Inpatient Glycemic Management:

Transcription

1 Disclosure to Participants Conflict of Interest (COI) and Financial Relationship Disclosures: Dr. Seley attended Advisory Board Meeting: Alliance (Boehringer-Ingelheim/Lilly) Bayer Diabetes Care Sanofi Diabetes TOPICS Inpatient Glycemic Management: How We Get Others To Follow Our Lead August 12 th, 2016 San Diego, CA Hardwiring in the EMR to promote safety & efficacy Patient Education: Multi-media resources, generic skills instructions Staff Education: Diabetes Champions, Clinical standards & pocket cards Transitional Care & Preventing Readmissions DNP MPH GNP BC-ADM CDE CDTC FAAN Diabetes Nurse Practitioner Inpatient Glycemic Control Team NewYork-Presbyterian Hospital Weill Cornell Medicine New York, New York Hardwiring Glycemic Control 1

2 Why Hardwire Insulin Orders? Reduces insulin dosing errors: Auto-calculates safe dose, can set dose limits Simplifies and promotes weight based dosing: Auto-populates weight into dosing algorithm Reduces insulin type errors: Basal, prandial & correction insulin are separated Reduces timing errors: Time due restricted so RN only sees color coded dose due in MAR 7 Secret to Success With Comprehensive Pre-Selected Matters Pre-Selected Orders Are Almost Always Placed! Step One Which Order Set Do I Choose? Type of Diabetes Bedside BGM Defaults to ac & bedtime for prandial orders & q6 hrs for NPO 11 NYPH Basal/Bolus Insulin Order Sets Auto-select A1c if needed *Medical Logic Memory to check if last A1C is >60 days Carb Controlled Meal Plan 12 2

3 NYPH DATA VIS Insulin & BG Tab NPO: no auto-basal for type 2 Very Low Dose.10 u/kg Low Dose.15 u/kg Med Dose.20 u/kg High Dose.30 u/kg Summary 13 Insulin Titration Algorithm: Step 1 WHICH INSULIN NEEDS ADJUSTMENT: If AM fasting BG is too high or low: If pre-lunch, pre-dinner or bedtime is too high or low: If BG is less than 50: If BG is less than 70: HOW TO ADJUST: Adjust Glargine Adjust Aspart Deduct 50% Deduct 20% If BG is : Deduct 10% If BG is : Add 10% If BG is >250: Add 20% 14 DIABETES MEDICATION ADJUSTMENTS PRIOR TO PROCEDURE AND SURGERY Medications Oral sulfonylureas Glyburide (Micronase ), glipizide(glucotrol ), glimepiride (Amaryl ) Day Before Procedure Take morning and/or lunch doses only, Do not take evening or bedtime doses Day of Procedure All other oral agents Take usual dose None Daily non-insulin injectables: GLP-1 RAs, pramlintide Weekly: Hold if dose is within 3 days Rapid/Short acting insulins Regular (Humulin R, Novolin R), Lispro (Humalog ), Aspart (Novolog ), Glulisine (Apidra ) Insulin NPH Humulin N, Novolin N Take usual dose Before meals: Take usual dose No bedtime dose Morning dose: Take usual dose Dinner/bedtime dose: T1DM: Reduce dose by 20% T2DM: Reduce dose by 30% None None None T1DM: Reduce dose by 30% T2DM: Reduce dose by 50% Insulin Titration Algorithm: Step 2 How to Increase aspart insulin dose when High Dose Order Set Is Not Enough Prandial Aspart High Dose Aspart Doses High Dose +10% For BGs mg/dl High +20% For BGs > 250 mg/dl > Bed Time Aspart > DIABETES MEDICATION ADJUSTMENTS PRIOR TO PROCEDURE AND SURGERY (Cont.) Medications Long-acting basal insulin U100 glargine (Lantus ), U100 detemir (Levemir ), Longer-acting basal insulin U300 glargine (Toujeo ), U100 & U200 degludec (Tresiba ) Pre-Mixed Insulin Humulin 70/30Novolin 70/30, Novolog Mix 70/30, Humalog Mix 75/25, Humalog Mix 50/50 Insulin Pumps DIABETES MEDICATION ADJUSTMENT GUIDELINES PRIOR TO PROCEDURE AND SURGERY Day Before Procedure Long-acting basal: Morning dose: Take 100% Dinner/bedtime dose: reduce dose by 20% Longer-acting basal: Reduce AM and/or PM dose by 20% Ask patient to contact PCP or endocrinologist OR Morning Dose: Take 100% T1DM: Reduce dinner dose by 20% T2DM: Reduce dinner dose by 30% Day of Procedure Long-acting basal: T1DM: Reduce dose by 20% T2DM: Reduce dose by 50% Longer-acting basal: T1DM: Reduce dose by 20% T2DM: Reduce dose by 50% Ask patient to contact PCP/endocrinologist OR T1DM: Reduce dose by 50% T2DM: Do not take Ask patient to contact PCP/endocrinologist for orders, otherwise reduce all basal rates by 20% for outpatients. Endocrine/Maternal Fetal Medicine consult mandatory for all inpatients 3

4 Timing is Everything Insulin Pen Teaching Safety Patient Education RN Education: Generic Pen Handouts Be Aware: Don t Share Teaching Kits Barcoding insulin type & Label Saline Pens: PATIENT ID Do Not Inject Pen returned to pt specific drawer right after use ISMP Newsletter, 2013, 2014 Cobaugh DJ. Am J Health-Syst Pharm. 7; , Teaching Diabetes Survival Skills Diabetes Teaching Resources Teaching Checklist Practice Pens In EMR Meters Handouts in Multiple Languages Carb Controlled Menus: Grams vs. Servings Diabetes Education Documentation Great Teaching Tool! 4

5 Staff Education: Be Creative Unit Based Education Online learning Case Studies Grand Rounds Pocket Cards Team Web Sites Games NYP/Weill Cornell Medicine Transition Guide From Inpatient to Outpatient A1c < 7% A1c 7-9% A1c > 9% Return to home regimen PTA if not contraindicated Restart home regimen if not contraindicated, start/keep basal at % of inpatient dose Best option: Basal insulin at % of current dose & bolus insulin with meals at fixed or calculated dose Other options: Basal Plus (basal qd + bolus at largest meal) Pre-mixed insulin before breakfast & dinner Basal insulin qd + repaglinide with meals Basal insulin qd & GLP-1 daily or weekly Bolus insulins: aspart, lispro, glulisine Basal insulins: degludec U100 & U200, detemir, glargine U100 & U300 Pre-Mixed insulins: aspart 70/30 & lispro 75/25 Adapted with permission from algorithm by Umpierrez, G, Diabetes Care 2014 Diabetes Champions Intensive then ongoing additional education for clinicians: e.g. RNs, NPs, PA, RDs, PharmDs Focus on management AND education Champions serve as unit based resource Most impact if house-wide & interdisciplinary Diabetes Prescription Writing Remember to Order Pen Needles with Pens & Syringes with Vials Instructions BOLUS: NovoLog Flexpen or Humalog KwikPen Take (range, up to) units before meals BASAL: Lantus U100 or Toujeo U300 Solostar Pen or Levemir or Take units at AM/PM Tresiba U100 or U200 FlexTouch Pen OR PREMIX: NovoLog Mix 70/30 Flexpen or Humalog Mix 75/25 Take units at AM and KwikPen NPH: Humulin N Kwik Pen Take units at PM BD Nano or DUO (safety) pen needles Dispense #100 (or #200), use as directed BD Ultrafine 6 mm 3/10 ml insulin syringe Dispense #100 (or #200) use as directed, DAW* (Holds up to 30 units) BD Ultrafine 6 mm 1/2 ml insulin syringe Dispense #100 (or #200), use as directed (Holds up to 50 units) BD Ultrafine 6 mm 1 ml insulin syringe Dispense #100 (or #200) use as directed (Holds up to 100 units) Accu-Chek Connect, Bayer Contour Next EZ, FreeStyle Freedom LITE OR OneTouch Verio Flex blood glucose meter Accu-Chek Connect, Bayer Contour Next EZ, FreeStyle Freedom LITE OR OneTouch Verio test strips Accu-Chek Connect, Bayer Contour Next EZ, FreeStyle Freedom LITE OR OneTouch Verio lancets Dispense: 1 meter Test BG x/day Test BG x/day 29 Transitional Care From Inpatient to Outpatient Current Concentrations of Insulin in the U.S. U-100 = 100 units/ml U-200 = 200 units/ml U-300 = 300 units/ml U-500 = 500 units/ml 30 5

6 Questions? 31 References American Diabetes Association (2016). Standards of Medical Care In Diabetes Diabetes Care: 39(1):S99-S104. Draznin, B., Gilden, J., et al (2013). Pathways to quality inpatient management of hyperglycemia and diabetes: A call to action. Diabetes Care; 36(7): Rodriguez, A., Magee, M. et al (2014). Best Practices for Interdisciplinary Care Management by Hospital Glycemic Teams: Results of a Society of Hospital Medicine Survey Among 19 US Hospitals. Diabetes Spectrum; 27(3): Rushakoff, R., et al (2014). Using a Mentoring Approach to implement an Inpatient Glycemic Control Program in United States Hospitals. Healthcare; 2: Ryan, D., Swift, C., (2014). The Mealtime Challenge: Nutrition and Glycemic Control In the Hospital. Diabetes Spectrum; 27 (3). Pp Mendez, C. Umpierrez, G.E. (2014). Pharmacotherapy for hyperglycemia in Noncritically Ill Hospitalized Patients. Diabetes Spectrum; 27 (3). Pp Umpierrez GE, Hellman R et al (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. Endocrine Society. J Clin Endocrinol Metab. Jan;97(1):