Reducing Hypoglycemia Events

Tina Claypool, PharmD, CDE

Clinical Pharmacy Specialist, Ambulatory Care

Kentucky Hospital Association Conference

March 16, 2018

Learning Objectives

1. Identify severity and cost of inpatient

hypoglycemia

2. Review methods to avoid hypoglycemia

3. Create strategies of collaboration and

communication to reduce hypoglycemia

Diabetes in Acute Care

• Almost 30.3 million estimated to have diabetes in US

• Hospitalizations In 2014, 7.2 million adult hospital discharges associated with diabetes

• ED admissions In 2014, 14.2 million adult ED visits associated with diabetes

• 245,000 for hypoglycemia

• 207,000 for hyperglycemic crisis

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 18, 2018.

Financial Impact of Diabetes in Acute Care

• Total diabetes cost in 2012 = $245 billion

• Approximately 50% inpatient hospital care

• Medical costs of patients with diabetes are

2.3 x higher than without

• Increased LOS and increased costs

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 18, 2018.

Hypoglycemia and Pay-For-Performance

• Pay‐for‐performance requirements

relevant to inpatient diabetes management

• CMS will not pay cost of conditions

resulting from medical errors or poor

quality of care during hospitalizations

• Hypoglycemia is included in Never Events

related to patient safety

https://improvement.nhs.uk/resources/never-events-policy-and-framework/#h2-revised-never-events-policy-and-framework-and-never-events-list-2018. Accessed 2.28.18

Diabetes Care in the Hospital:

ADA Standards of Medical Care of Diabetes• Insulin therapy should be initiated for treatment of persistent

hyperglycemia ≥180 mg/dL. A

• Target glucose 140–180 mg/dL on insulin therapy recommended for the majority of critically ill patients A– noncritically ill patients. C

• Basal plus bolus correction insulin is preferred for noncritically ill patients with poor oral intake or those NPO

• Insulin with basal, nutritional, and correction components is preferred for patients with good nutritional intake. A

• Sliding scale insulin monotherapy is strongly discouraged. A

• Patients should have individualized structured discharge plan B

Diabetes Care in the Hospital: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S144-S151

Diabetes Care in the Hospital:

ADA Standards of Medical Care of Diabetes• Check A1C on all hospital admitted patients with diabetes or

hyperglycemia (if not performed in last 3 months). C

• Consider BG goals of 110–140 mg/dL for selected critically ill patients, as long as achieved without significant hypoglycemia. C

• Treatment regimen should be reviewed and changed to prevent further hypoglycemia when BG <70 mg/dL . C

• IV insulin infusions using validated written or computerized protocols allowing predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E

• A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E

Diabetes Care in the Hospital: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S144-S151

Risk of Hypoglycemia: Patient specific

• Advanced age and comorbidities

• Reduced oral intake

• Renal failure and liver disease

• Medications – Insulin and oral hypoglycemic agents

– Corticosteroid therapy adjustments

– Monotherapy “sliding scale”

– Long-acting sulfonylureas in elderly

– BG testing reporting and transcription errors

– Similar names of products and/or labeling

– Accessibility as floor stock

– Nonstandard IV solutions and infusion rates

American Association of Clinical Endocrinologists And American Diabetes Association CONSENSUS STATEMENT ON INPATIENT GLYCEMIC CONTROL

Endocrine Practice Vol 15 No. 4 May/June 2009.

Risk of Hypoglycemia: Institution specific

• Lack of care team coordination– Transfer to different care teams

– Transporting patients + meal delay

• Changes in caloric intake– Mistiming of insulin and meals

– New NPO status

– Interruption of:• Intravenous dextrose

• TPN or Enteral feedings

• Continuous renal replacement therapy

• Inadequate glucose monitoring

• Inadequate insulin dose adjustment

• Errors in order writing and transcription

• Use of “U” for units

American Association of Clinical Endocrinologists And American Diabetes Association CONSENSUS STATEMENT ON INPATIENT GLYCEMIC

CONTROL

Endocrine Practice Vol 15 No. 4 May/June 2009.

Hypoglycemia Prevention

• Preventable causes– Inappropriate hypoglycemia med prescribing

– Improper management of first hypoglycemia episode

– Nutrition:insulin mismatch

• Improved communication/coordination

• Provider and care team education

• Care plans– Regular glucose monitoring

– Adjustment of insulin dose

– Administration of carbohydrate, IV dextrose, or glucagon as needed

– Hypoglycemia protocol

• “Bundled” preventative therapies– Proactive surveillance of glycemic outliers

– Interdisciplinary glycemic management

Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management.

Endocr Pract 2015;21:355–367.

Situations Requiring Increased BG Monitoring

• New NPO status

• Altered ability of patient to report symptoms

• Reduced oral intake

• Emesis

• Inappropriate timing of short-acting insulin

• Unexpected interruption of feedings

• Discontinuation or reduced IV dextrose rate

• Sudden reduction of corticosteroid dose

• Changes in renal function, HD, or CRRT

http://care.diabetesjournals.org/content/39/Supplement_1/S99 Accessed 2.28.2018.

Standards for Special Situations

• Enteral/parenteral feeding

• Glucocorticoid therapy

• Perioperative

• DKA and HHS

• Hospital policy and procedures should include guidelines for CSII therapy

Diabetes Care in the Hospital: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S148-S151

Hypoglycemia Protocol

• Clear definition of hypoglycemia – Glucose level (ADA) <70 mg/dL

• Nursing order to treat without delay– Stop insulin infusion (if patient on one)

– Administer• Oral glucose (if able to take oral)

• IV dextrose or glucagon (if unable to take oral)

– Repeat BG monitoring 15 min after hypoglycemia treatment and repeat treatment if BG not at target

– Provide directions for when and how to restart insulin

• Documentation is vital– Look hypoglycemia cause and determine if other treatment

changes are needed

ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468; ADA. Diabetes Care. 2009;31(suppl1):S1-S110; Umpierrez GE, et

al. J Clin Endocrinol Metab, 2012;97:16-38.

Hypoglycemia Protocol ULH

Patient care

Medications

Consults

Collaboration

• Diabetes expert clinicians other allied HCPs work together to:– Enhance the quality of care and improve outcomes

– Increase revenues with appropriate payment for care provided and resources expended

• Proactive implementation of programs to improve diabetes control improves both patient outcome and hospital bottom lines.

• Consensus statements for glucose targets are available to guide inpatient BG control

• Safe and appropriate treatment of hyperglycemia while avoiding hypoglycemia has been shown to lead to better patient outcomes.

http://inpatient.aace.com/financial-impact-of-glycemic-control-opportunities-for-clinical-and-financial-improvement.Accessed 2.28.2018.

Diabetes Health Care Team

Patient

Primary Care

Provider

Nurse

CDE

PharmacistDietitian

Discharge planner

Endo-crinologist

AHRQ: Minimum Discharge Plans

• Medication reconciliation

• Structured discharge communication

• Quality assurance standards

The Agency for Healthcare Research and Quality Patient Safety Network. Readmissions and adverse events after discharge.

https://psnet.ahrq.gov/primers/primer/11. Accessed 2.28.2018

Medication Reconciliation

• Medications must be cross-checked to

ensure that no chronic medications were

discontinued or changed

• Pharmacist review to ensure the safety of

new prescriptions

• New or changed medications should be

filled and reviewed with the patient and

family at or before discharge

The Agency for Healthcare Research and Quality Patient Safety Network. Readmissions and adverse events after discharge.

https://psnet.ahrq.gov/primers/primer/11. Accessed 2.28.2018

Structured Discharge Communication

• Prepare for transition to the outpatient setting beginning at the time of hospital admission

• Accurate & prompt communication of med changes, pending tests, and follow-up needs

• Discharge summaries to primary care provider ASAP after discharge

• Schedule outpatient appts by inpatient team prior to discharge (↑ adherence to appointments)

• Provide patients with appropriate durable medical equipment, meds, supplies, and prescriptions

• Provide patients with education at discharge to avoid a care gaps at TOC

The Agency for Healthcare Research and Quality Patient Safety Network. Readmissions and adverse events after discharge.

https://psnet.ahrq.gov/primers/primer/11. Accessed 2.28.2018.

American Association of Clinical Endocrinologists And American Diabetes Association CONSENSUS STATEMENT ON INPATIENT GLYCEMIC

CONTROL

Endocrine Practice Vol 15 No. 4 May/June 2009.

Prior to Hospital Discharge

• Identify the HCP providing diabetes care after discharge

• Schedule follow-up outpatient appointments

• Discharge planning, patient education, & clear communication with outpatient providers ensures safe & successful transition to outpatient BG management

• Education• Assess patient understanding of diabetes diagnosis, BG self-

monitoring, & home BG goals

• Assess patient understanding of definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia

• Share information on appropriate nutrition

• Discuss when and how to take diabetes medications

• Provide sick-day management plan

• Review proper use & disposal of needles syringes

American Association of Clinical Endocrinologists And American Diabetes Association CONSENSUS STATEMENT ON INPATIENT GLYCEMIC

CONTROL

Endocrine Practice Vol 15 No. 4 May/June 2009.The Agency for Healthcare Research and Quality Patient Safety Network. Readmissions and adverse events after discharge.

https://psnet.ahrq.gov/primers/primer/11. Accessed 2.28.2018.

Quality Assurance Standards

• Routinely evaluate for quality and accordance to up-to-date evidence:– medication orders

– care plans

– protocols

• TJC: accreditation program for hospital care of diabetes

• Society of Hospital Medicine: workbook for program development

Society of Hospital Medicine. Glycemic control for hospitalists.

https://www.hospitalmedicine.org/clinical-topics/glycemic-control. Accessed 2.28.2018.

Future Steps to Reducing Hypoglycemia

• Diabetes or BG management task force

• HCP collaboration creating BG

management guidelines

• Eliminate SS insulin monotherapy

• Health care provider education

• Identify and proactively manage high risk

patients

• Quality and safety measures

Ongoing Quality and Safety Measures

• Incidence– TJC recommends all hypoglycemia episodes be

evaluated for root cause

– Review hypoglycemia episodes to address systemic issues

• Management– Review of treatment regimen when BG <70 mg/dL

– Implement hypoglycemia protocol in all hospital systems

• Outcomes– Track all hypoglycemia episodes in medical records

Moghissi ES, Korytkowski MT, DiNardo M, et al.; American Association of Clinical Endocrinologists and American Diabetes Association consensus

statement on inpatient glycemic control. Diabetes Care 2009;32:1119–1131.

Reducing Hypoglycemia Events

Tina Claypool, PharmD, CDE

Clinical Pharmacy Specialist, Ambulatory Care

Kentucky Hospital Association Conference

March 16, 2018