Identifying and Treating Hyperglycemia in Non‐Critically Ill Inpatients
ll ll
from Admission to Discharge 1
Etiologies of Inpatient Etiologies
of Inpatient
Hyperglycemia
y Diagnosed diabetes mellitus1
y Undiagnosed diabetes mellitus1
y Impaired glucose tolerance2
y “Stress” hyperglycemia1,3
y Steroid‐induced hyperglycemia1,4
1
y Enteral and parenteral nutrition
p
1. Clement S, et al. Diabetes Care. 2004;27:553‐591; 2. Waddell M, et al. Postgrad Med. 2009;121:61‐66; 3. Dungan KM, et al. Lancet. 2009;373:1798‐1807; 4. Annane D, et al. COIITSS Study Investigators. JAMA. 2010;303:341‐348. 5. Mora PF, et al. Diabet Med. 1993;10:863‐865.
Inpatient hyperglycemia in patients with and without a history of diabetes is common
and is associated with increased hospital morbidity and mortality. What is the
etiology of patients coming in with high glucose levels? Some of those people have
diabetes, some of them have not yet had diabetes diagnosed, some people have
impaired glucose tolerance and the stress of being admitted actually tips them over
into hyperglycemia, some people truly have stress hyperglycemia, meaning they did
not have diabetes, they didn't have any abnormalities before admission, but upon
admission they were so stressed that they had hyperglycemia
admission,
hyperglycemia. There are special
situations, such as steroids, enteral, parenteral feedings, and others, that
iatrogenically cause inpatient hyperglycemia.
References
1 Clement S
1.
S, Braithwaite SS
SS, Magee MF
MF, et al.
al Management of diabetes and
hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.
2. Waddell M, Flanders SJ, Golas A, Zhang Q, Juneja R. Antidiabetic therapy before and 1
year after discharge for patients manifesting in-hospital hyperglycemia. Postgrad Med.
2009;121:61-66.
3. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009;373:17981807.
4. Annane D, Cariou A, Maxime V, et al. Corticosteroid treatment and intensive insulin
therapy for septic shock in adults: a randomized controlled trial. JAMA. 2010;303:341-348.
5. Mora PF, Ramirez LC, Lender D, Raskin P. Insulin requirements in lipodystrophic
diabetes. Diabet Med. 1993;10:863-865.
Patients at Ad
dmission
Prevalence and Etiology of Hyperglycemia in Inpatients
at Admission
Hyperglycemia = any blood glucose (BG) > 130 mg/dL during admission.
Waddell M, et al. Postgrad Med. 2009;121:61‐66. Summary
Less than 40% of patients had no glucose abnormalities. Nearly 60% of patients
either had DM or manifested hyperglycemia during their hospital stay. Almost a third
of patients without diabetes had transient or ‘stress’ hyperglycemia.
Study Description
A sample of a managed care outpatient database (8547 patients) with linkage to
inpatient data from June 1, 2003 to June 30, 2006, evaluating hyperglycemia
management pre-admission (PA), during index admission (IA), and post-discharge
(PD). Diabetes mellitus (DM) status was determined from ICD-9 codes.
Reference
Waddell M, Flanders SJ, Golas A, Zhang Q, Juneja R. Antidiabetic therapy before and 1
year after discharge for patients manifesting in-hospital hyperglycemia. Postgrad Med.
2009;121:61-66.
Hyperglycemia Is Linked to Mortality, Regardless of Diabetes Status
Unadjusted Mortality Rate (%)
No History Diabetes N=180,084
History Diabetes N= 77,850
70‐110 mg/dL
7.6
5.7
111‐145 mg/dL
11.3
6.3
146‐199 mg/dL
19.8
8.8
200‐300 mg/dL
30.5
11.1
> 300 mg/dL
40.5
15.4
Blood Glucose Level mg/dL
173 US medical, surgical, and cardiac intensive care units; 259,040 admissions. Falciglia M, et al. Crit Care Med. 2009;37:3001‐3009; Falciglia M. ADA Abstract; 66th Annual Scientific Sessions; June 13, 2006; Washington. Hyperglycemia was associated with increased mortality independent of illness
severity. Increasing hyperglycemia was associated with an increased risk of
mortality; this relationship was actually stronger for patients with no prior history of
diabetes.
Study Description
The relationship between glycemia and mortality was evaluated in 259,040
admissions from October 2002 to September 2005. Age, diagnosis, comorbidities,
and laboratory variables were used to calculate a predicted mortality rate, which
was then analyzed with mean glucose to determine the association of
hyperglycemia with hospital mortality.
References
Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemiarelated mortality in critically ill patients varies with admission diagnosis. Crit Care Med.
2009;37:3001-3009.
Falciglia M. Hyperglycemia and mortality in 252,000 critically ill patients. Late-breaking
clinical studies. Presented at the American Diabetes Association’s 66th Scientific
Sessions.
June 9-13, 2006. Washington, DC.
4
Inpatient Hyperglycemia Is Associated with Increased Morbidity/Mortality Even /
in Non‐ICU Patients
Patient Population
Glycemic Cutoff
(mg/dL)*
Acute exacerbation COPD
Quartiles, < 108, 108‐125 126‐160 108‐125, 126‐160, and ≥ 161
Cheung et al, 2005
TPN
≥ 126
• Each 18 mg/dL* ↑ in glucose = ↑ risk of complications by a factor of 1.58
McAlister et al, 2005
CAP
> 126 • Longer LOS
• Increased in‐hospital complications
• Increased risk of death
Umpierrez et al, p
,
2002
All admitted patients p
(87% non‐
ICU)
FPG ≥ 126 or RPG ≥ 200
Study
Baker et al, 2006
Significant Hyperglycemia‐
Related Outcomes
• Longer LOS
• 15% ↑ AEs for each 18 mg/dL* ↑ in glucose
• Increased risk of death
• Longer LOS
• More ICU admissions
• Increased risk of death
• Fewer home discharges
*Converted from mmol/L. CAP, community‐acquired pneumonia; COPD, chronic obstructive pulmonary disease, FPG, fasting plasma glucose, LOS, length of stay, RPG, random plasma glucose; TPN, total parenteral nutrition.
Baker EH, et al. Thorax. 2006;61:284‐289; Cheung NW, et al. Diabetes Care. 2005;28:2367‐2371; McAlister FA, et al. Diabetes Care. 2005;28:810‐815; Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978‐982.
Summary
While it is generally appreciated that inpatient hyperglycemia is a marker of poor
outcomes in critically ill patients, emerging data is showing that this is also true for
patients who are not critically ill. In non-critically ill patients, inpatient hyperglycemia
is associated with longer lengths of stay, increased complication rates, more
discharges to nursing homes or other non-home settings, and an increased risk of
death.
References
B k EH,
Baker
EH Janaway
J
CH,
CH Philips
Phili BJ
BJ, ett al.
l H
Hyperglycaemia
l
i iis associated
i t d with
ith poor
outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive
pulmonary disease. Thorax. 2006;61:284-289.
Cheung NW, Napier B, Zaccaria C, Fletcher JP. Hyperglycemia is associated with adverse
outcomes in patients receiving total parenteral nutrition. Diabetes Care. 2005;28:23672371.
McAlister FA, Majumdar SR, Blitz S, Rowe BH, Romney J, Marrie TJ. The relation between
hyperglycemia and outcomes in 2,471 patients admitted to the hospital with communityacquired pneumonia. Diabetes Care. 2005;28:810-815.
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an
independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin
Endocrinol Metab. 2002;87:978-982.
2009 AACE/ADA Target Inpatient Glucose Levels and Hypoglycemia Definitions
BG Value
Definition
> 140 mg/dL
Hyperglycemia*
Pre‐meal levels persistently above this level may necessitate treatment
Implications
> 180 mg/dL
Hyperglycemia
No random blood glucose levels should be, in general, above this goal
< 70 mg/dL
Hypoglycemia
Standard definition in outpatients, correlates with the initial threshold for release of counterregulatory hormones
< 40 mg/dL
Severe Hypoglycemia
Increased mortality risk, cognitive impairment begins at 50 mg/dL in normal individuals
Hypoglycemia
Recommendations based on limited data and no randomized controlled trials
*Reassess insulin regimen if BG levels fall below 100 mg/dL.
Occasional patients may be maintained with a glucose range below and/or above these cut‐points.
Moghissi ES, et al. Endocr Pract. 2009;15:353‐369.
Summary
For the majority of noncritically ill patients treated with insulin, the pre-meal blood glucose
(BG) target should generally be less than 140 mg/dL in conjunction with random BG levels
less than 180 mg/dL, provided these targets can be safely achieved.
To avoid hypoglycemia, consideration should be given to reassessing the insulin regimen if
BG levels decline below 100 mg/dL.
mg/dL
Modification of the regimen is necessary when BG values are < 70 mg/dL, unless the event is
easily explained by other factors (such as a missed meal).
More stringent targets may be appropriate in stable patients in whom tight glycemic control
was achieved previously. Less stringent targets may be appropriate in terminally ill patients or
patients with severe comorbidities.
Hypoglycemia
H
l
i iis d
defined
fi d as any BG llevell < 70 mg/dL.
/dL S
Severe h
hypoglycemia
l
i iin h
hospitalized
it li d
patients has been defined by many clinicians as BG < 40 mg/dL, although this value is lower
than the approximate 50 mg/dL level at which cognitive impairment begins in normal persons.
Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction
components, is the preferred method for achieving and maintaining glucose control.
Prolonged treatment with sliding-scale insulin as the sole regimen is discouraged. Noninsulin
anti-hyperglycemic agents are not appropriate in most hospitalized patients who require
treatment for hyperglycemia.
Reference
Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American
Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353-369.
Available at: http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf.
Accessed May 18, 2009.
6
Barriers to Good Glycemic
Barriers
to Good Glycemic Control in Control in
the Hospital
y Most patients are admitted for reasons other than hyperglycemia
y Reliance on sliding scale insulin regimens
y Fear of hypoglycemia F f h
l
i y Inadequate knowledge/understanding of diabetes, hyperglycemia, and their management among health care providers
y Poor communication during patient transfers
y A lack of ownership for hyperglycemia y Lack of integrated information systems that allow tracking and trending of glycemic control and hypoglycemia
Moghissi ES, et al. Endocr Pract. 2009;15:353‐369.
Summary
There are many barriers to good glycemic control in the hospital. Most
patients with hyperglycemia are admitted for other reasons and there may be
a lack of attention to this clinical finding. The use of sliding scale insulin is
discouraged because it is a reactive, rather than a proactive, method of
addressing hyperglycemia. Inadequate knowledge about the proper use of
insulin and/or a lack of hyperglycemia and hypoglycemia protocols contribute
to the challenge. Many of the changes needed to improve the management
of the inpatient with hyperglycemia involve changes to culture, long standing
practice patterns, as well as processes of care and work flow habits. Other
challenges are listed on the slide.
Reference
Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical
Endocrinologists and American Diabetes Association consensus statement on
inpatient glycemic control. Endocr Pract. 2009;15:353-369.
7
Transition Out of the Hospital
y Diabetes management therapy plan is tailored to the educational, financial, and motivational needs of the patient
f th ti t
y Provide adequate education for discharge
– Survival skills
y
Hypoglycemic event risk reduction
y Provide instructions for follow‐up
p
– Outpatient diabetes self‐management education
– Community resources
This slide summarizes the characteristics of a quality discharge plan.
8
Patients Newly Diagnosed with Patients
Newly Diagnosed with
Diabetes During Hospitalization
y Discharge plan must include follow‐up and treatment of hyperglycemia
y A clear care plan should include:
– Survival skills – Self‐monitoring of blood glucose
– How to administer medications if needed
– Signs/symptoms of hypoglycemia and treatment
– Medical nutrition therapy
y Follow‐up – Medication may or may not be required
– More likely if A1c > 7%
Improving Inpatient Diabetes Care: A Call to Action Conference, AACE, 2006. Available at: http://www.aace.com/meetings/consensus/IIDC/IDGC0201.pdf. Accessed May 14, 2010.
Summary
An effective diabetes discharge process has been defined as one in which the
patient has received the necessary skills training and has been provided with a clear
and understandable post-discharge plan for diabetes care. This also includes clear
instructions about medications.
Hospital pharmacists can work in collaboration with nursing to provide the basic
diabetes survival skills that patients need to comply with their diabetes regimen
safely until more thorough outpatient diabetes education can be obtained.
Reference
Improving Inpatient Diabetes Care: A Call to Action Conference, AACE, 2006. Available at:
http://www.aace.com/meetings/consensus/IIDC/IDGC0201.pdf. Accessed May 14, 2010.
Predischarge/Transition Checklist
9 Treatment goals
9 Nutrition information
9 Meter, strips, supplies
M
i li
9 Including prescription
9 Prescriptions for medications
9 Orals, insulin, syringes
9 Contact phone numbers
9 “Medi‐Alert” bracelet 9 “Survival Skills” training
Summary
Pharmacists should also work with nursing to ensure that patients have a blood
glucose meter, know how to use it, and have the necessary supplies to monitor their
BG once discharged.
10
Discharge Planning:
g
g
New Hyperglycemia
A1c
General Guidelines
< 5.2%
Patient does not have diabetes
Repeat screening in future with FBG or OGTT
5.2% to 6%
% 6%
May have diabetes
y
Repeat screening in future with FBG or OGTT
6% to 7%
Likely will have diabetes diagnosis in the future
Discharge with lifestyle therapy plan
FBG or OGTT as soon as patient is stable
7% to 9%
Likely will have diabetes diagnosis in the future
Discharge with lifestyle therapy plan
Consider oral BG‐lowering agent
> 9%
Most patients should be on basal‐bolus insulin regimen at discharge
FBG, fasting blood glucose; OGTT, oral glucose tolerance test.
Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement. http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf. Accessed April 15, 2009.
Summary
This slide summarize discharge plan considerations for patients with newly
identified hyperglycemia. As can be seen, the availability of a recent A1c level to
determine whether or not the patient has diabetes and if they do, what degree of
therapy is needed, is essential to determining next steps.
Reference
Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement.
http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf
11
Discharge Planning: Discharge
Planning:
Known Diabetes
A1c
General Guidelines
< 7%
7
Continue pre‐admission diabetes management therapy plan
p
g
py p
7% to 8%
Increase dose of preadmission diabetes medications and/or add a second/third oral agent or basal insulin at bedtime
> 8%
If on 2 diabetes medications, add basal insulin at bedtime
> 9% to 10%
9
Most patients should be on basal‐bolus insulin at discharge
p
g
Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement. http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf. Accessed April 15, 2009.
Summary
Similarly, this slide summarizes discharge planning considerations for patients with
known diabetes, depending on their current level of glycemic control.
Reference
Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement.
http://www hospitalmedicine org/ResourceRoomRedesign/pdf/GC Workbook pdf
http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/GC_Workbook.pdf
12
Discharge Planning for Discharge
Planning for
New Hyperglycemic
y Check HbA1C: – > 6% highly likely to have DM
– < 5.2% unlikely to have DM
lk l
h
– 5.2‐6% indeterminate
y Need close follow up – FBG or OGTT
– Consider home BG testing
y Refer patient for diabetes education with follow‐up R f i f di b
d
i i h f ll
education
Greci, et al. Diabetes Care. 2003;26(4);1064‐1068.
Summary
Often new hyperglycemia is ignored in the hospital and patients are
discharged with other diagnoses but without a plan for management of this
condition. We are well on our way though because throughout this
discussion we have been mentioning that the new hyperglycemic is going to
be treated similar to the known diabetic. When we approach d/c, it is already
toward the front of our consciousness but now we have to decide what to do.
Obtaining a HbA1c can be quite helpful for several reasons but in a patient
with “new” hyperglycemia, it has been predictive of who will later be
diagnosed with DM. The ADA recommends obtaining one if there is not one
available from the prior month, but as of yet there are no diagnostic criteria
for DM using the HbA1c.
Since the diagnosis of DM is based on OGTT or FBG during a steady state,
we have
h
tto make
k some “educated
“ d
t d guesses”” prior
i tto discharge
di h
and
d th
then
follow up with specific diagnostic testing.
Reference
Greci LS,, Kailasam M,, Malkani S,, Katz DL,, Hulinskyy I,, Ahmadi R,, Nawaz H. Utilityy
of HbA(1c) levels for diabetes case finding in hospitalized patients with
hyperglycemia. Diabetes Care. 2003;26(4):1064-1068.
13
Discharge Planning for Patients Discharge
Planning for Patients
With Known Diabetes
y Admission HbA1c Helpful
y If pre‐admission control acceptable, go back to g
home regimen
y If HbA1c > 8% on maximum oral agents, probably needs basal insulin
McDonnell ME, et al. ACP Hospitalist. 2009; 12(Suppl):24‐30. Available at: http://www.acphospitalist.org/archives/2009/12/hyperglycemia.pdf.
Summary
Hospitalization is an opportunity to evaluate long
long-term
term diabetes control and adjust or
initiate new therapy. If the A1c is > 8% on maximal doses of oral agents, it may be
time to transition to insulin.
Reference
McDonnell ME, Donahue M. Transitioning patients along the continuum of care—
intravenous to subcutaneous insulin,
insulin inpatient to outpatient settings: practical
considerations. ACP Hospitalist. Dec 2009;(Suppl):24-30. Available online:
http://www.acphospitalist.org/archives/2009/12/hyperglycemia.pdf.
14
“Survival Skills” to Be Taught “S
r i al Skills” to Be Ta ght
Before Discharge
y How and when to take medication/insulin
– What to expect from the medication
y How and when to test BG (SMBG)
– What are target glucose levels
y Basics on meal planning
as cs o
ea p a
g
y Sick‐day management plan
y Date/time of follow‐up visits
– Including diabetes education
y When and who to call on the healthcare team
– What community resources are available
y How to treat hypoglycemia
SMBG = self‐monitoring blood glucose.
Moghissi E, et al. Endocr Pract. 2009;15:353‐369. Summary
A primary focus of (often brief) education sessions in the hospital is on teaching
“survival skills.” Survival skills are crucial to safe practice at home. One of these
skills is blood glucose monitoring, including interpreting results and when to call for
help.
Because many patients in the hospital are at risk for subsequent illness, a clear
discussion of how to manage medications and glucose testing on “sick days” is
critical.
Also important is an understanding of how to take diabetes medications (including
insulin) and awareness of hypoglycemia, including its treatment and prevention.
Basic nutrition should also be incorporated into survival skills education, especially
the clear identification of carbohydrates versus fats versus proteins.
Reference
Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical
Endocrinologists and American Diabetes Association consensus statement on inpatient
glycemic control. Endocr Pract. 2009;15:353-369.
15
Functional Health Literacy and Understanding of Medications at d
di
f
di i
Discharge
172 patients discharged from community‐based teaching hospital with prescriptions for 1 or more new medications.
Maniaci MJ, et al. Mayo Clin Proc. 2008;83(5):554‐558.
Summary
In general, patients have limited knowledge about their medications after discharge,
an area where pharmacists can provide substantial support.
In this survey, 86% were aware that they had been prescribed new medications, but
fewer could identify the name (64%) or number (74%) of new medications or their
dosages (56%)
(56%), schedule (68%)
(68%), or purpose (64%)
(64%). Only 11% could recall being
told of any adverse effects, and only 22% could name at least 1 adverse effect.
Reference
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of
medications at discharge. Mayo Clin Proc. 2008;83:554-558.
16
Transition of Care to the Transition
of Care to the
Outpatient Setting
y Involve family and caregivers in patient education
y Ensure that patient has a plan for outpatient follow up
y Facilitate referral for outpatient services and healthcare providers
y Assist patient with resolving issues relating to the cost of outpatient services and treatments
Involvement of family and friends is especially important for interventions
involving lifestyle modifications.
This slide simply summarizes some practical aspect of improving the
transition of the patient to their home environment.
17
Summary
y Collaborate with HCPs and patient (and family)
y Tailor the plan to the educational, financial, and motivational needs of the patient
– Review and teach survival skills
y Assess the diabetes pharmacotherapy plan based on admission A1c
– Conduct a complete medication reconciliation
y Ensure that patient has a plan for outpatient follow up
– Facilitate referral for outpatient services and healthcare providers
– Assist patient with resolving issues relating to the cost of outpatient p
g
g
p
services and treatments
– Ensure patient (and family) understanding
Expert Opinion, Evidence Level C
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f ti i ti i thi ti it
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