Progress in Glycemic Control at Westchester Medical Center

Irene A. Weiss, MDChief, Division of Endocrinology

NYS Partnership for Patients WebinarJuly 26, 2017

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Glycemic Management Council• Diabetes nurse program manager (CDE)• Endocrinologists• Diabetes nurse educator• Pharmacy• Laboratory • Nurses• Intensive care• Quality• Dietary• Pediatrics• Bariatrics• Surgeon• Hospitalist• Endocrinology fellows

*Correction Insulin Scales

Normal scale - for most adult patients Sensitive scale - for most patients with type 1 diabetes, patients on hemodialysis, the elderly, and patients very sensitive to insulin Resistant scale - for patients requiring very high doses of insulin, patients receiving high dose glucocorticoids, those with morbid obesity, and those with known insulin resistance Custom scale - may be made for a patient whose requirements do not fit any of above scales

Hiah-Dose Glucocorticoid Therapy

In patients requiring basal-bolus insulin, calculate TDD and give (0.3 x TDD) as Basal insulin, and (0.7 x TDD) as Nutritional insulin, divided evenly among meals Consider Resistant scale for Correction insulin Adjust insulin doses as steroids are being increased or decreased

Discharge Planning

1. Determine whether patient will needmodification of prior outpatient regimen,based on recent HbA1c results, and inpatientglycemic trends/medication requirements

2. Assess need for home health referral/referralto outpatient diabetes education program

3. Diabetes self-management education (DSME)should start early., especially in those with newly diagnosed diabetes, or new to insulin

4. DSME topics should include:> Self-monitoring of blood glucose> Home glucose goals> Insulin preparation and administration> When and how to take diabetes medication> Recognition and treatment of hypoglycemia> Sick-day guidelines> Nutrition guidelines

5. Prescribe all meds/supplies on discharge:> Blood glucose meter, test strips, lancets> Oral medications, insulin (vials or pens)> Insulin syringes or insulin pen needles> Glucagon emergency kit

6. Schedule outpatient follow-up visits with theprimary care provider, endocrinologist, and/ordiabetes educator

Hypoglycemia Protocol

Non-responsive patient with capillary blood glucose (CBG) less than 70 mg/dL

> No IV access - Give glucagon 1mg SQ and establish IV access to administer D10W @ 100mL/hr. Give 30 grams of oral carbohydrate when alert and if able to swallow.

> IV_access - Give 50 ml (25 grams) of D50W by rapid IV push and administer D10W @ 100mL/hr. Give 30 grams of oral carbohydrate when alert and if able to swallow.

Responsive patient with capillary blood glucose (CBG) less than 50 mg/dL

> NPO / patient unable to swallow/ dysphagia> No IV access - Give glucagon 1mg SQ and

establish IV access to administer D10W @ 100mL/hr.

> IV_access - Give 50 ml (25 grams) of D50W by rapid IV push and administer D10W @ 100mL/hr.

> Patient can swallow - Give 2 tubes of glucose gel (30 grams), or 8 o z. of orange juice, or 8 oz. of apple juice (preferred for patients with renal failure). Give snack or meal containing at least 30 grams of carbohydrate.

Responsive patient with capillary blood glucose (CBG) 50-69 mg/rdL

> NPO / patient unable to swallow/ dysphagia> No IV access - Give glucagon 1mg SQ and

establish IV access to administer D10W @ 50 mL/hr.

> IV access - Give 25 ml (12.5 grams) of D50W by rapid IV push.

> Patient can swallow - Give 1 tube of glucose gel (15 grams), or 4 oz. of orange juice, or 4 oz. of apple juice (preferred for patients with renal failure). Give snack or meal containing at least 30 grams of carbohydrate.

Contact attending of record and/or covering. physician.

Repeat capillary Blood Glucose (CBG) testing every 15 minutes until blood glucose is greater

than 80 mg/dL on two consecutive determinations. Then, CBG every 30 minutes for

4 hours, or as ordered by physician.

References

Pichardo-Lowdon AR et al. Endocr Pract 2011; 17:249-260 Umpierrez GE et al. J Clin Endocrinol Metab 2012; 97:16-33 ADA.Diabetes Care 2017; 40 Suppl 1: S120-S127

(5/2017)

Hyperglycemia Management Reference Guide

For Adult Inpatients (Non-ICU, Non-Pregnant)

Initial AssessmentAssess for history of diabetes, complianco

with home diabetes medications and usual degree of glycemic control

Document clearly whether type 1 or typeoFor patients using insulin pumptherapyo

request Endocrinology consultation All patients, independent of history oo

diabetes, should have blood glucose (BG) testing on admission

o Order hemoglobin A1c (HbA1c) in all patientswith diabetes or with BG > 140 mg/dL, if not performed in the prior 3 months

o Initiate insulin therapy in all patients withtype 1 diabetes

o Initiate insulin therapy in most patientswith type 2 diabetes

o In patients without a history of diabetesbut with BG > 140 mg/dL, monitor capillary blood glucose (CBG) for 24-48 hours; if persistently > 140 mg/dL, initiate ongoing BG monitoring

o In patients receiving glucocorticoids,octreotide, or enteral or parenteral nutrition, monitor capillary blood glucose (CBG) for 24-48 hours; if persistently > 140 mg/dL, initiate ongoing BG monitoring

o Initiate and titrate insulin therapy inpatients whose glucose levels are persistently > 180 mg/dL

o A basal-prandial insulin regimen is thepreferred approach to manage inpatient hyperglycemia (see algorithm)

o Avoid using correctional (sliding scaleinsulin alone for more than 24 hours

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Definitions:Basal Insulin: Long-acting insulin required at all times by patients with typel diabetes and most patients with type 2 diabetes, even when NPO Nutritional (Bolus) Insulin: Scheduled short-acting insulin given for consumed carbohydratesCorrection Insulin: Short-acting insulin given as neededtotreat elevated blood glucose (BG) levels

OVERVIEW OF INSULIN THERAPY FOR THE ADULT INPATIENT (NON-ICU, NON-PREGNANT)

Initial Evaluation and Management:- Order HbA1c if not performed in the prior 3 months- Order hypoglycemia protocol- Review outpatient dietary patterns and compliance with medications- Determine inpatient diet- Diabetic 3-0 (3 meals, 0 snacks) is

preferred for most patients on basal bolus therapy- Discontinue oral and non-insulin injectable diabetes medications

Calculate the estimated total daily dose (TDD) of insulin; consider adjusting up or down based on patient's home regimen and HbA1c:- Standard— normal BMI (18.5-24.9) — 0.4 units/kg/day- If very lean, on hemodialysis, elderly, very sensitive to insulin (hypoglycemic risk factors) - 0.3 units/kg/day- If overweight (BM I 25-29.9) —0.5 units/kg/day- If obese (BMI >30), on high dose glucocorticoids, or known insulin resistance -0.6 units/kg/day or higher

Determinethe distribution of theTDD based on nutritional regimen

If patient NPO or nearly NPO:- Check blood glucose g4h or q6h- Basal insulin — glargine (0.5 xTDD) qd- Nutritional insulin — none- Correction Insulin - lispro q4h or regular

insulin q6h, see other side*

If patient eating:- Check blood glucose qac and qhs (add 2 am check if

high risk for hypoglycemia)- Basal insulin - glargine (0.5 xTDD) qd- Nutritional insulin — lispro up to (0.16 xTDD) qac

(start with less than 0.16 in patient with limited nutritional intake)

- Correction insulin - lispro qac (added to nutritionalinsulin dose) and qhs, see otherside*

If patient receiving continuous tube feeds:- Check blood glucose q4h or q6h- Basal insulin - glargine (0.4 x TDD) qd or

NPH (0.13 x TDD) qSh- Nutritional insulin - lispro (0.1 x TDD) q4h

or regular insulin (0.15 x TDD) q6h (when tube feeds running at goal rate)

- Correction insulin - lispro q4h or regular insulin q6h (added to nutritional insulin dose), see otherside*

- If tube feeds unexpectedly stopped. continue basal insulin, hold nutritional insulin, give D10 at rate of tube feeds for up to 6 hours, monitor closely for hypo or hyperglycemia

Reevaluate and adjust the insulin regimen daily based on the glycemic control and patterns in the last 24 hours- For most patients, maintain premeal blood glucose < 140 mg/dL and random blood glucose < 180 mg/dL- Consider higher target range (i.e., < 200 mg/dL) in patients with terminal illness, limited life expectancy, or at high risk for hypoglycemia- Consider changing regimen if blood glucose< 100 mg/dL; Change regimen if blood glucose < 70 mg/dL- If a patient's nutrition status is to be changed from meals or continuous tube feeds to NPO (i.e., in preparation for a procedure), hold the

Nutritional insulin, and consider reducing the Basal insulin to 75% of the current dose- starting with the dose prior to the change

Self-Learning Module:

Management of HyperglycemiaAt

Westchester Medical Center

To select the insulins that will beordered:

(1) Check the appropriate box to choose one Basal Insulin (glargine is preferred)

(2) Check the appropriate box to choose one Nutritional Insulin (lispro is preferred)

(3) Check the appropriate box(es) to choose tlhe Correction Insulin that matches the Nutritional Insulin

If the insulin dose requirements are unknown, click on this new button tosee the suggested starting doses

IV insulin protocol in intensive care• Since 2011, WMC has used Glucocare, a computer based algorithm for

dosing of IV insulin• From 2011 – 2016 1761 patients were treated to target 100 – 139 mg/dL 815 patients were treated to target 120 – 140 mg/dL 509 patients were treated to target 140 mg/dL 82% of the patients were on the cardiothoracic unit

Hypoglycemia with IV insulin protocols

- If glucose readings performed > 25% late were eliminated from the calculation, the percent of patients with glucose < 70 mg/dL would be 2.8% - In the last six months more of the intensive care units are using the IV infusion protocol on a more consistent basis- Currently working on protocol for transition from IV to subcutaneous insulin

Non- Critical Care

Critical CareFirst 6 months 82.2

Last 6 months 53.1

% change -35.4%

First 6 months 105.3

Last 6 months 61.3

% change -41.8%

Mean time* between first glucose < 70 and

resolution

Mean time* between first glucose < 70 and

resolution

First 6 months 4.3%

Last 6 months 3.4%

% change -20.9%

Percent Days with results <

70