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Multidisciplinary Approach to Inpatient Blood

Glucose Management

Presented by:

CAPT Christine Chamberlain, PharmD, BCPS, CDE

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1,500 studies currently in progress.

Most Phase 1 & 2 trials.

240 inpatient beds, 82 day hospital stations, and outpatient clinics.

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List important factors that were considered in the design of blood glucose management service (BGMS)

Explain the design of electronic medical record to support the service

Implement new strategies for managing inpatients requiring insulin efficiently in similar environments

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All patients seen at NIH are on a clinical research protocol

Some investigational drugs may affect glucose or insulin action

Some research protocols require steroids

Minimizing serious adverse events of glycemia related to protocol

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Patients come from all 50 states and other countries as often we are studying rare diseases

Many foreign languages

Many without insurance

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n engl j med 355;18 www.nejm.org november 2, 2006

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 No consistency

 Changing management guidelines

 New drugs to use in controlling blood glucose

 Late endocrine consults

 Delay in implementing consult recommendations

 Discharge planning

 Disjointed patient education

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Members

Attending

Fellows

Pharmacist

Dietitian

Nurse Practitioner

Nurse

Social Worker as needed

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 Attending Physician

 Champion

 Expert

 Training

 Liaison

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 Fellow

 Initial visit and history

 Orders

 On-call

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 Dietitian

 Patient teaching

 Participation in daily rounds

 Determination of diet/TPN

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Nurse

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

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Nurse Practitioner

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

Facilitate order entry

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Pharmacist

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

Medication Profile review

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Multidisciplinary team consult service

Provide around the clock responsibility for blood glucose management for referred patients.

Manage only inpatients receiving insulin

Team will participate in multidisciplinary rounds each working day and a fellow during weekends

Team interdisciplinary notes will be recorded daily in the EMR

Insulin orders will be entered in the EMR rather than a recommendation in a note

Resources: laptops, pager, conference room, supervisor support

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Report

Discussion

Orders

Discharge planning

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January 8, 2007

Piloted on one unit initially

Medical executive committee endorsement

Hospital wide at 7 months

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Census form

Occurrences

Daily Rounds log

Monthly on-call schedule

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Primary team physicians changing orders

Communication between BGMS and primary team

Transfers to the ICU (transition of care)

Misinterpretation of insulin order

No resources for diabetes supplies

(glucometer, strips)

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 Flowsheet ( Eclipsys electronic medical record)

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BGMS team pager

Appropriate education for each patient care unit

Sufficient “beta-testing” of the EMR systems, including:

 The BG flowsheet- worklist link and

 System for recording daily BGMS progress notes

“Stamp” for the BGMS fellow to place a note in each patient’s medical record indicating the service is following that patient, and where progress notes can be found (On service note)

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 Consult Note (structured note)

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 Consult Note (structured note)

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Selling the concept

Finding the data

Transfers to the ICU

Misinterpretation of insulin order

No meter when discharged

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 Consult Note (structured note)

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 Consult Note (structured note)

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 Consult Note (structured note)

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 Consult Note (structured note )

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Report

Discussion

Orders

Discharge planning

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We are following Mr/Mrs ________ whose primary diagnosis underlying their hospitalization is _______.

Our present blood glucose management orders for him/her are ________.

Issues today that may have influenced the BGs you can see on the flowsheet include _____ (and examples may be infections, alterations in his/her diet, procedures, new medications like glucocorticoids).

Upcoming plans for his/her hospitalization that may effect his/her blood glucose control include ____ (and examples may include alterations in his/her diet, procedures, new medications like glucocorticoids, plans

for discharge).

State pertinent lab values for that day

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Quoting Lennon and McCartney, “I have to admit its getting better, a little better all the time.”

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Prepare for home regimen

Prepare for insulin pump or adjust setting if admitted on pump

Transition to outpatient

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Selling the concept

Finding data

Primary team physicians changing orders or putting them in hold status

Communication between BGMS and primary team

Transfers to the ICU

 No meter when discharged

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Established rules for initial insulin dosing

Created treatment plans specific to glycemia issue

Created Standard operating procedures

Created insulin ordering templates

 Insulin drip

 High concentration insulin

 Insulin subcutaneous pump

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 Pre-meal goal

 Critically ill 140-180 mg/dl

 Non critically ill pre-meal <140 mg/dl and random <180 mg/dl

Individualize per patient condition

Issues with hgb A1C, low hematocrit, blood glucose level data

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Weight based regular insulin

▪ Regular insulin 0.2-0.5 units/kg/day divided four times daily with meals or every 6 hr if not eating

▪ 30%-25%-25%-20% for breakfast, lunch, dinner and bedtime snack plus correction regular insulin based on BG level

Basal/ bolus

▪ Continue home regimen or weight based

▪ Insulin glargine or detemir 50% TDD

▪ Lispro insulin with meals 50% of TDD

▪ Correction with lispro

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Regular insulin QID schedule will have overlap

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On admission obtain insulin pump program settings

Patient must have an order that includes specific pump settings, self administer, and using own supplies

If patient needs MR,I pump needs to be suspended (MD to order a bolus)

Nurse assess patient’s competence for insulin pump use – self administration

Monitor labs, and blood glucose pre-meal and bedtime

Review with patients s/s of hypoglycemia to report

Validate emergency medications available – glucagon, 50% dextrose

Site, tubing and cartridge are changed every 3 days

Patient to communicate with nurse bolus amount and time

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Documentation on Flowsheet Specific for insulin pump

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Oral Corticosteroids

▪ prednisone, dexamethasone, methylprednisolone, hydrocortisone

▪ Budesonide (drug interaction/systemic effect)

NPH insulin single dose in morning and correction with regular insulin

Regular insulin 4 times/day (30%-25%-

25%-20%)

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Add in correction amount given over past 24 hr

Increase dose by 10-15% if not at target

Reduce dose by 50% if episode of hypoglycemia

Reduce dose by 15-20% for below target blood glucose levels

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 NPO guidelines

 Reduce insulin dose by 50% if on regular insulin regimen

 Basal bolus regimen –

▪ stop mealtime insulin

▪ Give basal insulin or decrease dose by 20%

Prevention of hypoglycemia due to good communication and quickly adjusted medication orders

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Laboratory

Postprandial

Nursing orders

Insulin Stat orders

Nutrition

Medications (insulin orders, ID bracelet)

OGTT orders

Gradually increase dextrose content in TPN

Initiate 0.1 units of regular insulin per gm of dextrose in TPN infusion

Our maximum insulin dose in TPN is 0.3 units/gm of dextrose in TPN

Correction dose of short acting insulin based on blood glucose level every 6 hours

Continuous insulin infusion if cannot achieve goal

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 Computerized order set

 Four algorithms per insulin sensitivity

Blood glucose monitoring required hourly initially

Medical floor with adequate staffing

ICU if hemodynamically unstable

Transition to subcutaneous insulin when the event resolves

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Regular insulin 100 units in a total volume of

100ml of sodium chloride 0.9% for final concentration of 1 unit/ml

Additional instructions: See ORDER DETAILS for dosing algorithm. Notify BGMS on call physician (102-12200) when blood glucose result is above 180mg/dL and glucose does not decrease by at least 60mg/dL within 1 hour of a rate change. Page 102-12200 for all blood glucose/insulin related issues.

Patients requiring more than 200u/day-severe insulin resistance

 More than 100U/day by insulin pump is also high dose requirement

 Pediatrics-more than 2-3U/kg/day

Typically seen in patients with severe forms of insulin resistance

Increased incidence of high dose insulin requirements related to obesity epidemic

Other forms of diabetes:

 Genetic defects in insulin secretion or action

 Autoantibodies to insulin receptor

 Endocrinopathies-Cushing’s and Acromegaly

 Most common- corticosteroid induced diabetes

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What is influencing insulin requirements…

Influenced by type of diabetes

Influenced by energy intake

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Insulin requirements when fasting

Insulin requirements after bariatric surgery

Influenced by device/mechanical issues:

-Pumps with bolus rate limits of 1 unit per

40 seconds, maximum bolus of 25-30 units, and cartridge that holds 180-300 units

Pens with maximum amount of 60 unit or

80 unit bolus

Cost and insurance

• Use of U-500 Insulin inpatient setting

Hospital Policy For use

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 Multidisciplinary approach

 Consistent plan of care

 Continuous endocrinology input

 Quick response to medication errors

 Training for staff

 Discharge instructions for patients

 Electronic communication

 Data-driven blood glucose targets

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David Harlan, MD

Rana Malek, MD

Kathryn Feigenbaum,

RN, CDE

Elaine Cochran,

CRNP, BC-ADM

Pamela Brooks, CNP

Mahfuzul Khan, MD

Christine Salaita, RD

Allison McLean-

Adams, RN

Ann McNemar RN, IT specialist

NIDDK Diabetes

Branch Support Staff

NIDDK and NICHD

Endocrine Fellows

Clinical Center

Nursing Staff

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