Managing Diabetes and Hyperglycemia Safely in the Complex Hospital - PowerPoint PPT Presentation

Managing Diabetes and Hyperglycemia Safely in the Complex Hospital Setting Greg Maynard MD, MSc Clinical Professor of Medicine and CQO, UC Davis Medical Center Sacramento, CA

Greg Maynard – Disclosure SHM Glycemic Control Tools No personal financial interest -

21 million in US with dx of DM 8.1 million with undiagnosed DM

Why Glycemic Control? (It ’ s about more than infusion insulin glycemic targets!)  DM / Hyperglycemia Very Common  Opportunity to identify and intervene – poorly controlled DM, previously undiagnosed DM, stress hyperglycemia (pre-diabetes)  Hypoglycemia and extreme hyperglycemia – Safety problem and a Quality problem  Inpatient Care - Complex w/ unique challenges – Education alone insufficient, need systems change  Huge Implementation Gap - Chaotic baseline  Public reporting, regulatory guidelines etc. Society of Hospital Medicine. http://www.hospitalmedicine.org/ResourceRoomRedesign/ pdf/GC_Workbook.pdf.

Implementation Gap Focus on the Wards:  > 1/3 with mean glucose > 180 mg/dL  60%-70% of insulin regimens sliding scale only  >15% with hypoglycemic episodes during their stay  >6% of patient-days hypoglycemic  40% of patients with hypoglycemia suffer recurrence  Uneven training / performance amongst staff  Poor coordination of nutrition, monitoring, and insulin  Inconsistent transitions  Patients often confused or angry  Readmissions and return to ED common

Achieving good glycemic control AND low hypoglycemia  Institutional / system support – Will to standardize, goals, help with metrics  Empowered centralized steering team  Local teams addressing barriers  Protocols / order sets  Common approach for special populations and failure modes  Metrics (balanced approach)  Active surveillance (aka measure-vention)  EHR tools  Automation / closed loop algorithms / computerized glucose management

Algorithms Best practices to reinforce  Actionable glycemic target  Consistent carbohydrate / dietary / consult  A1c  Patient education plan  Hypoglycemia protocol  Guidance for transitions (linked protocols)  Coordinated monitoring / nutrition / insulin  DC oral agents, insulin preferred  Insulin regimens for different conditions  Dosing guidance

Glycemic Targets in Non-ICU Setting 1. Premeal BG target of <140 mg/dl and random BG <180 mg/dl for the majority of patients. 2. Glycemic targets be modified according to clinical status. For patients who achieve and maintain glycemic control without – hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life – expectancy or at high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be reasonable. 3. For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values are 100 mg/dl). Modification of glucose-lowering treatment is usually necessary when BG values are <70 mg/dl. Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metabol 97(1):16-38, 2012

A1C for Diagnosis of Diabetes in the Hospital  In-hospital hyperglycemia is defined as an admission or inhospital BG > 140 mg/dl.  A1c > 6.5% can be identified as having diabetes, < 5.2% can exclude diabetes.  Implementation of A1C testing can be useful:  assist with differentiation of newly diagnosed diabetes from stress hyperglycemia  assess glycemic control prior to admission  designing an optimal regimen at the time of discharge Moghissi ES, et al; AACE/ADA Endocr Pract. 2009;15(4). Umpierrez et al,. J Clin Endocrinol Metabol 97(1):16-38, 2012

Pharmacological Treatment of Hyperglycemia in Non-ICU Setting Antihyperglycemic Therapy OADs SC Insulin Not Generally Recommended for Recommended most medical- surgical patients Continuous IV Infusion Selected medical-surgical patients 1.ACE/ADA Task Force on Inpatient Diabetes. 2.Diabetes Care. 2006 & 2009 3.Umpierrez et al,. J Clin Endocrinol Metabol 97: January 2012

Algorithmic guidance based on four simple factors Johns Hopkins example

Pre-op recommendations for insulin treated patients with diabetes  Give 70 to 100% of usual dose of glargine or detemir insulin or 50 to 70 % of NPH insulin  PLEASE don’t hold basal insulin altogether!  Nurses, this means you too!  For patients undergoing prolonged procedures (e.g. CABG) hold SQ insulin and start IV insulin infusion DiNardo MM et al Endo Pract 17:552 2011

Guidance for Scheduled Temporary NPO Example UC San Diego  Basal / Nutritional / Correction insulin terms reinforced across orders, MAR, documentation venues  New orders not required for temporary NPO Insulin glargine (LANTUS) injection: “basal glargine insulin should still be administered even if the patient is temporarily NPO for a procedure, or has temporary interruption of procedure” Nutritional RAA- I guidance for eating patients: “Give with first bite of food (or up to 30 minutes after first bite of food if patient is nauseated or has poor appetite). Give 0% if patient ate less than 50%, half if patient eats 50%, and full dose if they eat all / almost all of meal.”

Anesthesia and Analgesia 2017. 124:1041 Traditional “NPO after Midnight” still common, but should it be?

Carb loading: Not just because it tastes good! Cochrane Collaboration review March 2014

ASHP Foundation Recommendation Every hospital should prospectively monitor/measure: – rates of hypoglycemia and hyperglycemia – Insulin use patterns – Coordination of insulin administration, glucose testing, and nutrition delivery Real-time, institution-wide glucose reports should be provided to health care team members to ensure appropriate surveillance and management of patients with unexpected hypoglycemia and hyperglycemia Cobaugh D, Maynard G, et al. Am J Health-Syst Pharm 2013;70:1404-13.

“ Glucometrics ” – Unit of measure Operational definitions  Unit of analysis – – the individual reading (not recommended) – the patient-day – the patient-stay  No consensus on best methods yet, but SHM offers a variety of measures  Hypoglycemia:< 70 mg/dL  Severe hypoglycemia: < 40 mg/dL  DWM ≥ 180 mg/dl  Percent patient-days with BG > 299 mg/dL  Recurrent hypoglycemia: > 1 hypoglycemic day

Society of Hospital Medicine: https://www.studydata.net/qgen/LoginSecure.php Data / Reporting for Glucometrics, Community, and More

Benchmarking Ranking Bar Chart Hypoglycemia Rates

SHM Benchmarking Scatterplot Hypoglycemia (x axis) Uncontrolled Hyperglycemia (y axis) How do these hospitals get low hypoglycemia AND good glycemic control?

Iatrogenic Hypoglycemia A Top Source of Inpatient Adverse Drug Events (ADEs)  ADEs: most common cause of inpatient complications – affecting 1.9 million stays annually – costing $4.2 billion / year – responsible for 1/3 of hospital acquired conditions (HACs).  50-60% of ADEs are preventable  57% of ADEs are from hypoglycemic agents  > 10% of those on a hypoglycemic agent suffer at least one hypoglycemic ADE Classen DC et al. Health Aff (Millwood) 2011;30:581 – 9. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109. Classen DC et al. JAMA 997;277:301 – 6. Bates DW et al. JAMA 1997;277:307 – 11. Classen et al. Jt Comm J Qual Patient Saf. 2010;36:12-21

Hypoglycemia Risk Factors - Different Flavors Inherent Low BMI / cachexia / Advanced Malignancy / Age Liver / Kidney disease / CHF Iatrogenic Insulin / oral agents Some risk with appropriate use. Risk magnified with inappropriate use or failure to react / anticipate preventable problems. Overly aggressive targets, inappropriate prescribing Hypoglycemic (< 70 mg/dL) events - 50% preventable Severe Hypoglycemic events ( < 40 mg/dL) - 50-80% preventable Improved Glycemic Control AND Reduced Hypoglycemia possible.

Iatrogenic Hypoglycemia from Insulin Most common failures and strategies to address them  Inappropriate prescribing Standardized orders with embedded CDS – mandatory use – Ongoing monitoring for inappropriate prescribing, just in time intervention –  Failure to respond to unexpected nutritional interruption Protocols and Education – Methods to reduce interruptions in tube feeding –  Poor coordination of nutrition delivery, monitoring, and insulin delivery Clear directions in protocols and order sets – Regular education / competency training – Redesign process –  Failure to respond to a prior hypoglycemic day Make sure ASSESSMENT is part of hypoglycemia protocol – Competency and case based-training – Monitor recurrent hypoglycemia rates – Cobaugh DJ et al. Am J Health Syst Pharm ;70(16):1404-13. Hellman R. Endocr Pract 2004;10 Suppl 2:100-8. Maynard GA, et. Diabetes Spectr 2008;21 241-247.

RR 2013 vs 2009-10 baseline hypoglycemic stay 0.71 (0.65,0.79) severe hypoglycemic stay 0.44 (0.34, 0.58) recurrent hypoglycemia 0.78 (0.64,0.94) hypoglycemic day 0.73 (0.66,0.79) severe hypoglycemic day 0.48 (0.37,0.62) Days with BG > 299 mg/dL 0.76 (0.73,0.80)