Inpatient Glycemic
Control
Sherry Buske RN, MSN,NP-C, CDE
April 2010
UNDERSTANDING THE
CURRENT STATE





Lack of A1C
Inconsistent patient education
Lack of coordination of BG testing, meals, insulin
administration
Inconsistent treatment of hyperglycemia
Insulin use:
 Sliding scale 83%
 Basal bolus 10%
 NPH/split mixed 7%
RESTRAINING FORCES
 Lack
of knowledge
 Concern of time involved
 Increased monitoring
 Counting carbs
 Basal bolus insulin
 Fear of hypoglycemia
RESTRAINING FORCES (cont)
Timing:
 Any other big changes (Care Cast)
 How long will change take
 Time of year (summer and vacations)
INTERDISCIPLINARY
GLYCEMIC STRATEGY TEAM
Needs:
 Executive Leadership
 Medical Champion(s)
 Nursing Champion(s)
IMPLEMENTING A SUCCESSFUL
INPATIENT GLYCEMIC CONTROL
PROGRAM
Requires:
 Interdisciplinary advisory committee
to develop and guide ALL initiatives
related to glycemic control
 Full time RN, CDE
IMPLEMENTING A SUCCESSFUL
INPATIENT GLYCEMIC CONTROL
PROGRAM (cont)
 Designated
champion(s)
 Quality department support
 Referrals to Home Health and
Outpatient Diabetes Center at
discharge
IMPLEMENTING A SUCCESSFUL
INPATIENT GLYCEMIC CONTROL
PROGRAM
 Development and implementation of new or
revised interventions
 Standardized order sets
 Protocols
 Policies
 Algorithms


Initial & ongoing staff education to follow above
Metrics: Recognized Targets, Review GPOC
(glucose point of care) data
DIABETES
DIABETES
ADVISORY
ADVISORY
COMMITTEE
COMMITTEE
IHS MEDICAL
IHS MEDICAL
DIRECTORS
DIRECTORS
Dr Iverson
Dr Iverson
Dr I. Brady
Dr I. Brady
TRMC
TRMC
MEDICAL
MEDICAL
DIRECTORS
DIRECTORS
DrDr
M.Lee
M.Lee
DrDr
Schminke
Schminke
DIABETES ADVANCED PRACTICE
NURSE
INPATIENT DIABETES SERVICES
HOME HEALTH
OUTPT DIABETES CENTER
UNIT EDUCATORS/PATIENT
CARE FACILITATORS AS
DIABETES RESOURCE NURSES
TRMC’s Glycemic Management
Campaign
AIM: Improve glycemic control of the
inpatient with diabetes or hyperglycemia
without causing hypoglycemia
 80% of the point of glucoses will be between
100 and 180 in CCU.
 80 % of the point of care glucose will be
between 100 and 180 on our medical/surgical
areas.
 Keep hypoglycemic episodes at or below 4%
house wide
AIM (cont)
 The aim will be accomplished through:
1. Active surveillance
2. Using standardized evidence based order sets
and protocols supported by the American Diabetes
Association (ADA), the American Association of
Endocrinologists (AACE) and/or American Heart
Association (AHA)
3. Education on evidence based glycemic
management to the nursing staff, support
staff and physicians
The committee defines safe ranges hyperglycemia
between 100 mg/dL and 180mg/dL.
GLYCEMIC MANAGEMENT
CAMPAIGN:
STRATEGIES TO SUCCESS
Assessed:
 Meal Items, Menus, Supplements
 Timing of GPOC, Diabetes Meds & Meal Trays
 Reviewed “look alike, sound alike” meds,
 Removed SQ regular insulin, added rapid analog


order sets
Use of insulin infusions
GPOC : Glucose meter supplies, pt comfort, ?
need for lab confirmation  or 
IHS INPATIENT GLYCEMIC
COLLABORATIVE






Tap into system resources
Share best practices
Corporate support
Database development
Computerized insulin program
Share point internal website
PHARMACY






Partnership formed “Inpatient Diabetes
Services”
Basal/bolus order set
Formularies
Standardize through out hospital
Removal of mixed Insulins
Pyxis
LESSONS LEARNED
 Communicate
 Re-communicate
 Vary
communication
 Consistent
 Transition is ongoing
JOINT COMMISSION
INPATIENT DIABETES CERTIFICATION
 Specific staff education requirements
 Written
blood glucose monitoring
protocols
 Plans
for treatment of hypo &
hyperglycemia
 Data
collection of incidences of
hypoglycemia
 Diabetes self care education
 Identified program champion or team
www.jointcommission.org/certificationprograms/inpatient+diabetes
CENTERS FOR MEDICARE & MEDICAID SERVICES
(CMS)
LIST OF HOSPITAL-ACQUIRED CONDITIONS (HAC)






Diabetic Ketoacidosis
Nonketotic Hyperosmolar Coma
Hypoglycemic Coma
Secondary Diabetes with Ketoacidosis
Secondary Diabetes with hyperosmolarity
Exempt: Long Term Care, Veterans, Psychiatric,
Cancer, Rehab & more
www.cms.hhs.gov/HospitalAcqCond/
GLYCEMIC MANAGEMENT CAMPAIGN:
STRATEGIES TO SUCCESS
Standardized Orders:




Hypoglycemia: what, when, how much, & then
what?
Hyperglycemia: insulin infusion; not specific to
DKA
Basal/Bolus Insulin Order Sets: includes A1C,
POC testing times, basal and prandial insulin,
and correction insulin
A1c should be run daily weekdays for timely
results
KEY CHARACTERISTICS OF
COMPREHENSIVE
INSULIN INFUSION PROTOCOL ORDERS
Glycemic target range (100-180)
 Clear dosing instructions


Calculation requirements for nurses (will be
considering computerized or % of glucose
drop)
Glucose monitoring frequency
 Easy prescriber ordering; CHECK BOX
simplicity

Adapted from Ahmann AJ, Maynard G. J Hosp Med. 2008;5(Suppl 5):42-54.
KEY CHARACTERISTICS OF
COMPREHENSIVE
INSULIN INFUSION PROTOCOL ORDERS
Indicates criteria for calling prescriber
 Includes recommendations for nutrition
coverage (will be added on next version)
 Built in hypoglycemia protocol
 States guidelines on infusion initiation,
termination and transition to SQ

PATIENT EDUCATION &
DISCHARGE PLANNING

Sooner rather than later
Incorporated into usual care
 Survival Skills Booklet / Available
Resources Toolkits
 Communication of status across settings
 Follow Up Plan / Referrals
 Benefit of Inpatient Diabetes Services

STANDING ORDERS FOR PATIENTS
ON SCHEDULED INSULIN

Nutritional insulin


Hold if patients are NPO or eat <50% of their
meal
Administer scheduled rapid-acting nutritional
insulin during or immediately following meal
if oral intake is questionable (i.e., nausea,
emesis, or newly advancing diet)
O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65.
STANDING ORDERS FOR PATIENTS
ON SCHEDULED INSULIN

Tube feedings: When tube feeds are stopped
unexpectedly

Start dextrose containing IV fluids (many institutions
use D10W at the same rate as the prior tube feeds)

Hold scheduled nutritional insulin, Consider NPH or
70/30
Notify prescriber

O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65
STANDING ORDERS TO FOR PATIENTS
ON SCHEDULED INSULIN (CONT.)

Basal insulin
Continue glargine/detemir if NPO
 Reduce morning dose of NPH by 50% if NPO;
may need to ↓ dose of bedtime NPH


Steroids

Use NPH or split mix?
O’Malley CW et al. J Hosp Med. 2008;3(Suppl 5):55-65.
Inpatients
served
Inpatients
with
Diabetes
% of
Inpatients
With DM
Females
with
diabetes
Males with Average
diabetes
age
2007 6,973
1,630
23.4
51%
49%
67
2008 6339
1592
25.1%
56%
44%
69
2009 5,498
1,327
50.1%
49.9%
69
24.1%
70
60
50
40
30
20
10
0
June
July
Aug
Sept
OCT
Nov
Dec
census all
64
53
64
57
58
60
51
pts with DM
27
19
19
22
22
21
17
%inpt DM
40
40
29
39
38
35
33
GLUCOSE UNDER 70
2007
2008
2009
2N
5%
3.75 %
3.3 %
3N
4%
3.75 %
3.0 %
CCU
4.59%
3.57 %
3.4 %
Housewide
Average
4.53 %
3.69 %
3.2 %
COMMON ERRORS LEADING
TO HYPOGLYCEMIA

Use of single dose long acting insulin


Elderly
Liver or kidney insufficiency






Need to split or give small dose in am
Failure to adjust dosage to clinical situation
Sliding scale as monotherapy
Reduction in or cessation of caloric or carbohydrate
intake
Correction scale at HS
No HS snack
Hypoglycemia in
Time Range
18:01 to midnight
18%
%
46 %
25%
11%
12:01 to 18:00
06:01 to
noon
Midnight to 06:00
# of GPOC in hypoglycemic range
85
47
31
1
20-29
4
30-39
2
40-49
50-59
60-70
Total
SMALL TESTS OF CHANGE
Eliminated daytime snacks
 HS snacks given and are 2 carbs
 Times of GPOC and carbohydrates eaten
written on daily log located outside each
room
 Encourage substitution of carbs not eaten
 Snacks stocked on unit – i.e. ice cream,
pudding, yogurt

TEST OF CHANGE (CONT)
 Education
provided on:
Risk factors for developing
hypoglycemia
 Symptoms of hypoglycemia
 Treatment of hypoglycemia
 Timing of GPOC to meals/snacks
 Carbohydrate counting

TEST OF CHANGE (CONT)
 Hypoglycemic
episodes have been
decreased by 50%
 Episodes during night due to sliding
scale at bedtime
 Episodes during day due to mismatch
of carb intake to insulin
GLUCOSE OVER 180
2007
2008
2009
2N
41.5 %
40.5 %
41.6 %
3N
40.0 %
38.75 %
37.0 %
CCU
66.5 %
58.25 %
31.3% *
Housewide
Average
49.3 %
45.8 %
40.8 %
LENGTH OF STAY
2007
Inpatient
3.79
Diabetes
4.85
2008
3.88
5.15
2009
3.65
4.65
“The greater the obstacle, the more
glory in overcoming it.”
—Moliere