Hyperglycemia in Hospitalized Patients

1. Robert J. Rushakoff, MD Clinical Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu Hyperglycemia in Hospitalized Patients • Strategies For Implementing Change • Nuts and bolts of management

2. Insulin Administration • Order Written • Order Sent to Pharmacy • Order Entry by Pharmacist • Drug Preparation by pharmacy • Insulin delivery to unit • Medication Administration • Documentation

3. Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database Endocrine Practice 2008. 14:535

4. Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database Endocrine Practice 2008. 14:535

5. Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database Endocrine Practice 2008. 14:535

6. Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2598 Incidents from a Voluntary Electronic Error-Reporting Database Endocrine Practice 2008. 14:535

7. "Each blind man perceived the elephant as something different: a rope, a wall, tree trunks, a fan, a snake, a spear..."

8. Patient Assessment of Skills, Education Diabetes Assessment Form 1.----------------------------------------------------------------------------- 2.----------------------------------------------------------------------------- 3.----------------------------------------------------------------------------- 4.----------------------------------------------------------------------------- 5.----------------------------------------------------------------------------- 6.----------------------------------------------------------------------------- 7.----------------------------------------------------------------------------- 8.----------------------------------------------------------------------------- 9.----------------------------------------------------------------------------- 10.---------------------------------------------------------------------------- 11.---------------------------------------------------------------------------- 12.---------------------------------------------------------------------------- 13.---------------------------------------------------------------------------- 14.---------------------------------------------------------------------------- 15.---------------------------------------------------------------------------- 16.---------------------------------------------------------------------------- 17.---------------------------------------------------------------------------- 18.---------------------------------------------------------------------------- 19.---------------------------------------------------------------------------- 20.---------------------------------------------------------------------------- 21.---------------------------------------------------------------------------- 22.---------------------------------------------------------------------------- 23.---------------------------------------------------------------------------- Page 1 of 6 Medical Errors JCAHO Coordination of Outpatient Care Home care services Outpatient diabetes classes Jargon CQI ICU Protocols

9. Diabetes as a Secondary Diagnosis What is inpatient diabetes care?

10. Inpatient Diabetes Goals Appropriate Glucose Control Based on physiology and outcome studies Inpatient Diabetes Goals Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable Inpatient Diabetes Goals Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia

11. Benefits of Improved Diabetes Management • Outpatient • DCCT • UKPDS (United Kingdom Prospective Diabetes Study) • Blood pressure control • Lipids • Inpatient/perioperative - ????????

12. Target Glucose Levels Alive

13. Target Glucose Levels No DKA or Hyperosmolar Coma

14. Target Glucose Levels Occasional hypo- and hyperglycemia

15. Target Glucose Levels No hypo- or hyperglycemia • Prevent fluid and electrolyte abnormalities secondary to osmotic diuresis • Improve WBC function • Improve gastric emptying • Decrease surgical complications • Earlier hospital dischange • Decreased post-MI mortality • Decreased post-CABG morbidity and mortality

16. Target Glucose Levels Normal Glucoses Decreased Morbidity and Mortality

17. Problems With High Glucoses

18. Glucose and post-CABG morbidity and mortality Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and outcomes Diabetes Care 2003; 26:1518-1524 • Retrospective Review of 291 patients surviving 24 h post op • 40% with retinopathy, nephropathy or neuropathy Inpatient Complications For each 1 mmol/l (18 mg/dl) increase in postop day 1 over 6.1 mmol/l (110 mg/dl), a 17% increase risk of complications

19. HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati • Hyperglycemia was an independent predictor of mortality starting at 111 mg/dl. • Effect was greatest with acute myocardial infarction, unstable angina, and stroke • heart attack - 1.6-5 time • a stroke it raised risk from 3.4 to 15.1 times • unstable angina it raised risk from 1.7 to 6.2 times Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

20. HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati • A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism. Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure. • In diabetes patients, the increase in mortality risk was not seen until mean glucose was >146 mg/dl Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

21. TPN: Adverse Outcomes Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition Cheung et al: Diabetes Care, 28:2367-2371, 2005 Risk of complications in relation to mean daily blood glucose level

22. Intervention Studies

23. Decreased Infections Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999; 88:1011-6. Perioperative IV insulin infusion Neutrophil phagocytic activity % baseline Control 47 Insulin 75

24. Decreased Infections Glucose control lowers the risk of wound infection in diabetics after open heart operations Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61Furnary et al. Annals of Thoracic Surgery 1999, 67:352-60Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021 Perioperative IV insulin infusionProtocol to maintain glucoses <200 Incidence of Deep Wound Infections (%) 19971999 Routine Control 2.4 2.0“Tight” Control 1.5 0.8

25. Decreased Infections Glucose control decreases mortality in diabetics after open heart operations Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021 14.5% 6.0% 4.1% 2.3% 1.3% 0.9%

26. AACE Position Statement: Hospital Glycemic Goals Intensive Care Units: 110 mg/dL Non-Critical Care Units: Pre-Prandial 110 mg/dL Max. Glucose 180 mg/dL

27. How to Obtain “Tight” Control • Bedside glucose monitoring • IV insulin drips • Diabetic Flow sheets • Discourage the use of traditional Sliding Scale insulin

28. INSULIN SLIDING SCALE

29. INSULIN SLIDING SCALE

30. Roller Coaster Effect of Insulin Sliding Scale

31. Mr. And Mrs. XXXXX are admitted for spring fever. Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.” Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night.

32. Fingerstick qid with regular insulin SQ coverage: FSBG Action < 50 1 amp D50 iv and call HO 51-80 give juice and repeat in 0.5-1 hr 81-200 no coverage 201-250 3U regular insulin SQ 251-300 6U regular insulin SQ 301-350 8U regular insulin SQ 351-400 10U regular insulin SQ >400 12U regular insulin SQ, call HO

33. INSULIN SLIDING SCALE

34. Insulin and Glucose Patterns Normal Glucose Insulin 400 120 100 300 80 mg/dL U/mL 200 60 40 100 20 0600 1000 1400 1800 2200 0200 0600 0600 1000 1400 1800 2200 0200 0600 B L S B L S Time of Day Time of Day Polonsky, et al. N Engl J Med. 1988;318:1231-1239.

35. Insulin Regimens Relative Insulin Level 12pm Breakfast Lunch Dinner Time

36. Insulin Regimens AM NPH Relative Insulin Level 12pm Breakfast Lunch Dinner Time

37. Insulin Regimens BID NPH Relative Insulin Level NPH 12pm Breakfast Lunch Dinner Time

38. Insulin Regimens BID R and NPH regular Relative Insulin Level NPH 12pm Breakfast Lunch Dinner Time

39. Insulin Regimens PM glargine Relative Insulin Level glargine 12pm Breakfast Lunch Dinner Time

40. Insulin Regimens TID lispro/aspart/glulisine and hs glargine Relative Insulin Level Lispro/aspart/glulisine glargine 12pm Breakfast Lunch Dinner Time

41. Subcutaneous Insulin Order Sheet Introduction

42. Subcutaneous Insulin Order Sheet : - PATIENT EATING

43. Subcutaneous Insulin Order Sheet : Meal time insulin adjustments

44. Subcutaneous Insulin Order Sheet : Bedtime and 2am insulin adjustments Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses.

45. Subcutaneous Insulin Order Sheet : - NPO, Tube Feeds or TPN

46. Subcutaneous Insulin Order Sheet : q4hour correctional dosing for NPO, Tube Feeds or TPN q4hour correctional insulin options are shown. Here correctional insulin is generally used to add or subtract insulin from the q4hour nutritional insulin ordered in section A. There are times it can be used even if no standing q4hour dose is written.

47. Low Glucose Reading The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose. • For BG <70 mg/dl, use Hypoglycemia Protocol below:For patient taking PO, give 20 g of oral fast-acting carbohydrate: 4 glucose tablets (5 grams glucose/tablet)-OR- Give 6 oz. fruit juice Give 25 ml of D50 IV pushIf patient cannot take POCheck fingerstick glucose every15 minutes and repeat above treatment until BG is ≥100 mg/dl.

48. Transition from IV to SQ Insulin Take 80% of last 24 h insulin infusion Basal: ½ of the value premeal: ½ of the value divided for the meals Example: 1.5 units per hour = 36U 36 x .8= 29 Basal: 30x.5=15 premeal: 30x.5=15 5 per meal

49. Transition from IV to SQ Insulin

50. Transition from IV to SQ Insulin Glucose 140 255 180 150 Insulin 5 A(5+0) 8 A(5+3) 6 A(5+1) 15 glargine Change for next day would be increase in Breakfast and lunch Aspart