123 Are You Providing Evidence-Based Diabetes Care? - Martin

Size: px

Start display at page:

Download "123 Are You Providing Evidence-Based Diabetes Care? - Martin"

Paula Cook
5 years ago
Views:

Donna Martin, DNP, RN, CDE, CMSRN Lewis University Learner will be able to: Identify current

hypoglycemia in the hospitalized patient Explain treatment options for hyperglycemia /

studies September 2015 Total: 29.1 million children and adults in the United States 9.

1 million people Prediabetes: 86 million people New Cases: 1.

Inpatient hyperglycemia was considered acceptable and benign in the past.

2014 Diabetes Control & Complications Trial (DCCT) Hyperglycemia is an independent marker of

Patients who are encouraged to become actively involved in managing their diabetes and feel

1 Donna Martin, DNP, RN, CDE, CMSRN Lewis University Learner will be able to: Identify current inpatient standards of care for patients with diabetes Describe causes of hyperglycemia / hypoglycemia in the hospitalized patient Explain treatment options for hyperglycemia / hypoglycemia in the inpatient setting Apply inpatient diabetes management standards to case studies September 2015 Total: 29.1 million children and adults in the United States 9.3 % of the population have diabetes. Diagnosed: 21.0 million people Undiagnosed: 8.1 million people Prediabetes: 86 million people New Cases: 1.7 million new cases of diabetes are diagnosed in people aged 20 years and older in Inpatient hyperglycemia was considered acceptable and benign in the past. Transient Stress related American Diabetes Association National Diabetes Statistics Report, 2014 Diabetes Control & Complications Trial (DCCT) Hyperglycemia is an independent marker of inhospital mortality in patients with undiagnosed diabetes (Guillermo et. al.,2002). Patients who are encouraged to become actively involved in managing their diabetes and feel they are competent to do so tend to be less depressed, more satisfied and have lower blood sugar levels (Williams et al., 2005). NICE-SUGAR study Wahab NW et al. J Amer Coll Cardiology 2002;40(10):

Inpatient hyperglycemia was associated with adverse clinical outcomes.

in absolute mortality and a 50% reduction in risk-adjusted mortality.

and greater overall infection rates than patients who did not have hyperglycemia. Zerr KJ et al. Ann Thorac Surg.

2004 In non-icu patients with Community Aquired Pneumonia, for each 18 mg/dl increase in admission blood glucose, in-hospital

In non-icu patients with COPD exacerbation, for every 18 mg/dl increase in blood glucose the risk of death increased 10%, on average.

Mayo Clinic Proc. 2003;78(12): 1471-1478.

2 Inpatient hyperglycemia was associated with adverse clinical outcomes. In patients with diabetes undergoing CABG as an independent procedure, intensive glycemic control was associated with a 57% reduction in absolute mortality and a 50% reduction in risk-adjusted mortality. Patients with hyperglycemia undergoing cardiac surgery had higher mortality rates, increased rates of deep sternal wound infection, and greater overall infection rates than patients who did not have hyperglycemia. Zerr KJ et al. Ann Thorac Surg. 1997;63(2): American College of Endocrinology. Endocr Pract In non-icu patients with Community Aquired Pneumonia, for each 18 mg/dl increase in admission blood glucose, in-hospital mortality rose 8% and rate of complications rose 5% in patients with diabetes. In non-icu patients with COPD exacerbation, for every 18 mg/dl increase in blood glucose the risk of death increased 10%, on average. In general medical and surgical units, hyperglycemia has been associated with an 18-fold increase in inpatient mortality. Krinsley JS. Mayo Clinic Proc. 2003;78(12): Glycemic control with intensive treatment reduced complications among critically ill patients as follows: Sepsis 46% Dialysis 41% Blood transfusion 50% Polyneuropathy 44% In one study, admission blood glucose level 130 mg/dl was associated with higher mortality rates at 30 days, 1 year, and 6 years in patients hospitalized with acute ischemic stroke versus patients admitted with blood glucose < 130 mg/dl. VAN DEN Berghe et. al., NEJM, 2001 Williams LS et al. Neurology. 2002;59 (1 of 2):

Medical history of diabetes: diabetes has been previously

diabetes: hyperglycemia occurring during the hospitalization

as diabetes during hospitalization Hospital related

that reverts to normal after hospital discharge American

Diabetes and Metabolic Control Glycemic control initiatives are

Commission Advanced Inpatient Diabetes Certification ICU

Patients Medications Oral Medication Insulin Basal / Bolus

Monitoring Bedside blood glucose AC & HS Glycohemoglobin /

3 Medical history of diabetes: diabetes has been previously diagnosed and acknowledged during hospitalization Unrecognized diabetes: hyperglycemia occurring during the hospitalization and confirmed as diabetes after hospitalization, unrecognized as diabetes during hospitalization Hospital related hyperglycemia: hyperglycemia that occurs during hospitalization that reverts to normal after hospital discharge American Diabetes Association 2015 ACE position paper on Inpatient Diabetes and Metabolic Control Glycemic control initiatives are getting the attention of Medicare, Medicaid, and private health insurance payers. CMS Never Events related to poor glycemic control The Joint Commission Advanced Inpatient Diabetes Certification ICU Patients American Diabetes Association (ADA) Non-Critically Ill Patients Medications Oral Medication Insulin Basal / Bolus Insulin mg/dl Premeal <140 mg/dl Random <180 mg/dl Monitoring Bedside blood glucose AC & HS Glycohemoglobin / HbA1c DIABETES CARE, VOLUME 38, SUPPLEMENT 1, JANUARY 2015 S80-85 Diabetes / Insulin Order Sets Leahy JL. In Insulin Therapy. New Your, NY: Marcel Dekker Inc; 2002:87-108

The use of two insulins to mimic the pancreas.

analogs cover carbohydrates consumed at meals.

glucose level, used in addition to basal and bolus insulin.

In stress hyperglycemia insulin requirements are increased and

Fear of hypoglycemia Persistent hyperglycemia over 180 mg/dl Oral

Service NPO Diagnostic tests Surgery Steroids Timing issues Basal

low. Supplemental insulin should not be held and should be given

4 The use of two insulins to mimic the pancreas. Long acting insulins provide background coverage Rapid acting analogs cover carbohydrates consumed at meals. The purpose of supplemental insulin is to lower an elevated glucose level, used in addition to basal and bolus insulin. Blood sugars stay in target due to the basal/bolus insulins. In stress hyperglycemia insulin requirements are increased and must be treated. Fear of hypoglycemia Persistent hyperglycemia over 180 mg/dl Oral agents often have to be stopped IV s, Tube feedings, TPN Room Service NPO Diagnostic tests Surgery Steroids Timing issues Basal insulin should not be routinely held if NPO and/or blood sugar is low. Supplemental insulin should not be held and should be given for high blood glucose levels. Scheduled bolus insulin at meals should be held if patients are NPO. For low blood sugars do not just hold insulin. Call physician for a decrease in dosage.

Treatment mild-moderate hypoglycemia with 15-20 grams fast acting carbohydrate glucose

NPO Glucagon D50 Test blood sugar in 15-20 minutes Repeat treatment if needed $245

direct medical costs $69 billion in reduced productivity Average medical expenditures

3 times higher than what expenditures would be in the absence of diabetes.

with diabetes on admission Assess knowledge and previous glucose control Blood glucose

management order sets Survival skill education Subcutaneous Insulin Order Set Monitoring /

Monitoring / Basal / Correction 38 year old female with Type 1 diabetes, wears an insulin

5 Treatment mild-moderate hypoglycemia with grams fast acting carbohydrate glucose tablets glucose gel 4 oz apple or orange juice Treat moderate-severe hypoglycemia or if NPO Glucagon D50 Test blood sugar in minutes Repeat treatment if needed $245 billion: Total costs of diagnosed diabetes in the United States in 2012 $176 billion for direct medical costs $69 billion in reduced productivity Average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes. American Diabetes Association National Diabetes Statistics Report, 2014 Identify patients with diabetes on admission Assess knowledge and previous glucose control Blood glucose monitoring Hemoglobin A1C Identify target glucose range Use of Diabetes / Glycemic management order sets Survival skill education Subcutaneous Insulin Order Set Monitoring / Basal / Bolus / Correction Subcutaneous Insulin Protocol for Continuous Tube Feeding Monitoring / Basal / Correction 38 year old female with Type 1 diabetes, wears an insulin pump Came to the ER with abdominal pain Admitted Post Lap choley Correction insulin ordered Glucose Monitoring in Critical Care Units Glucose Management Programs and Insulin Infusion Orders

65 year old male with Type 1 diabetes, wears an insulin pump Came to the ER with stroke symptoms

DKA Unexpected high Patient received 10 units of regular insulin for a blood glucose of 325 mg/dl

Admitted to the hospital and endocrinologist ordered 25 units of U500 insulin at the hospital.

episodes of hypoglycemia American Diabetes Association (ADA) 2015 Clinical Practice Guidelines.

Guidelines American Association of Clinical Endocrinologists (AACE) 2015 Clinical Practice

Continuous insulin infusion reduces mortality in patients undergoing coronary artery bypass

Association between hyperglycemia and increased hospital mortality in a heterogeneous population

, Siedlecki, S. L., Sauvey, R., Kaser, N., & Yager, C. (2014).

Applied Nursing Research :ANR, 27(3), 157. doi:10.1016/j.apnr.2013.12.003 Umpierrez, G. E.

Diabetes Technology & Therapeutics, 17(4), 225-228. doi:10.1089/dia.2014.

6 65 year old male with Type 1 diabetes, wears an insulin pump Came to the ER with stroke symptoms Had a CT scan and MRI, which confirmed a stroke Stat order of Lantus was not given Resulted in DKA Unexpected high Patient received 10 units of regular insulin for a blood glucose of 325 mg/dl Patient takes 125 units of U500 Regular insulin at home using a traditional insulin syringe Admitted to the hospital and endocrinologist ordered 25 units of U500 insulin at the hospital. Patient received 1/5 th of the insulin needed Patient experiences hypoglycemia Continues to have episodes of hypoglycemia American Diabetes Association (ADA) 2015 Clinical Practice Guidelines. Diabetes Care The Joint Commission Advanced Inpatient Diabetes Management Disease Specific Care Guidelines American Association of Clinical Endocrinologists (AACE) 2015 Clinical Practice Guidelines Furnary AP, Gao G, Grunkemeier GL et al. Continuous insulin infusion reduces mortality in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5): doi: /mtc Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78(12): Modic, M. B., Vanderbilt, A., Siedlecki, S. L., Sauvey, R., Kaser, N., & Yager, C. (2014). Diabetes management unawareness: What do bedside nurses know? Applied Nursing Research :ANR, 27(3), 157. doi: /j.apnr Umpierrez, G. E., & Dungan, K. (2015). Update on inpatient diabetes management: Call for action. Diabetes Technology & Therapeutics, 17(4), doi: /dia Van den Berghe G, Wouters PJ, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19): Williams LS, Rotich J, Qi R, et al. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology. 2002;59(1 of 2):67-71.

7 Contact Information: Donna Martin

Deepika Reddy MD Department of Endocrinology

Deepika Reddy MD Department of Endocrinology Management of hyperglycemic crisis Review need for inpatient glycemic control Brief overview of relevant trials Case based review of diabetes management strategies/review