Managing Diabetes and Hyperglycemia Safely in the Complex Hospital Setting

Managing Diabetes and Hyperglycemia Safely in the Complex Hospital Setting Greg Maynard MD, MSc Clinical Professor of Medicine and CQO, UC Davis Medical Center Sacramento, CA

Greg Maynard Disclosure SHM Glycemic Control Tools No personal financial interest -

21 million in US with dx of DM 8.1 million with undiagnosed DM

Why Glycemic Control? (It s about more than infusion insulin glycemic targets!) DM / Hyperglycemia Very Common Opportunity to identify and intervene poorly controlled DM, previously undiagnosed DM, stress hyperglycemia (pre-diabetes) Hypoglycemia and extreme hyperglycemia Safety problem and a Quality problem Inpatient Care Complex w/ unique challenges Education alone insufficient, need systems change Huge Implementation Gap Chaotic baseline Public reporting, regulatory guidelines etc. http://www.hospitalmedicine.org/resourceroomredesign/ pdf/gc_workbook.pdf.

Blood glucose >250 mg/dl Altered Mental Status Marked hypovolemia Electrolyte disturbances +/- Acidosis/Acidemia Underlying illness: Infection, MI, Stroke

Achieving good glycemic control AND low hypoglycemia Institutional / system support Will to standardize, goals, help with metrics Empowered centralized steering team Local teams addressing barriers Protocols / order sets Common approach for special populations and failure modes Metrics (balanced approach) Active surveillance (aka measure-vention) EHR tools Automation / closed loop algorithms / computerized glucose management

Algorithms Best practices to reinforce Actionable glycemic target Consistent carbohydrate / dietary / consult A1c Patient education plan Hypoglycemia protocol Guidance for transitions (linked protocols) Coordinated monitoring / nutrition / insulin DC oral agents, insulin preferred Insulin regimens for different conditions Dosing guidance

Glycemic Targets in Non-ICU Setting 1. Premeal BG target of <140 mg/dl and random BG <180 mg/dl for the majority of patients. 2. Glycemic targets be modified according to clinical status. For patients who achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG <200 mg/dl) may be reasonable. 3. For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values are 100 mg/dl). Modification of glucose-lowering treatment is usually necessary when BG values are <70 mg/dl. Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metabol 97(1):16-38, 2012

A1C for Diagnosis of Diabetes in the Hospital In-hospital hyperglycemia is defined as an admission or inhospital BG > 140 mg/dl. A1c > 6.5% can be identified as having diabetes, < 5.2% can exclude diabetes. Implementation of A1C testing can be useful: assist with differentiation of newly diagnosed diabetes from stress hyperglycemia assess glycemic control prior to admission designing an optimal regimen at the time of discharge Moghissi ES, et al; AACE/ADA Endocr Pract. 2009;15(4). Umpierrez et al,. J Clin Endocrinol Metabol 97(1):16-38, 2012

Pharmacological Treatment of Hyperglycemia in Non-ICU Setting Antihyperglycemic Therapy SC Insulin Recommended for most medicalsurgical patients OADs Not Generally Recommended Continuous IV Infusion Selected medical-surgical patients 1.ACE/ADA Task Force on Inpatient Diabetes. 2.Diabetes Care. 2006 & 2009 3.Umpierrez et al,. J Clin Endocrinol Metabol 97: January 2012

Source: University of California, San Diego Health System

Algorithmic guidance based on four simple factors Johns Hopkins example Source: Epic Electronic Medical Record. More at: http://www.epic.com/

Pre-op recommendations for insulin treated patients with diabetes Give 70 to 100% of usual dose of glargine or detemir insulin or 50 to 70 % of NPH insulin PLEASE don t hold basal insulin altogether! Nurses, this means you too! For patients undergoing prolonged procedures (e.g. CABG) hold SQ insulin and start IV insulin infusion DiNardo MM et al Endo Pract 17:552 2011

Anesthesia and Analgesia 2017. 124:1041 Preoperative Fasting Guidelines: Why Are We Not Following Them?: The Time to Act Is NOW Ramon E. Abola, MD, and Tong J. Gan, MD, MHS, FRCA Your patient should be drinking clear liquids until 2 hours before surgery. If they are not, you should stop reading and change your hospital practices. Your patients will thank you. They will be less thirsty, be less anxious, and have improved patient satisfaction without an increase in the rate of pulmonary aspiration. 1 Traditional NPO after Midnight still common, but should it be?

Cochrane Collaboration review March 2014 Carb loading: Not just because it tastes good!

ASHP Foundation Recommendation Every hospital should prospectively monitor/measure: rates of hypoglycemia and hyperglycemia Insulin use patterns Coordination of insulin administration, glucose testing, and nutrition delivery Real-time, institution-wide glucose reports should be provided to health care team members to ensure appropriate surveillance and management of patients with unexpected hypoglycemia and hyperglycemia Cobaugh D, Maynard G, et al. Am J Health-Syst Pharm 2013;70:1404-13.

Glucometrics Unit of measure Operational definitions Unit of analysis the individual reading (not recommended) the patient-day the patient-stay No consensus on best methods yet, but SHM offers a variety of measures Hypoglycemia:< 70 mg/dl Severe hypoglycemia: < 40 mg/dl DWM 180 mg/dl Percent patient-days with BG > 299 mg/dl Recurrent hypoglycemia: > 1 hypoglycemic day

Society of Hospital Medicine: https://www.studydata.net/qgen/loginsecure.php Data / Reporting for Glucometrics, Community, and More

Benchmarking Ranking Bar Chart Hypoglycemia Rates

SHM Benchmarking Hypoglycemia (x axis) Scatterplot Uncontrolled Hyperglycemia (y axis) How do these hospitals get low hypoglycemia AND good glycemic control?

Iatrogenic Hypoglycemia A Top Source of Inpatient Adverse Drug Events (ADEs) ADEs: most common cause of inpatient complications affecting 1.9 million stays annually costing $4.2 billion / year responsible for 1/3 of hospital acquired conditions (HACs). 50-60% of ADEs are preventable 57% of ADEs are from hypoglycemic agents > 10% of those on a hypoglycemic agent suffer at least one hypoglycemic ADE Classen DC et al. Health Aff (Millwood) 2011;30:581 9. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109. Classen DC et al. JAMA 997;277:301 6. Bates DW et al. JAMA 1997;277:307 11. Classen et al. Jt Comm J Qual Patient Saf. 2010;36:12-21

Hypoglycemia Risk Factors Different Flavors Inherent Low BMI / cachexia / Advanced Malignancy / Age Liver / Kidney disease / CHF Iatrogenic Insulin / oral agents Some risk with appropriate use. Risk magnified with inappropriate use or failure to react / anticipate preventable problems. Overly aggressive targets, inappropriate prescribing Hypoglycemic (< 70 mg/dl) events - 50% preventable Severe Hypoglycemic events ( < 40 mg/dl) - 50-80% preventable Improved Glycemic Control AND Reduced Hypoglycemia possible.

Iatrogenic Hypoglycemia from Insulin Most common failures and strategies to address them Inappropriate prescribing Standardized orders with embedded CDS mandatory use Ongoing monitoring for inappropriate prescribing, just in time intervention Failure to respond to unexpected nutritional interruption Protocols and Education Methods to reduce interruptions in tube feeding Poor coordination of nutrition delivery, monitoring, and insulin delivery Clear directions in protocols and order sets Regular education / competency training Redesign process Failure to respond to a prior hypoglycemic day Make sure ASSESSMENT is part of hypoglycemia protocol Competency and case based-training Monitor recurrent hypoglycemia rates Cobaugh DJ et al. Am J Health Syst Pharm;70(16):1404-13. Hellman R. Endocr Pract 2004;10 Suppl 2:100-8. Maynard GA, et. Diabetes Spectr 2008;21 241-247.

Impact of Hypoglycemia Reduction Bundle and a Systems Approach to Inpatient Glycemic Management Greg Maynard, MD, MS, SFHM 1,2 ; Kristen Kulasa, MD 3 ; Pedro Ramos, MD 1 ; Diana Childers, MD 1 ; Brian Clay, MD 1 ; Meghan Sebasky, MD 1 ; Ed Fink MHSM 2 ; Aaron Field 2 ; Marian Renvall, MS 2 ; Patricia S. Juang, MD 3 ; Charles Choe, MD 3 ; Diane Pearson, RN, BSN, MPH, PHN, CDE 4 ; Brittany Serences, MSC, RN, FNP-BC, BC-ADM 4 ; Suzanne Lohnes, MA, BSN, RN, CDE 4 RR 2013 vs 2009-10 baseline hypoglycemic stay 0.71 (0.65,0.79) severe hypoglycemic stay 0.44 (0.34,0.58) recurrent hypoglycemia 0.78 (0.64,0.94) hypoglycemic day 0.73 (0.66,0.79) severe hypoglycemic day 0.48 (0.37,0.62) Days with BG > 299 mg/dl 0.76 (0.73,0.80)

New BPA for Tube Feedings on hold + Insulin Appears for pt s w/ 0 charted for TF rate + on insulin Hypoglycemic Risk Patient is at risk for hypoglycemia since on insulin and tube feeds held. Please refer to the insulin and nutrition on hold unexpectedly guidelines. Potential Problems RNs don t consistently chart TF interruptions in I/O Charting, if done, not always timely Source: University of California, San Diego Health System

Source: University of California, San Diego Health System

Source: University of California, San Diego Health System

Source: University of California, San Diego Health System STROKE CODE June 10

Recurrent hypoglycemia on same insulin doses for several days preceding stroke code Source: University of California, San Diego Health System

Proposed CDS Display for Hypoglycemia Evaluation Federal Interagency Workgroup to Prevent ADE Report etiology of hypoglycemic event after event resolution Etiology of hypoglycemic event Nutritional interruption without reducing insulin or adding carbohydrate Prior hypoglycemic event without medication or carbohydrate adjustment Excessive basal insulin dosing that inappropriately covered nutritional needs, as well as basal needs Glycemic target that is too stringent for patient condition/co-morbidities Failure to discontinue oral hypoglycemic agents in the inpatient setting Time interval between testing was too long Other failure mode: No preventable factors detected Report ACTION taken to MITIGATE hypoglycemia ACTION Call to reduce hypoglycemic agent Call to increase CHO Education/reinforcement of policy/protocols Other

Why was patient Hypoglycemic? Critical Thinking to prevent next episode! Source: University of California, San Diego Health System

Active Surveillance Identify patients with a potential deficit in care, who are in the hospital right now. Triage tools to quickly determine if the patient is truly uncontrolled or off protocol. Intervene to bring onto protocol, reduce risk of glycemic excursions and continued deficits in care, provide just in time education. aka measure-vention

Glucose Rounding Report Dashboard RED: Any POC Glucose result in the past 24 hours > 299 OR Any POC Glucose result in the past 24 hours < 70 YELLOW: Any POC Glucose result in the past 24 hours between 181 299 Or Any POC Glucose result in the past 24 hours between 70 100 GREEN: All POC Glucose result in the past 24 hours between 100 180 Source: Epic Electronic Medical Record. More at: http://www.epic.com/

Annals of Internal Medicine ORIGINAL RESEARCH Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients An Observational Study Robert J. Rushakoff, MD; Mary M. Sullivan, DNP; Heidemarie Windham MacMaster, PharmD; Arti D. Shah, MD; Alvin Rajkomar, MD; David V. Glidden, PhD; and Michael A. Kohn, MD, MPP Big Brother Daily Reports: 2 or more glucoses>225 Glucose <70 On insulin pump Dx type 1 DM

Source: Epic Electronic Medical Record. More at: http://www.epic.com/

Annals of Internal Medicine ORIGINAL RESEARCH Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients An Observational Study Robert J. Rushakoff, MD; Mary M. Sullivan, DNP; Heidemarie Windham MacMaster, PharmD; Arti D. Shah, MD; Alvin Rajkomar, MD; David V. Glidden, PhD; and Michael A. Kohn, MD, MPP The Impact of the Virtual Glucose Management Services Decrease in Hyperglycemia: 39% decrease in number of patients on daily hyperglycemia morning list Decrease in Hypoglycemia: 38% decrease in glucoses >70 mg/dl* 64% decrease in glucoses >40 mg/dl* (only 15 total last year) Decreased by 50% number of patients with high glucoses for more than 1 day Decreased by 40% the time patients remain hyperglycemic Ann Inter Med. 2017 May 2; 166(9):621-627

Factors to consider in crafting transition regimen Outpatient regimen / control Major changes from recent illness / hospitalization Inpatient regimen / control Changing stress levels, weaning prednisone A1c Patient preferences Financial / social / insurance picture Access to follow up Patients with poor health literacy, new insulin, and advanced age at highest risk of transitional problems

Transition Guide Inpatient to Outpatient Regimen A1c <7% A1c 7-10%* Return to same regimen as prior to admission (oral agents and/or insulin) Restart outpatient oral agents, optimize orals, consider adding basal insulin once daily at 50% inpt dose A1c >10%* Restart outpatient oral agents, optimize orals, add basal insulin once daily at 75% inpt dose Alternative: stop orals and start 70/30 or basal/bolus at same inpt dose *Ensure compliance with home regimen, maximize lifestyle changes, optimize orals and add insulin according to funding, compliance and lifestyle on individual basis Adapted with permission from algorithm by Umpierrez, G.,Emory University School of Medicine, 2011.

Additional Discharge Orders for Diabetic Patients Most defaults on these orders are already set in order to save clicks. These are ambulatory orders/prescriptions; they file to the After Visit Summary. Source: University of California, San Diego Health System

EDRP at Boston Medical Center Emergency Department Diabetes Rapid Referral Program Acute Management 10/2011 Education Follow-up

How the EDRP Model Works There is a 10 a.m. and a 2 p.m. slot in the diabetes clinic. This is part of your ED care Can you commit to going to this appointment? Case Managers in the ED can directly book into generic Acute Diabetes provider slots (10 a.m. and 2 p.m. M F)

Computerized Glucose Management Now available for IV, SubQ, and Transitions Timely adjustment of dosing Adjusts for variable carbohydrate intake Embedded glucometrics Improved glycemic control with low hypoglycemia rates in research and real world settings CV Surgery J Diabetes Sci Technol 2(3);370-375 Basal bolus J Diabetes Sci Technol 11(1) Coronary Artery Bypass Graphs (CABG) J Diabetes Complications 2017 31(4):742-747 CABG Diabetes Care. 2015 38(9):1665-1672. BMT Bone Marrow Transplant 2016 S1, 973-979

Now Available at the Society of Hospital Medicine Glycemic Control Website www.hospitalmedicine.org/gc Best Practice Review Assess Current State Metrics and Data Collection High Performing Teams SC Insulin Orders / Protocols Insulin infusion protocols DKA protocols / order sets Perioperative DM management Transitions and Reliability Education programs Hypoglycemia reduction bundle Coordination of nutrition / insulin Insulin pens Insulin pumps Example order sets and tools

Questions and Comments? Thank you!