Module Two Current Status of Diabetes Care at Mayo Clinic Hospital

Module Two Current Status of Diabetes Care at Mayo Clinic Hospital Curtiss B. Cook Professor of Medicine Mayo Clinic College of Medicine Learning Modules Module no. 1 2 3 4 5 6 7 Topic Hyperglycemia and hospital outcomes Current status of diabetes care at MCH Initial recognition, triaging, and management Principles of pharmacologic management: Insulin 1 Principles of pharmacologic management: Insulin 2 Review of policies and procedures Getting patient ready for discharge This module will describe current knowledge of our hospital diabetes care and ongoing efforts to improve Objectives • Discuss the challenges to managing hyperglycemia in the hospitalized patient • Describe the current status of diabetes management at MCH • Use operational definitions for inpatient glucose control Challenges to managing hyperglycemia in the hospital • Type of hyperglycemic patients – Patients with preexisting diabetes – Patients with undiagnosed diabetes – Patients with stress hyperglycemia • Types of hospitalized patients – – – – Short stay Elective/Urgent/Emergent Post-surgical Critically ill Patient population with hyperglycemia is heterogeneous Challenges to managing the hospitalized diabetes patient • Variables exacerbating hyperglycemia – Increased counter-regulatory hormones – Decreased insulin secretion – Decreased insulin sensitivity – Accelerated glucose production • Increased protein catabolism • Increased lipolysis • Medications (steroids, vasopressors) Challenges to managing the hospitalized diabetes patient • Care-related issues – Incorrect classification of diabetes – Problem overlooked or not addressed – Fear of hypoglycemia – Nutrition • Type of nutritional support • Missed injections/missed meals • Mismatching of insulin with meals – Unpredictable timing of procedures Distribution of diabetes cases, by discharge service 50 40 Percent 30 20 10 0 Primary Care Surgical Cardiology Transplant Other Distribution (%) of bedside glucose, non-ICU, MCH 2001 to 2004 First 24h average (n=2,408) 40 35 30 Overall average Staying hyperglycemic Admitted hyperglycemic 25 20 15 10 5 0 0 50 100 150 200 250 300 350 400 450 42% of patients admitted with poor control (200 mg/dl) 40 remained in poor control at 35 time of discharge 30 Last 24h average (n=2,318) Discharged hyperglycemic need to do a better job 20treating hyperglycemia 15 10 5 25 We Results of similar survey regarding operational definitions of hyperglycemia among MCH providers X = 140 mg/dl Need to develop internal consensus so everyone is practicing the same Frequency of hypoglycemia and hyperglycemia No. events/person/100 measurements 30 30 Hypoglycemia frequency 20 20 Hyperglycemia frequency 10 10 0 0 <70 <60 <50 <40 >200 >250 >300 >350 >400 Bedside glucose (mg/dl) Bedside glucose (mg/dl) Hypoglycemia rare, hyperglycemia common Which is the bigger problem? Units of insulin delivered, last vs. first 24 hours of hospitalization 100% Percent in each category 80% 60% 40% 20% 0% Tertile of BedGlucav Mean glucose 1 2 3 129 165 218 Increased Decreased No change Not just clinical inertia (failure to intensify treatment), but also… Negative therapeutic momentum (decrease in treatment despite hyperglycemia) Documentation of diabetes N= 90 charts reviewed 100 Percent of cases 80 60 Not documented 40 20 0 Diabetes in admission note Diabetes or hyperglycemia in daily progress note Diabetes or hyperglycemia in discharge note Need for diabetes or hyperglycemia follow-up Documented Diabetes often overlooked after admission Diabetes and assessment of inpatient glucose control 100 Percent of cases 80 60 40 20 0 Beside glucose measurements ordered Bedside glucose values recorded in progress notes Assessment of glucose control Not documented Documented Bedside glucose ordered, but often not tracked Final Summary • Hospitalizations are common in diabetes—you will see these patients • Good glycemic control is essential for good outcomes • There is room to improve inpatient diabetes care at MCH