Meeting the Challenge of Inpatient Glycemic · Structured Insulin Order Sets in EMR 18...

Meeting the Challenge of Inpatient Glycemic Management in the Non-Critical Care Setting

Jane Jeffrie Seley, DNP, MPH, GNP, BC-ADM, CDE, CDTC, FAAN, FAADE

Diabetes Nurse Practitioner, Inpatient Diabetes Team Division of Endocrinology, Diabetes & Metabolism NewYork-Presbyterian Hospital / Weill Cornell Medicine

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Goals

•  To review the current guidelines for the management of hyperglycemia in the non-critical care setting

•  To discuss potential strategies to assist clinicians in meeting the current guidelines

At the end of this program the participant will be able to:

Objectives

•  List current glycemic targets in non-critical care

•  Identify and apply the current American Diabetes Association guidelines for when to initiate blood glucose monitoring, A1c testing and insulin therapy in non-critical care setting

•  Discuss strategies for initiating and intensifying subcutaneous insulin therapy

•  Identify key strategies that lower risk of hypoglycemia

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Scope of the Problem

•  In 2002, close to 5 million hospital discharges in the US had diabetes listed as a diagnosis, with an estimated cost of $40 billion (Umpierrez et al, 2002)

•  In 2008, Healthcare Cost and Utilization Project (HCUP) Statistical Brief estimated up to 24% of inpatients have diabetes, with longer length of stays and higher costs (Fraze et al, 2010)

•  38% of patients in US community hospitals have hyperglycemia and/or diabetes (Umpierrez et al, 2012)

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Umpierrez, GE; Hellman, R; Korytkowski, M; Kosiborod, M; Maynard, G; Montori, VM, Seley, JJ; Van den Berghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. (2012). J Clin Endocrinol Metab 97: 16–38 Fraze, T., Jiang, H. J., & Burgess, J. (2010). Hospital stays for patients with diabetes, 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK52658/ Umpierrez, G. E., Isaacs, S. D., Bazargan, N., You, X., Thaler, L. M., & Kitabchi, A. E. (2002). Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. The Journal of Clinical Endocrinology & Metabolism, 87(3), 978-982.

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Polling Question

What percentage of patients in the hospital with hyperglycemia have no history of diabetes?

A) 8%

B) 12%

C) 24%

D) 38%

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•  Of the 38% of inpatients with hyperglycemia, 26% have pre-existing diabetes and the remaining 12% have “new” hyperglycemia

•  Many patients learn that they have diabetes during hospitalization (~6%)

•  This provides an opportunity to identify untreated diabetes and send these patients home on an individualized diabetes self-care regimen

Scope of the Problem

Umpierrez, GE; Hellman, R; Korytkowski, M; Kosiborod, M; Maynard, G; Montori, VM, Seley, JJ; Van den Berghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. (2012). J Clin Endocrinol Metab 97: 16–38 Fraze, T., Jiang, H. J., & Burgess, J. (2010). Hospital stays for patients with diabetes, 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK52658/ Umpierrez, G. E., Isaacs, S. D., Bazargan, N., You, X., Thaler, L. M., & Kitabchi, A. E. (2002). Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. The Journal of Clinical Endocrinology & Metabolism, 87(3), 978-982.

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Polling Question

The pre-prandial blood glucose target range in the inpatient setting is the same as in the outpatient setting.

A) True

B) False

Endocrine Society Guidelines for Management of Hyperglycemia

Glycemic Targets in Non-Critical Care

•  Premeal blood glucose (BG) 100-140 mg/dL (5.6–7.8 mmol/L)

•  Random BG <180 mg/dL (10 mmol/L)

•  Some patients may be maintained with a BG range below and/or above these targets

•  Hypoglycemia = BG <70 mg/dL (3.9 mmol/L)

•  To avoid hypoglycemia, re-assess insulin regimen if BG levels fall below 100 mg/dL (5.6 mmol/L)

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Umpierrez, GE; Hellman, R; Korytkowski, M; Kosiborod, M; Maynard, G; Montori, VM, Seley, JJ; Van den Berghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. (2012). J Clin Endocrinol Metab 97: 16–38

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ADA Recommendations: Monitoring

•  Obtain A1C for patients with diabetes or hyperglycemia if no result is available for the past 2-3 months

•  Start insulin therapy for persistent hyperglycemia: BG >180 mg/dL (10 mmol/L)

•  Once insulin is initiated, BG target range is 140–180 mg/dL (7.8–10 mmol/L) for non-critically ill patients

•  Endocrine Society guidelines recommend 100-140 mg/dL (5.6-7.8 mmol/L) before meals for patients that are eating

American Diabetes Association, Diabetes Care 2016 Jan; 39 (Supplement 1): S99-S104. http://dx.doi.org/10.2337/dc16-S016 Umpierrez, GE; Hellman, R; Korytkowski, M; Kosiborod, M; Maynard, G; Montori, VM, Seley, JJ; Van den Berghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. (2012). J Clin Endocrinol Metab 97: 16–38

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Strategies that Succeed

Blood Glucose Monitoring:

American Diabetes Association, Diabetes Care 2016 Jan; 39 (Supplement 1): S99-S104. http://dx.doi.org/10.2337/dc16-S016

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Patients likely to require BG monitoring and insulin therapy during hospital stay:

•  History of diabetes

•  BG >140 mg/dL (7.8 mmol/L) twice in 24 hrs: start BGM

•  BG >180 mg/dL (10 mmol/L) twice in 24 hrs: start insulin

•  Patients taking corticosteroids, enteral & parenteral nutrition

Avoid Hyperglycemia: Identify High Risk Patients

American Diabetes Association, Diabetes Care 2016 Jan; 39 (Supplement 1):

S99-S104. http://dx.doi.org/10.2337/dc16-S016

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Polling Question

According to the American Diabetes Association 2016 guidelines, the best diabetes medication regimen for a person with type 2 diabetes in the non-critical care setting is:

A) Oral agents and correction insulin

B) GLP-1 RA and basal insulin injections

C) Nutritional and correction insulin

D) Basal, nutritional and correction insulin

For Managing Hyperglycemia in Non-Critical Care

Current Recommendations

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Anti-hyperglycemic Therapy

Subcutaneous Insulin

Recommended for most non-critical

care patients

Oral Agents Not Generally

Recommended

Umpierrez, GE; Hellman, R; Korytkowski, M; Kosiborod, M; Maynard, G; Montori, VM, Seley, JJ; Van den Berghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. (2012). J Clin Endocrinol Metab 97: 16–38

Why Check A1c During Hospital Stay? •  To diagnose diabetes: in patients with stress hyperglycemia with no

history of diabetes

•  For patients with pre-existing diabetes: To identify patients who would benefit from intensive insulin therapy (e.g. need for basal insulin)

•  For discharge planning: To determine which diabetes medications are needed to reach glycemic targets

•  A1c can be auto-ordered in electronic medical record (EMR) if no result within 60 days

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Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., ... & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 97(1), 16-38.

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ADA Recommendations: Insulin Therapy

(JAMA, 2009)

•  Sliding scale insulin in the hospital setting is strongly discouraged

•  An insulin regimen with basal, nutritional and correction components is the preferred treatment for non-critically ill patients

American Diabetes Association, Diabetes Care 2016 Jan; 39 (Supplement 1): S99-S104. http://dx.doi.org/10.2337/dc16-S016 Hirsch, I. B. (2009). Sliding scale insulin—time to stop sliding. Jama, 301(2), 213-214. Mendez, C. E., & Umpierrez, G. E. (2014). Pharmacotherapy for hyperglycemia in noncritically ill hospitalized patients. Diabetes Spectrum, 27(3), 180-188.

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Hardwiring!!!

Insulin Therapy: Strategies that Succeed


Structured Insulin Order Sets in EMR

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NewYork-Presbyterian Hospital (NYPH) insulin aspart-glargine subcutaneous order set cull list (2016) Naina Sinha Gregory, Jane Jeffrie Seley, Linda M. Gerber, Chin Tang & David Brillon (2016): Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting, Hospital Practice. http://dx.doi.org/10.1080/21548331.2016.1250603

Hardwired Insulin Dosing Guidelines

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NewYork-Presbyterian Hospital (NYPH) insulin aspart-glargine subcutaneous order sets dosing guidelines (2016) Naina Sinha Gregory, Jane Jeffrie Seley, Linda M. Gerber, Chin Tang & David Brillon (2016): Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting, Hospital Practice. http://dx.doi.org/10.1080/21548331.2016.1250603

(3.9–5.6 mmol/L)

(5.6-8.3 mmol/L)

(8.4-11.1 mmol/L)

(11.2-13.9 mmol/L)

(13.9-16.7 mmol/L)

(16.7-19.4 mmol/L)

(19.5-22.2 mmol/L)

(22.2 mmol/L)

(13.9-16.7 mmol/L)

(16.7-19.4 mmol/L)

(19.5-22.2 mmol/L)

(22.2 mmol/L)

Adjusting Insulin Dose Based on Current BG

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Which Insulin Needs Adjustment: If AM fasting BG is

too high or low: Adjust Basal

If pre-lunch, pre-dinner or bedtime BG is too high or low:

Adjust Bolus

How to Adjust:

If BG is less than 50 mg/dL (2.8 mmol/L): If BG is less than 70 mg/dL (3.9 mmol/L):

Deduct 50% Deduct 20%

If BG is 70-100 mg/dL (3.9-5.6 mmol/L): Deduct 10%

If BG is 180-250 mg/dL (10-13.9 mmol/L): If BG is >250 mg/dL (13.9 mmol/L):

Add 10% Add 20%

NewYork-Presbyterian Hospital- Weill Cornell Campuses: Insulin Titration Algorithm Naina Sinha Gregory, Jane Jeffrie Seley, Linda M. Gerber, Chin Tang & David Brillon (2016): Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting, Hospital Practice. http://dx.doi.org/10.1080/21548331.2016.1250603

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•  Holding insulin or reducing the dose without an order is a medication error

•  Teach RNs to discuss any concerns about safety and/or efficacy of an insulin dose with the prescriber

•  A new order must be written to hold or change the dose

Registered Nurse Insulin Administration

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Hypoglycemia

•  A hypoglycemia management protocol should be implemented by each hospital

•  A plan for preventing and treating hypoglycemia should be established for each patient.

ADA Recommendations:


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Hypoglycemia Prevention

•  Episodes of hypoglycemia should be documented in the EMR including treatment given and outcome

•  The treatment regimen should be reviewed and modified if needed to prevent further hypoglycemia


American Diabetes Association, Diabetes Care 2016 Jan; 39 (Supplement 1): S99-S104. http://dx.doi.org/10.2337/dc16-S016 Society of Hospital Medicine. Maynard, G., Berg, K., Kulasa, K., O'Malley, C., Rogers, K. M. (Eds.) The Glycemic Control Implementation Guide: Improving Glycemic Control, Preventing Hypoglycemia and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes. Society of Hospital Medicine Website, Glycemic Control Quality Improvement Implementation Toolkit available at http://www.hospitalmedicine.org

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Hypoglycemia Prevention Strategies that Succeed

•  Protocol should delineate specific steps for when and how to treat hypoglycemia

•  Specify approved treatments e.g. 15 gm tube glucose gel, 4 oz juice

•  Written nursing policy should state when to check pre-prandial BG and give insulin in relation to meal

•  Review timing of BG re-checks post hypo events and monitor recurrence rates, educate staff if needed

Facilitates Matching the Insulin Dose to the Meal

Controlled Carbohydrate Meal Plan

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Menu should include grams of carb to assist in insulin dosing & substitutions

Ryan, D., Swift, C.. The mealtime challenge: Nutrition and glycemic control in the hospital. Diabetes Spectrum; 27:163-168, 2014.

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Transitional Care from Hospital to Home

There should be a structured discharge plan tailored to the individual patient.



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Strategies that Succeed

Transitional Care:


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Preventing Readmissions: •  Who’s at high risk? Lower socio-economic

status, minorities, multiple comorbidities, public insurance, recent and/or urgent hospitalization

•  Readmission rates for patients with diabetes is 14.4-22.7% compared to 8.5-13.5% without diabetes

•  Strategies known to reduce readmission: Diabetes self-management education, individualized diabetes specific discharge instructions, care coordination in and beyond hospitalization and specialty care

Rubin, D. J. (2015). Hospital readmission of patients with diabetes. Current diabetes reports, 15(4), 1-9.

Inpatient Survival Skills Education TOPICS •  Type 1 vs. type 2 diabetes

•  How type of diabetes relates to current treatment

•  Blood glucose monitoring skills, pre/post meal targets

•  How and when to take diabetes medications, basics of how each medication works

•  Basic meal planning: identifying foods that contain carbohydrates, appropriate portions, number of servings/meal

•  Detecting, treating and preventing hypoglycemia and hyperglycemia, when and who to call

•  Sick day management, when and who to call

•  Follow up plan including who will review blood glucose records, make diabetes medication adjustments and continue education

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Umpierrez GE, Hellman R et al (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. Endocrine Society. J Clin Endocrinol Metab. Jan;97(1):16-38.

Diabetes Education Resources

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Teaching Checklist

Handouts in Multiple Languages

Practice Pens

Take Home Meters

Healy S.J., Black D., Harris C., Lorenz A., Dungan K.M.. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 36;2960-2967, 2013.

from Hospital to Home

Transitioning Medications

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A1c < 7% A1c 7-9% A1c > 9%Return to home regimen, if not contraindicated

Restart home regimen if not contraindicated, start/keep basal at 50-100% of inpatient dose

Best option: Basal insulin at 75-100% of current dose and bolus insulin with meals at fixed or calculated dose

Other options: •  Basal Plus (basal once daily + bolus at largest meal) •  Pre-mixed insulin before breakfast & dinner •  Basal insulin once daily + repaglinide with meals •  Basal insulin daily and GLP-1 daily or weekly to cover prandial needs

Adapted with permission from algorithm by Umpierrez, G. Diabetes Care 2014

Adapted with permission from algorithm by Umpierrez, G, Diabetes Care 2014

Summary •  High risk patients should be

started on blood glucose monitoring to evaluate need for insulin therapy

•  An A1c should be obtained early in the admission if there is no result in the past 2-3 months to guide therapy in and out of the hospital

•  To avoid hypoglycemia, re-assess insulin regimen if BG levels fall below 100 mg/dL (5.6 mmol/L)

•  Basal, prandial and correction insulin is the treatment of choice in the non-critical care setting

•  Diabetes self-management education is a key strategy to prevent readmissions. Education should begin as soon as a learning need is identified to allow for ample time for practice.

•  An individualized follow up plan should identify who will be reviewing blood glucose records, adjusting diabetes medication and continuing self-management education post discharge

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Meeting the Challenge of Inpatient Glycemic · Structured Insulin Order Sets in EMR 18...

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