Inpatient Glycemic Control

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Inpatient Glycemic Control Powered By Docstoc
					 Inpatient Glycemic
       Control
Sherry Buske RN, MSN,NP-C, CDE
           April 2010
         UNDERSTANDING THE
           CURRENT STATE
   Lack of A1C
   Inconsistent patient education
   Lack of coordination of BG testing, meals, insulin
    administration
   Inconsistent treatment of hyperglycemia
   Insulin use:
      Sliding scale 83%

      Basal bolus 10%

      NPH/split mixed 7%
   RESTRAINING FORCES
 Lack of knowledge
 Concern of time involved
 Increased monitoring
 Counting carbs
 Basal bolus insulin
 Fear of hypoglycemia
RESTRAINING FORCES (cont)
Timing:
 Any other big changes (Care Cast)
 How long will change take
 Time of year (summer and vacations)
   INTERDISCIPLINARY
 GLYCEMIC STRATEGY TEAM
Needs:
 Executive Leadership
 Medical Champion(s)
 Nursing Champion(s)
    IMPLEMENTING A SUCCESSFUL
   INPATIENT GLYCEMIC CONTROL
            PROGRAM

Requires:
 Interdisciplinary advisory committee
  to develop and guide ALL initiatives
  related to glycemic control
 Full time RN, CDE
    IMPLEMENTING A SUCCESSFUL
   INPATIENT GLYCEMIC CONTROL
         PROGRAM (cont)

 Designated  champion(s)
 Quality department support
 Referrals to Home Health and
  Outpatient Diabetes Center at
  discharge
      IMPLEMENTING A SUCCESSFUL
     INPATIENT GLYCEMIC CONTROL
              PROGRAM
 Development and implementation of new or
    revised interventions
     Standardized order sets
     Protocols
     Policies
     Algorithms
   Initial & ongoing staff education to follow above
   Metrics: Recognized Targets, Review GPOC
    (glucose point of care) data
                 DIABETES
              DIABETES
                 ADVISORY
              ADVISORY
                COMMITTEE
             COMMITTEE


       IHS MEDICAL
IHS MEDICAL                   TRMC MEDICAL
                            TRMC MEDICAL
        DIRECTORS
 DIRECTORS                     DIRECTORS
                             DIRECTORS
        Dr Iverson
 Dr Iverson                       M.Lee
                               DrDr M.Lee
        Dr I.
 Dr I. Brady Brady              Schminke
                             DrDr Schminke




       DIABETES ADVANCED PRACTICE
                  NURSE

       INPATIENT DIABETES SERVICES
                                          HOME HEALTH
                                      OUTPT DIABETES CENTER

           UNIT EDUCATORS/PATIENT
            CARE FACILITATORS AS
          DIABETES RESOURCE NURSES
TRMC’s Glycemic Management
         Campaign
AIM: Improve glycemic control of the
 inpatient with diabetes or hyperglycemia
 without causing hypoglycemia
   80% of the point of glucoses will be between
    100 and 180 in CCU.
   80 % of the point of care glucose will be
    between 100 and 180 on our medical/surgical
    areas.
   Keep hypoglycemic episodes at or below 4%
    house wide
                 AIM (cont)
 The aim will be accomplished through:
     1. Active surveillance
     2. Using standardized evidence based order sets
     and protocols supported by the American Diabetes
     Association (ADA), the American Association of
     Endocrinologists (AACE) and/or American Heart
     Association (AHA)
     3. Education on evidence based glycemic
     management to the nursing staff, support
     staff and physicians
             The committee defines safe ranges hyperglycemia
                   between 100 mg/dL and 180mg/dL.
        GLYCEMIC MANAGEMENT
             CAMPAIGN:
        STRATEGIES TO SUCCESS
Assessed:
 Meal Items, Menus, Supplements
 Timing of GPOC, Diabetes Meds & Meal Trays
 Reviewed ―look alike, sound alike‖ meds,
 Removed SQ regular insulin, added rapid analog
    order sets
   Use of insulin infusions
   GPOC : Glucose meter supplies, pt comfort, ?
    need for lab confirmation  or 
     IHS INPATIENT GLYCEMIC
          COLLABORATIVE
   Tap into system resources
   Share best practices
   Corporate support
   Database development
   Computerized insulin program
   Share point internal website
               PHARMACY
   Partnership formed “Inpatient Diabetes
    Services”
   Basal/bolus order set
   Formularies
   Standardize through out hospital
   Removal of mixed Insulins
   Pyxis
         LESSONS LEARNED
 Communicate
 Re-communicate
 Vary communication
 Consistent
 Transition is ongoing
       JOINT COMMISSION
INPATIENT DIABETES CERTIFICATION

 Specific staff education requirements
 Written blood glucose monitoring
  protocols
 Plans for treatment of hypo &
  hyperglycemia
 Data collection of incidences of
  hypoglycemia
 Diabetes self care education
 Identified program champion or team
 www.jointcommission.org/certificationprograms/inpatient+diabetes
CENTERS FOR MEDICARE & MEDICAID SERVICES
                   (CMS)
LIST OF HOSPITAL-ACQUIRED CONDITIONS (HAC)

   Diabetic Ketoacidosis
   Nonketotic Hyperosmolar Coma
   Hypoglycemic Coma
   Secondary Diabetes with Ketoacidosis
   Secondary Diabetes with hyperosmolarity
   Exempt: Long Term Care, Veterans, Psychiatric,
    Cancer, Rehab & more

                        www.cms.hhs.gov/HospitalAcqCond/
GLYCEMIC MANAGEMENT CAMPAIGN:
     STRATEGIES TO SUCCESS
Standardized Orders:
   Hypoglycemia: what, when, how much, & then
    what?
   Hyperglycemia: insulin infusion; not specific to
    DKA
   Basal/Bolus Insulin Order Sets: includes A1C,
    POC testing times, basal and prandial insulin,
    and correction insulin
   A1c should be run daily weekdays for timely
    results
          KEY CHARACTERISTICS OF
              COMPREHENSIVE
    INSULIN INFUSION PROTOCOL ORDERS
 Glycemic target range (100-180)
 Clear dosing instructions
       Calculation requirements for nurses (will be
        considering computerized or % of glucose
        drop)
 Glucose monitoring frequency
 Easy prescriber ordering; CHECK BOX
  simplicity
Adapted from Ahmann AJ, Maynard G. J Hosp Med. 2008;5(Suppl 5):42-54.
          KEY CHARACTERISTICS OF
              COMPREHENSIVE
    INSULIN INFUSION PROTOCOL ORDERS
 Indicates criteria for calling prescriber
 Includes recommendations for nutrition
  coverage (will be added on next version)
 Built in hypoglycemia protocol
 States guidelines on infusion initiation,
  termination and transition to SQ
       PATIENT EDUCATION &
       DISCHARGE PLANNING
   Sooner rather than later
 Incorporated into usual care
 Survival Skills Booklet / Available
  Resources Toolkits
 Communication of status across settings
 Follow Up Plan / Referrals
 Benefit of Inpatient Diabetes Services
    STANDING ORDERS FOR PATIENTS
        ON SCHEDULED INSULIN
   Nutritional insulin
       Hold if patients are NPO or eat <50% of their
        meal
       Administer scheduled rapid-acting nutritional
        insulin during or immediately following meal
        if oral intake is questionable (i.e., nausea,
        emesis, or newly advancing diet)
                    O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65.
    STANDING ORDERS FOR PATIENTS
        ON SCHEDULED INSULIN
   Tube feedings: When tube feeds are stopped
    unexpectedly
       Start dextrose containing IV fluids (many institutions
        use D10W at the same rate as the prior tube feeds)
       Hold scheduled nutritional insulin, Consider NPH or
        70/30
       Notify prescriber


                O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65
STANDING ORDERS TO FOR PATIENTS
  ON SCHEDULED INSULIN (CONT.)
   Basal insulin
     Continue glargine/detemir if NPO
     Reduce morning dose of NPH by 50% if NPO;
       may need to ↓ dose of bedtime NPH
   Steroids
       Use NPH or split mix?


              O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65.
     Inpatients   Inpatients   % of         Females    Males with Average
     served       with         Inpatients   with       diabetes   age
                  Diabetes     With DM      diabetes

2007 6,973        1,630           23.4        51%        49%     67


2008 6339         1592          25.1%         56%        44%     69


2009 5,498        1,327        24.1%        50.1%      49.9%     69
         70



         60



         50



         40



         30



         20



         10



             0
                 June   July   Aug   Sept   OCT   Nov   Dec

census all       64     53     64     57    58    60    51
pts with DM      27     19     19    22     22    21    17
%inpt DM         40     40     29    39     38    35    33
     GLUCOSE UNDER 70
              2007      2008       2009

2N          5%       3.75 %    3.3 %

3N          4%       3.75 %    3.0 %

CCU         4.59%    3.57 %    3.4 %

Housewide   4.53 %   3.69 %    3.2 %
Average
    COMMON ERRORS LEADING
       TO HYPOGLYCEMIA
   Use of single dose long acting insulin
       Elderly
       Liver or kidney insufficiency
            Need to split or give small dose in am
   Failure to adjust dosage to clinical situation
   Sliding scale as monotherapy
   Reduction in or cessation of caloric or carbohydrate
    intake
   Correction scale at HS
   No HS snack
                  Hypoglycemia in
                    Time Range



      18:01 to midnight
                   18%                                   %



                                     46 %
       25%                  11%
                                     Midnight to 06:00
12:01 to 18:00            06:01 to
                          noon
# of GPOC in hypoglycemic range


                                                  85




                                          47

                                  31



              4         2
    1


 20-29      30-39      40-49      50-59   60-70    Total
    SMALL TESTS OF CHANGE
 Eliminated daytime snacks
 HS snacks given and are 2 carbs
 Times of GPOC and carbohydrates eaten
  written on daily log located outside each
  room
 Encourage substitution of carbs not eaten
 Snacks stocked on unit – i.e. ice cream,
  pudding, yogurt
  TEST OF CHANGE (CONT)
 Education   provided on:
   Risk factors for developing
    hypoglycemia
   Symptoms of hypoglycemia

   Treatment of hypoglycemia

   Timing of GPOC to meals/snacks

   Carbohydrate counting
  TEST OF CHANGE (CONT)
 Hypoglycemic    episodes have been
  decreased by 50%
 Episodes during night due to sliding
  scale at bedtime
 Episodes during day due to mismatch
  of carb intake to insulin
      GLUCOSE OVER 180
            2007     2008      2009

2N          41.5 %   40.5 %    41.6 %

3N          40.0 %   38.75 %   37.0 %

CCU         66.5 %   58.25 %   31.3% *

Housewide   49.3 %   45.8 %    40.8 %
Average
       LENGTH OF STAY
          Inpatient   Diabetes
2007      3.79        4.85

2008      3.88        5.15


2009      3.65        4.65
“The greater the obstacle, the more
      glory in overcoming it.”
             —Moliere

				
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