate sliding scale or
    hyperglycemia/Inexperience                       drip
•   Nurse avoiding initiation of IV drip         •   Lack of insulin availability
•   Tight glycemic control not valued            •   Delayed delivery of drip from pharmacy
•   Knowledge deficit for switching from drip    •   Initiation of dialysis/Termination of
    to sliding scale or vice versa                   dialysis
•   Delays in starting protocol                  •   Lack of real time accucheck report
                                                     capability
•   MD does not order protocol/drip
                                                 •   Patient preference/Patient refusal
•   MD avoids protocol
                                                 •   Inconsistent accucheck source (finger
•   Difficulty obtaining admission orders with       stick vs. blood draw vs. A-line)
    protocol
                                                 •   Conversion to Bolus feeds or PO diet
                                                 •   Nurse deviates from protocol
       Kn
         ow
              le
                 dg
                   e
                        De
                             fic
               De
  Ad M l N it fo
       m D ay u r r s
         iss d in se w




                                                    0%
                                                         1%
                                                                2%
                                                                      3%
                                                                             4%
                                                                                        5%
                                                                                               6%
                                                                                                      7%
                                                                                                            8%
                                                                                                                  9%


Di           io oe st a v itch
   ffe N n o s n artin oid ing
       re u rs rde ot o g dr
         n t e rs r pr ip
            pr d e w de oto s
               o t vi ith r p c
                   o c at o ro ol
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              er            p e fro r o col
                                 r u m to c
                 sio                     p o
                     n To nit & r ot l
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                            bo m se co l
                       Di lu an r vi
                           ffe s f y c ce
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                 ot Fe ren ed he if
     Ti             oc ar ce o s
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   la              em I foll glyc ie fs
      y                              o
        in D ic nad we em
           re iff co e q d ia
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                  ivi en r ol ate al
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                is M fo al t lue
                   ta D m rig d
                      nt a p g
                         ac vo ha er
                              cu ids rm s
                 La               ch p ac
                     ck              ec ro y
                         of N k s toco
                    R a o o
               Pu e lu gg Al ur c l
                    m cta e rg gor e
                      p n a ith
                         Pr ce te m
                             og to re
                                  ra c po
                                    m al rt
                       St La min l MD
                           a r ck g
                               t            e
                          Pa /Sto of i rro
                               tie p nsu r
                                   nt D ia lin
                                                                                                                         ICU Barriers to Tight Glycemic Control




                                      pr ly
                                        ef sis
                                          er
                                            en
                                               ce
                                                    0%
                                                         10%
                                                               20%
                                                                     30%
                                                                           40%
                                                                                  50%
                                                                                         60%
                                                                                                70%
                                                                                                      80%
                                                                                                            90%
                                                                                                                  100%
               Kn
                 ow
                        le
                          dg
                            e
                                 De
                                       fic
                                           it
                                                fo
                         D           N            r
                            el          ur sw
           Ad M ay se                                     itc




                                                                       0%
                                                                            2%
                                                                                 4%
                                                                                      6%
                                                                                           8%
                                                                                                10%
                                                                                                      12%




              m D                   in            a v hin
                 is do st
                   si                                o            g
                      on e s a rti i d d
        D                   o n                    ng ri
          iff Nu rde ot o pr ps
             er       r
               en se rs w rde otoc
                  t p de                    i rp                   o
                      ro vi a tho rot l
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              C                       p e m oc
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                   ve                            ni o t
                        rs
                           io To t & oco
                              n
                                 to o m ser l
                                       bo an vi c
                                D l us y c e
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                                       er fe e heif
                                          e           d           s
                     Pr F n ce or
                          ot ea                                 d
                             oc r H i n B iet
             Ti                  ol              yp el i
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                       ly                      ol            ce
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                              m ad                                i
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                in       D             co qu                   t




MCCU
                   re iff e ntr ate all
                       ce ren ol                             or
                           iv
                              i n t cl not der
                                 g            i
               In                    dr ni ca va lu
                                         ip
                 co                                               ed
                    ns                        f lt
                         is       M o m rigg




STICU
                            ta D a                   p e
                                nt vo har rs
                                    ac id                      m
                                        cu s p ac
                                             c h ro y
                        La                        ec to
                             ck                      k co

TICU
                                 of No so u l
                                       a                        rc
                                                                   e
                              R gge Al g
                                 e                         o
                         Pu l uc rga rith
                             m tan te m
                                 p
                                     Pr ce rep
                                         og to                   or
                                              ra c a t
                                                  m ll
                                                    m M
                                           La          i           D
                                  St c ng e
                                      ar          k              rr
                                          t / of
                                              S          in or
                                                                                                            Barriers by Unit Current Practice




                                   Pa to su
                                        t ie p D li n
                                             nt            i
                                                  pr a lys
                                                     ef
                                                        er is
                                                              en
                                                                 ce
Implementing TGC
Interventions
• Standardization of tight glycemic control protocols

                  mostly….
      Unit                  Initiation of TGC Protocol   Initiation of insulin drip
      STICU                 Blood Glucose>110            Blood Glucose>120
      MCCU                  Blood Glucose>120            Blood Glucose>150
      TICU-Cardiothoracic   Blood Glucose>130            Blood Glucose> 130
      TICU-Transplant       Blood Glucose>150            Blood Glucose> 150
Implementing TGC
Interventions
•   Yale
•   Leuven
•   Portland
•   Digami
•   University of Washington
•   Rush University
•   Northwestern University
                           Patient admitted
                                to unit

            STICU
Implementing TGC
      Insulin Algorithm     Patient started
                                                       Follow NPO

Interventions
       for Patients on a
                              on diet or
                             bolus feeds
                                                No
                                                        Algorithm




        Regular Diet or           Yes



         Bolus Feeds       Perform 3 Accu-
                               Checks           Yes
                                                         Serum
                                                      Glucose > 120
                                q 4hr


                                                           No


                                                      Is Patient to
                               Accu-                                        Follow serum
                                                No         be         No
                             Checks>110                                    glucose on labs
                                                      transferred?


                                  Yes

                             Follow Insulin
                              sliding scale
                           and notify MD for
                             further Accu-
                            Check schedule

                                                          Yes
                                Patient
                           transferred out of
                                  unit
      STICU                     Patient Arrives
                                    on Unit
  Algorithm for

Implementing TGC
 Patients that are
NPO alone or with                 PO Diet or
                                 Bolus Feeds      Yes
                                                               Follow
                                                            PO Diet/Bolus


Interventions
TPN, Continuous
  Feeds or IVF
                                   Ordered


                                      No
                                                           Feed Algorithm




                                 Perform q 4hr
                                 Accu-Checks
                                      x 3
                                                                                     Yes



                                      1
                                  One Accu-
                                 Accucheck
                                 Check >150
                                                  Yes
                                    >150
                                      No
                                                                 Insulin
                                                             Start Insulin Drip
                                                             with q 1hr Accu-

                                     Two          Yes              Drip
                                                                  Checks

                                     2
                                 consecutive
                                 Accu-Checks
                     Yes         Accuchecks
                                    > 120                                        Patient on
                                    >120                                        Regular Diet /
                                      No                                         Bolus Feed
                                                                                                 Yes      Insulin Drip
                                                                                                            Titration
                                 Monitor Serum                                                             Required
                                Glucose on Labs                             No
                                for Values >120

                                                                                                                           No
                                                              Perform q 1hr
                                                              Accu-Checks

                                     Patient
                                                                                                         Switch to q 2hr
                                  Transferring
                           No                                                                             Accu-Checks
                                    to Floor



                                      No
                                                              Insulin Drip at
                                                              Constant Rate
                                                    No                                             Yes
                                                               for 4 or more
                                                                     hrs
                                    Serum
                                                  Yes
                                 Glucose >120




                                                         Transfer Patient
Implementing TGC
Interventions
• Develop protocol
  – Prompt users to initiates drip
  – Permits titration by ICU nurses
  – Ensure continuous administration of
    glucose
  – Specifies frequency glucose
    monitoring
  – Specify treatment plan for
    hypoglycemia.
  – Ensure nurses can handle increased
    burden of frequent glucose checks
  – Transition to subcutaneous insulin
                               BS 111-140        BS 141-180        BS 181-250       BS 251-400           BS >400
  Initial     Same BS         Reg. Insulin 2    Reg. Insulin 4     Reg. Insulin    Reg. Insulin 8    Reg. Insulin 10
Infusion    defined as +/-    units IVP and     units IVP and      6 units IVP     units IVP and      units IVP and
   Rate           5.          start drip at 2    start drip at   and start drip    start drip at 4    start drip at 4
                                 units/hr.        2 units/hr.     at 2 units/hr.      units/hr.          units/hr.



            Infusion Rate     Infusion Rate     Infusion Rate    Infusion Rate     Infusion Rate     Infusion Rate
              1-3 units/hr     4-6 units/hr.     7-9 units/hr.   10-12 units/hr.   13-16 units/hr.    >16 units/hr.



                              Stop infusion.    Stop infusion.   Stop infusion.    Stop infusion.    Stop infusion.
            Stop infusion.
                              Call provider.    Call provider.   Call provider.    Call provider.    Call provider.
             Call provider.
                                Give 50ml         Give 50ml        Give 50ml         Give 50ml         Give 50ml
BS 0-50     Give 50ml D50.
                              D50. Recheck      D50. Recheck     D50. Recheck      D50. Recheck      D50. Recheck
            Recheck BS in
                                  BS in             BS in            BS in             BS in             BS in
              30mins.***
                                30mins.***        30mins.***       30mins.***        30mins.***        30mins.***


            Stop infusion.    Stop infusion.    Stop infusion.   Stop infusion.    Stop infusion.    Stop infusion.
            Recheck BS in      Recheck BS       Recheck BS in    Recheck BS in     Recheck BS in     Recheck BS in
              30mins.***      in 30mins.***       30mins.***       30mins.***        30mins.***        30mins.***
BS 51-70
            When BS>110       When BS>110       When BS>110      When BS>110       When BS>110       When BS>110
            restart@ 50%      restart@ 50%      restart@ 50%     restart@ 50%      restart@ 50%      restart@ 50%
             of previous       of previous       of previous      of previous       of previous       of previous




            Decrease rate     Decrease rate     Decrease rate    Decrease rate     Decrease rate     Decrease rate
BS 71-80
            by 2 units/hr     by 3 units/hr.    by 4 units/hr.   by 6 units/hr.    by 8 units/hr.    by 9 units/hr.
Implementing TGC Interventions
• Matheny (2007)
       – 3616 diabetic patients
             • 613 Lacking POC BG two days


• Colard 2004
       – St. Lukes Hospital Kansas City MO
       – 12,000 POC BG tests month
             •   400-500 (up to 12.4%)
             •   274 4.9%
             •   102 1.7%
             •   6    .18%

Matheny M et al. Treatment Intensification and Blood Glucose Control Among Hospitalized Patients. J Gen Intern Med.
2007;23(2):184-189 Colard D. Reduction in Patient Identification Errors Using Technology. 2004 Clinical Lab Expo AACC
               Invalid POC Blood Glucose Monitoring
igned      Date/Time Device ID   Operator ID   Operator   Sample ID   Accession-Reason For Failure
 Fl Hart   11/05/2008 21:24      UJ85005670    33560      123555945   -;;ADT: Invalid Patient ID
 Fl Hart   11/06/2008 11:07      UJ40005272    31447      130231812   -;;ADT: Invalid Patient ID
 Fl Hart   11/07/2008 07:37      UJ85005670    31688      130542952   -;;ADT: Invalid Patient ID
 Fl Hart   11/07/2008 10:24      UJ40005272    31447      130231812   -;;ADT: Invalid Patient ID
 Fl Hart   11/07/2008 16:22      UJ40005272    31480      130231812   -;;ADT: Invalid Patient ID
 Fl Hart   11/08/2008 11:12      UJ40005272    32688      130520931   -;;ADT: Invalid Patient ID
 Fl Hart   11/09/2008 17:06      UJ40005272    33676      130231812   -;;ADT: Invalid Patient ID
 Fl Hart   11/10/2008 04:07      UJ40005272    20538      130544599   -;;ADT: Invalid Patient ID
 Fl Hart   11/10/2008 09:54      UJ40005272    32755      130231812   -;;ADT: Invalid Patient ID
 Fl Hart   11/12/2008 05:32      UJ40005272    20538      130544599   -;;ADT: Invalid Patient ID
 Fl Hart   11/14/2008 16:23      UJ85005670    31688      130684688   -;;ADT: Invalid Patient ID
 Fl Hart   11/15/2008 12:38      UJ40005272    29677      138604795   -;;ADT: Invalid Patient ID
 Fl Hart   11/16/2008 11:00      UJ85005670    31547      130629187   -;;ADT: Invalid Patient ID
 Fl Hart   11/16/2008 16:39      UJ40005272    21280      130587666   -;;ADT: Invalid Patient ID
 Fl Hart   11/16/2008 21:03      UJ40005272    21280      130587666   -;;ADT: Invalid Patient ID
 Fl Hart   11/18/2008 21:48      UJ85005670    22248      130367766   -;;ADT: Invalid Patient ID
 Fl Hart   11/18/2008 22:16      UJ40005272    21480      130129101   -;;ADT: Invalid Patient ID
 Fl Hart   11/19/2008 21:40      UJ85005670    31688      130627094   -;;ADT: Invalid Patient ID
 Fl Hart   11/21/2008 10:04      UJ85005670    31547      130397398   -;;ADT: Invalid Patient ID
 Fl Hart   11/21/2008 16:24      UJ40005272    33560      130616361   -;;ADT: Invalid Patient
 Fl Hart   11/21/2008 21:32      UJ40005272    33560      130616361   -;;ADT: Invalid Patient ID
 Fl Hart   11/25/2008 11:20      UJ40005272    31547      130364544   -;;ADT: Invalid Patient ID
 Fl Hart   11/26/2008 12:45      UJ40005272    30765      130744178   -;;ADT: Invalid Patient ID
 Fl Hart   11/30/2008 17:08      UJ40005272    22248      130653710   -;;ADT: Invalid Patient ID
                                                    % Invalid




                   0.00
                                0.50
                                             1.00
                                                            1.50
                                                                         2.00
                                                                                      2.50
                                                                                                   3.00
     Au
Se gu
  pt        s
     em t
         b
   O er
      ct
        o
 No be
   ve r
       m
 De be
   ce r
       m
          b
   Ja e r
       nu
  Fe a ry
     br
        ua
            ry
      M
         ar
            ch
         Ap
             ril
         M
            ay
         Ju
            ne
          Ju
     A u ly
Se gu
  pt        st
     em
                                                                                                          Invalid POC Blood Glucose




         b
   O er
      ct
        o
 No be
   ve r
 De mb
   ce e r
       m
          b
   Ja e r
       nu
  Fe a ry
     br
        ua
            ry
                   0
                          100
                                       200
                                             300
                                                      400
                                                                   500
                                                                         600
                                                                                700
                                                                                             800
                                                                                                   900




                                              # of samples
Implementing TGC
Interventions
• Education
       – Physicians
       – Nurses
       – Techs
• Cook (2008)
       –   S/S vs IV
       –   Options/works?
       –   Policies/protocols?
       –   Target ranges?
Cook B et al. Beliefs About Hospital Diabetes and Perceived Barriers to Glucose Management Among
Inpatient Midlevel Providers. The Diabetes Educator. 2008;34(1):75-83
Implementing TGC Metrics
• Identify Program Goal
  – 80-110, 80-140
  – What are you comfortable with?

• Identify how to measure metrics/compliance
  – Who: QA department, bedside nurse, director, lab, POC office
  – How: Chart audits, crystal or lab report, data mining software
  – When: Per shift, daily, weekly, monthly, or quarterly

• Identify what to measure
  –   Mean value (basic) good for trending
  –   % values in range (basic) good for trending
  –   % time in range
  –   % time in range by patient (best)
 Implementing TGC Metrics
 • Goal:
        – Critically Ill patients
              • 110mg/dl or as close as possible and generally<140mg/dl
        – Non-Critically Ill patients
              • 126mg/dl fasting and all random 180-200




ADA. Standards of Medical Care in Diabetes-2008. Diabetes Care. 2008;31(1):S12-S54
Implementing TGC Metrics
• Monitor, assess, and reassess
   – Daily, Weekly, Monthly


• Share the results
   – E-mail
   – Bulletin board
   – Staff meeting
STICU Case Study
Insulin Usage
• Bags used
  – 361 in 2003
  – 1063 in 2005
  – 2427 last 12 months


• Patient on Insulin drips
  – 76 in 2003 (7%)
  – 193 in 2005 (14.3%)
  – 510 in last 12 months (33%)
Evaluation of Mean Blood
Glucose
• 2003 156.1
• 2004 139.5
• 2005 130.8
• 2006 115.0
Evaluation of Mortality
Compared to Published Studies
• Krinsley (2004) 29.3% reduction in
  mortality

• Van den Bergh (2001) 34% reduction in
  mortality

• Mortality % in STICU 2001 thru 2004
  unchanged.
                 STICU Mortality

8.0%   7.1% 7.2% 6.9% 7.0%
                                        5.7% 5.8%
6.0%                             4.4%
4.0%
2.0%
0.0%
       2001   2002   2003   2004 2005   2006   2007
Evaluation of Mortality
• 2005 Mortality was reduced by:
                          30.2%

Lives Saved   28
Journal of American College of Surgeons
Data Mining
Implementation Data Mining Software
• A TGC survey was developed to evaluate the
  nursing staff’s:
    –   Knowledge of existing protocol.
    –   Perceived percentage of effectiveness in achieving target range.
    –   Perceived barriers to TGC.
    –   Knowledge of available research literature on TGC.
    –   Knowledge of benefits related to TGC.


•   60 nurses, 92.3% participated in the survey.
    – 100% knew of the protocol and target range.
    – 86% believed they achieved target range 50% to 90%
    – 59% believed they achieved target range 70-90% of the time.
Implementation of Data Mining Software

• Pulled data from 5 consecutive quarters
  –   Feb 2, 2006 - May 1, 2006
  –   May 2, 2006 - Aug. 1, 2006
  –   Implementation of Software Aug. 2, 2006
  –   Aug. 2, 2006 - Nov. 1, 2006
  –   Nov 2, 2006 - Feb 1, 2007
  –   Feb 2, 2007 - May 1, 2007
Implementation of Data Mining Software
                                        Percent of Time in Range 80-110 mg/dl

50

                                                                                                               46.4
45                                                                                          44.7
                                                                                                                        43.8                          43.2
                                                                                                                                   42.3
                                                                                                   40.8                                   41.4
40                                                                                39.7


35
                                                     33.6

30                               29.7
                                         29                    29.2
                                                                      28.3
              25.9
25                   24.9


20
     F eb -     M ar -   A pr-     M ay-      Jun-      Jul-     A ug -   Sep -     Oct -     N o v-   D ec-     Jan-     F eb -     M ar -   A pr-
      06         06       06        06         06        06       06       06        06        06       06        07       07         07       07
Results                                                  Mean Glucose Value
                                                                  p<0.001
                                               125       121
     91,536 glucose results collected          120
                                               115                              112
            % Values in Targe Range            110
                     p<0.001                   105
50                                  46
                                                      Mean Pre               Mean Post

45
              39
40
                                                       % Time in Target Range
35
                                                                  p<0.001
          % Values Pre         % Values Post
                                               50                               41
                                               40
                                                        27
                                               30
                                               20
                                               10
                                                     % Time Pre             % Time Post
 Submitted to SCCM
                                                        Value




                         0
                             25
                                  50
                                       75
                                            100
                                                  125
                                                         150
                                                                175
                                                                      200
                                                                            225
                                                                                  250
                                                                                        275
                                                                                              300
              1/4/2003

              3/4/2003

              5/4/2003

              7/4/2003

              9/4/2003

             11/4/2003

              1/4/2004

              3/4/2004

              5/4/2004

              7/4/2004

              9/4/2004

             11/4/2004

              1/4/2005

              3/4/2005




Data Point
              5/4/2005
                                                                                                     January 2003- February 2007




              7/4/2005
                                                                                                    Average Daily Glucose Levels




              9/4/2005

             11/4/2005

              1/4/2006

              3/4/2006

              5/4/2006

              7/4/2006

              9/4/2006

             11/4/2006

              1/4/2007
Managing Inpatients

• Continuous variable rate IV drip
    – Regular Insulin
• Premixed Insulin (Basal only)
• Basal-bolus
    – Long acting Insulin and rapid acting Insulin
• Oral hypoglycemic agents
    – Stable patients eating (stability in nutrition &
      condition)
ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
 Insulin Preparations
• Human                                            • Human
  – Rapid Acting                                         – Pre-mixed
     • Lispro                                                  • Humalog™ 75/25
     • Aspart                                                    Novolog Mix™ 70/30
     • Glulisine                                               • Humulin™ 70/30
                                                                 Novolin™ 70/30
  – Short Acting
     • Regular
  – Intermediate Acting                            • Animal Source
     • Lente                                             – Regular
     • NPH                                               – NPH
  – Long Acting                                          – Lente
     • Insulin glargine
       analog Detemir
     • Ultralente National Diabetes Education Program. Http://www.ndep.nih.gov/diabetes/wtmd/diabets_suppl_2.htm
Transitioning IV to SC
• Continue IV Insulin until patient tolerating
  food/feeds
• Continue IV Insulin at least 2 hrs after 1st SC
  Insulin dose given (longer if basal Insulin)
• Regular insulin sliding scale – not effective
• Options to consider
    – Basal Insulin
    – Basal Bolus with supplemental Insulin
• Oral agents –not appropriate
ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468
Transitioning Home
• Inpatient Hyperglycemia
  – Stress Hyperglycemia (Temporary)
     • Resolves, no further action needed
  – Previously Undiagnosed Diabetes
     • Need to confirm
     • Implement therapy & Education
     • Outpatient follow-up
  – Previously Diagnosed Diabetes
     •   Evaluate level of control and compliance
     •   Adjust therapy if necessary
     •   Assess for complications
     •   Outpatient follow-up
Transitioning Home
Discharge Checklist
• Diet Information
• Contact numbers
   – Resources
   – Follow-up appointments
• Treatment Goals
• Monitor and strips
• Prescription
   – Insulin & supplies
• “Survival Skills” training
“survival Skills” Training
•   Target range for blood glucose
•   How and when to monitor blood glucose
•   How and when to take medication/Insulin
•   Basics regarding meal planning
•   How to treat hypoglycemia
•   Sick day management
•   Data and time of follow up appointment
•   How to access other resources
•   When should they call their healthcare provider
Case Studies:
More than just a number
• Utilizing hyperglycemic episodes as a
  patient indicator for a worsening condition:
  – Bleeding
  – Sepsis

• Failure to Rescue
  – Careful surveillance and timely identification of
    complication
  – Initiating appropriate intervention and notifying
    the team
250
      Clinical Case Study 1


200                                                                       200          200
                                                                                 195

                                                                   181

                                                            167

150                                                                                                                                149    149

                         132    131                                                                                          132
                                                                                                                                                123
                  111                                                                         111                108
                                                     106
100                                                                                                                    100
                                                                                                    91    90
          80
                                              76
                                       70

50

          36.1
                                                                                                          26.7
                                                                                                                                   16.8
                                10                                               8     11     11
                  5      7                                         4      6                         5            4           4     6      6     6
 0        3                            0      0      0      2                                             3            2
    00

           00

                   00

                          00

                                 00

                                        00

                                               00

                                                      00

                                                             00


                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0

                                                                      0
                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0

                                                                    :0
  1:

         2:

                 3:

                        4:

                               5:

                                      6:

                                             7:

                                                    8:

                                                           9:

                                                                  10

                                                                  11

                                                                  12

                                                                  13

                                                                  14

                                                                  15

                                                                  16

                                                                  17

                                                                  18

                                                                  19

                                                                  20

                                                                  21
                                                           Insulin drip         Accu checks         Hct
200   Clinical Case Study 2

180
                                                                                       175


160
                                                                                              156


140


                                 127         125
120                                                                             118
                                       116                                                          115
                           111
         109
         108         107                                          107                                                       107
100            101
                                                        96                                          98
                                                   94                                                                 93          93
                                                                                                                87
80                                                                                                        81
                                                                        79



60



40
      8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 0:00    2:00   4:00     6:00   8:00   9:00 10:00 11:00 12:00 13:00 14:00 15:00

                                                            POC         Serum
      9:
         00
4/




                       70
                                           95
                                                                                   120
                                                                                                                              145
                                                                                                                                                                          170
  23 :22
    /2           A
        0         M
4/ 08
  23         1
    / 2 0:0
        00         2




                                                               108
4/
  23 8 1
    / 2 0:5
        0




                                                98
4/ 08 5
  23         1
    / 2 2:0
        0




                                                             106
4/ 08 0
  23         1
    / 2 5:1
        0




                                                                                             130
4/ 08 9
  23         1
    / 2 6:0
        0




                                                               108
4/ 08 3
                                                                                                                                Angio

  23         1
    / 2 6:4
        0                                                                                  128
4/ 08 7
  23         1
                                                                                                                           Patient in CT and




    / 2 7:5
        0
                                                                                                         135




4/ 08 4
             1
                                                                                                                                                                                                  Clinical Case Study 3




  23
    / 2 8:5
        0                                                            113
4/ 08 0
  23         1
    / 2 9:4




                                      91
4/
        00         6
  23 8 2
    / 2 1:0
        0
                                                98
4/ 08 1
  23         2
    / 2 1:5
        00         0
                                                               108




4/
  23 8 2
    / 2 3:0
        00         7
                                                                                                                                                                                 00:20 Elevated




                                                                             118
                                                                                                                                                                                ICPs MD Aware




 4/ 8
   24        23
       / 2 :5
          0 6
                                                                             118




 4/ 08
   24          1
       / 2 :09
          0
                                                                           117




 4/ 08
   24          2
       / 2 :14
          0
                                                                                                   132




 4/ 08
   24          2
       / 2 :45
          0
                                                                                                                                                                    164




 4/ 08
   24          3
       / 2 :50
                                                                                                                                                                           ABG




          0
                                                                                                     134




 4/ 08
   24          5
       / 2 :02
          0
                                                 100
                                                                                                                                                                           aware of poor




 4/ 08
               6
                                                                                                                                                                           03:15 MD made




   24
       / 2 :33
          0
                                                 100




 4/ 08
                                                                       05:15 Pt




   24          6
                            72




       / 2 :53
                                                                       taken to CT




          00
 4/
                                                                                                                                               03:19 Licox tissue
                                                                                                                                               oxygenation drops




   24 8 7
                                                                                                         vent changes




                                 78




       / 2 :58
          00
                                                                                                         04:00 MD making




            8
               8:
                 56
                                                       103
                                                                                     122
      Clinical Case Study 4
200


180                                                                                                                       181 181             182
                                                                                                                                            179
                                                                                 174                                                            175
                                                                                                                                                172
                                                                                                                            170 168             168
                                                                                                                                    165
                                                                                                                                  165 164
160                                                                                                                             160
                                                                                                   153
                                                                                                 150                  150
                                                                                                                    150
                                                                                                                                         143
140      137                                              137
                                                        137                                                 140
                                                                                                              139
                                                                                                                    132
           128
120                                                            123
                                                             120
             119                                                            119
                                             116 113                        115                         114     113
                                           108 111
                                         109                                  111                 112
                                                                                                109
                                                                                                          112
100                 103
                      100              100                        102                         101                   100         100             100
                          95                                                                     98
                                         93
                                                                       88
                                                                                    84
80                             78 81
                 67 65
60                                                                                       60
                                         50                                 50
40                  40

20


 0
       6:53
       7:59
      11:54
      17:53
      19:44
       0:02
       4:05
       7:53
      11:51
      16:01
      19:50
       0:02
       3:57
       7:53
      12:04
      15:10
      15:26
      17:03
      18:02
      19:07
      19:50
      23:51
       3:43
       8:07
      11:55
      16:14
      16:18
      19:50
      23:51
       3:58
       8:11
      12:03
      16:14
      19:59
      21:00
      23:06
       3:58
       7:57
      11:54
      16:08
      19:55
       0:07
       4:00
       8:05
      11:51
      16:14
      17:11
      18:11
      18:48
       Pt admitted       Pt on 50%            Pt on 50 % venti mask,        Pt placed on Cool Pt placed on 100% Pt A&O x1-2, Pt A&O x2 conf used
       s/p f all w ith ventimask Sao2             suction q 1hrs.             Aerosol 98%     NRB, desaturating desaturation    on 100% oxygen
      multi Rib Fxs.        95%                                                                 into the 80's. Pt into the 60's
        Pt A&O x4                                                                                A&O x 2-3 but      w ith any
         on 40%                                                                                     lethargic        activity

      Blood Glucose Results             Mean Blood Glucose per day               % Oxygen Requirements          Linear (Mean Blood Glucose per day)

				
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