Topics in Inpatient Glycemic Control

Transcription

1 Topics in Inpatient Glycemic Control Jane Jeffrie Seley DNP MPH MSN GNP BC-ADM CDE CDTC FAADE FAAN Diabetes Nurse Practitioner Program Manager, Inpatient Glycemic Control Program NewYork-Presbyterian/ Weill Cornell Medicine New York, NY 1

2 Centers for Disease Control and Prevention Guidelines for Prevention of Surgical Site Infections (SSI), 2017 Glycemic Control Guideline 3A.1. Implement perioperative glycemic control & use blood glucose (BG) target levels less than 200 mg/dl in patients with and without diabetes. Category IA strong recommendation; high to moderate quality evidence. Berrios-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,... & Dellinger, E. P. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical siteinfection, JAMA surgery.

3 Centers for Disease Control and Prevention Guidelines for Prevention of SSI, 2017 Glycemic Control, Continued 3B. The search did not identify randomized controlled trials that evaluated the optimal hemoglobin A1C target levels for the prevention of SSI in patients with and without diabetes. No recommendation/unresolved issue

4 Centers for Disease Control and Prevention Guidelines for Prevention of SSI, 2017 Glycemic Control Bottom Line: During surgery, blood glucose target levels should be less than 200 mg/dl Future revisions to this guideline will be guided by new research and technological advancements for preventing SSIs.

5 30-Day Readmission Rates for Diabetes Patients: How Bad Is It? General Inpatient Population: % Inpatients with diabetes: % Risk Factors: co-morbidities, ED admission, low socioeconomic status, public insurance, racial/ethnic minority, recent admission Rubin, D.J., et al., Early readmission among patients with diabetes: a qualitative assessment of contributing factors. Journal of Diabetes and Its Complications, (6): p

6 Transitional Care Strategies Known To Identify high risk patients Help Lower Risk of Readmission Obtain & utilize A1c results during hospital stay Improve discharge prescription writing Med-to-Bed discharge medication delivery Diabetes self-management education in survival skills Follow up phone calls Follow up appointments Rubin, D.J., Hospital readmission of patients with diabetes. Current diabetes reports, (4): p.1-9.

7 Barriers to Obtaining A1c at NewYork-Presbyterian/Cornell Campus 80 charts were found to have 2 or more BGs >180 mg/dl in 24 hours, A1c requested by research assistant Took 1-3 days with multiple requests to get A1c ordered on 48 of the 80 patients with hyperglycemia. 32 of the 80 patients never had an A1c ordered prior to discharge. Lesson Learned: Consider auto-selecting A1c order in insulin order set to if A1c not done within past 2-3 months to facilitate timely result Seley, J.J., Sinha N., et al (2016) Designing a Transitional Care Program for High-Risk Diabetes Patients: A Feasibility Study. 76th American Diabetes Association Scientific Sessions New Orleans, LA; June 13.

8 Preventing Readmissions Barrier: Right Prescriptions ¾ of pts with Rx s for insulin had no Rx s for needles Seley, J.J., Sinha N., et al (2016) Designing a Transitional Care Program for High-Risk Diabetes Patients: A Feasibility Study. 76th American Diabetes Association Scientific Sessions New Orleans, LA; June 13.

9 Med-To-Bed Barriers at NYP/Cornell Results: 61.1% (n=22) received medication reconciled to match insurance and delivered to bedside prior to discharge Barrier: Delays in obtaining RX to send to med-to-bed pharmacy, Medto-Bed pharmacy did not check for missing RXs e.g. needles, test strips despite educating pharmacists to check Reason for delay in writing RX: Prescriber uncertainty about what meds/doses patient would go home on (not needed to verify coverage) Lesson Learned: Get RXs for current Diabetes Meds at current dose to check which insulin/devices are covered with med-to-bed pharmacy Seley, J.J., Sinha N., et al (2016) Designing a Transitional Care Program for High-Risk Diabetes Patients: A Feasibility Study. 76th American Diabetes Association Scientific Sessions New Orleans, LA; June 13.

10 Diabetes Self-Management Education Promote EARLY Diabetes Education Alert Bedside RN to educate high-risk patients as soon as patient is ready to learn Use routine BG monitoring, insulin administration & meal trays as teachable moments Improve RN access to diabetes self-management tools: selfcare guides, insulin pen training kits & blood glucose meters to take home Train Diabetes Champions on Key Units to assist with education, availability of teaching resources, reviewing rates of hypo/hyperglycemia

11 Preventing Readmissions Best Strategy: Diabetes Education 75% of the 8 patients who had no diabetes education were readmitted w/in 30 days Seley, J.J., Sinha N., et al (2016) Designing a Transitional Care Program for High-Risk Diabetes Patients: A Feasibility Study. 76th American Diabetes Association Scientific Sessions New Orleans, LA; June 13.

12 ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults Insulin pens should have patient-specific barcoded label Store Insulin pens in patient-specific bins & return IMMEDIATELY after use RN should never have more than one pen in possession at any time Never use insulin pen as vial, withdrawing insulin with syringe At time of pt. transfer or discharge, insulin pen should be removed from patient bin and transferred with patient or returned to pharmacy Concentrated insulins: Pens preferred. U-100, U-200, U-300 should NOT follow name of insulin in MAR or med lists to reduce risk of mistaking strength of insulin as DOSE ONE EXCEPTION: regular insulin U-500 vial should have U-500 after name

13 Selected References Berrios-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,... & Dellinger, E. P. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, JAMA surgery. Dungan, K., et al., An Individualized Inpatient Diabetes Education and Hospital Transition Program for Poorly Controlled Hospitalized Patients with Diabetes. Endocr Pract, 2014: p Healy, S.J., et al., Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care, (10): p Institute for Safe Medication Practices (ISMP, 2017). Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. Available at: Rubin, D.J., et al., Early readmission among patients with diabetes: a qualitative assessment of contributing factors. Journal of Diabetes and Its Complications, (6): p Rubin, D.J., Hospital readmission of patients with diabetes. Current diabetes reports, (4): p.1-9. Rubin, D.J., Meneghini, L. F., Seley, J.J., Cagliero, E., Gaudiani, L. M., Gilden, J. L. Chapter 30 Transition of Care: Discharge from the Hospital. In Managing Diabetes and Hyperglycemia in the Hospital Setting. Draznin B, Ed. Alexandria, VA, American Diabetes Association, Seggelke, S.A., et al., Transitional care clinic for uninsured and medicaid-covered patients Umpierrez, G.E., et al., Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care, (11): p Wexler, D.J., et al., Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control months after discharge. Diabetes Res Clin Pract, (2): p