Document

Report
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
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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
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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
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“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
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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
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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
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Basal/ bolus
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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)
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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%
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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
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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.
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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
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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
- Insulin requirements when fasting
- Insulin requirements after bariatric surgery
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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 McLeanAdams, RN
Ann McNemar RN, IT
specialist
 NIDDK Diabetes
Branch Support Staff
 NIDDK and NICHD
Endocrine Fellows
 Clinical Center
Nursing Staff
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