Improving Inpatient Diabetes Care: Focus on Safe Use of Anti-diabetic Therapies

Transcription

1 Improving Inpatient Diabetes Care: Focus on Safe Use of Anti-diabetic Therapies Leigh Briscoe-Dwyer, PharmD, BCPS, FASHP Chief Pharmacy and Medication Safety Officer North Shore Long Island Jewish Health System Lake Success, NY May 14, 2013

2 Inpatient Diabetes Case Presentation 58 year old man with a past history of CAD, HTN, HLD, Type 2 DM was admitted to the medicine service with cellulitis of the left lower extremity. Admission medications included: Continuation of home medications for coronary artery disease, hyperlipidemia, hypertension Antibiotics Sliding scale insulin Insulin glargine (Lantus ) 20 units SQ QHS NovoLog Mix 70/30: 10 Units SQ three times daily before meals

3 Case Continued On day 2 of hospitalization a rapid response was called for altered mental status. Upon evaluation a finger stick blood glucose was 35 mg/dl. 1 amp 50% Dextrose was given via IV push and the patient recovered mental status

4 Insulin Therapy The Joint Commission considers insulin to be one of the 5 highest-risk medicines in the inpatient setting The consequences of errors with insulin therapy can be catastrophic Insulin errors account for 9 10% of our hourse staff error reports There are varying degrees of comfort and confidence in prescribers who routinely write inpatient orders for insulin

5 Grand Rounds Survey: Results N= 81 prescribers; 44 Housestaff and 37 Attendings;

6 Grand Rounds Survey: Results

7 Grand Rounds Survey: Results

8 Insulin Errors Prescribed Novolog 70/30 instead of Insulin aspart (Novolog ) Insulin glargine (Lantus ) not given in a patient with DKA when transitioned from an insulin drip Missed doses of scheduled insulin Patients with multiple sliding scales Insulin glargine held due to low glucose Insulin glargine ordered instead of Insulin aspart Insulin glargine ordered twice daily Insulin aspart given at bedtime

9 Ordering Insulin Problem: Orders were being written in CPOE for 100 units of insulin when, in fact, that is the concentration of the insulin not the dose Solution: Warning in CPOE to verify dose is 100 Units and not concentration REMINDER: Please confirm the value of 100 in the dose field is the appropriate dose of insulin and NOT the concentration of the product.

10 Prescribers: U-500 Insulin Procedure U-500 insulin will be ordered in accordance with the institutions nonformulary policy and procedure Must clearly state U-500 insulin is to be utilized when prescribing The prescriber must document how many units as well as the volume to be administered to the patient If a patient brings his/her own insulin from home, the physician must specify Patient s Own Meds as per policy and the insulin MUST be sent to the pharmacy for storage Nursing: Nurses must not draw up U-500 insulin Nurses will only administer U-500 insulin drawn up by pharmacy using a tuberculin syringe and the same needle used to draw up the dose so as not to lose the 35 units contained in the needle

11 U-500 Insulin Procedure Pharmacy: Vials of U-500 insulin will not be dispensed to the unit or stored as floor stock U-500 insulin will only be ordered and prepared on a patient-specific basis U-500 insulin must be stored segregated from other insulin products, and inventory managed in a similar manner to controlled substances Pharmacist will verify that the dose (written in units and volume) is accurate Pharmacy will draw up the syringe utilizing a tuberculin syringe (not a U-100 syringe) Pharmacy will label the syringe with a patient label and a high alert sticker Any U-500 insulin purchased for a specific patient will either be sent home with the patient or discarded upon discharge; it is not to be routinely stored in the pharmacy

12 Dispensing Insulin Glargine Potential for error if regular insulin and Insulin glargine are both stored on nursing units All orders for insuln glargine are drawn up by pharmacy, labeled for individual patient and delivered to the floor once daily Insulin detemir is used for pregnant patients and follows the same process

13 Avoidable Hypoglycemia 36 patients with hypoglycemia in May 2012 Average age: 72 years 22% with multiple episodes of hypoglycemia 42% with BG>300 in week prior 42% with BG <100 in week prior 42% had no treatment modification after low Blood Glucose 39% had serum creatinine >1.5 mg/dl 31% were on oral sulfonylurea

14 Inpatient use of Sulfonylureas 30 day chart review 5/13/12-6/12/12 81 patients over age 65 received an oral sulfonylurea during admission 18 patients prescribed glyburide Potentially Inappropriate Medication as per Geriatric Beers Criteria Majority were greater than 80 years old 41 patients were >80 years old 18 of those patients had HgA1c <7.0 The oldest patient was 99 years old HgA1c 5.5

15 Inpatient use of Sulfonylureas 13 patients with hypoglycemia 7 were receiving oral sulfonylureas

16 Conclusions The inpatient diabetic patient is a population at risk for medication-related events Insulin remains a medication class at high risk for potential errors and adverse events Steps can be taken to continue to make the medication use process around insulin safer Prescriber education remains a priority The use of oral sulfonylureas should be reviewed for appropriateness at each admission