1. Presenter Disclosure Information In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure to the participants: NAME OF PRESENTER: Charles Reed, MSN, RN, CNRN Speaker’s Bureau: Indiana University Consultant: Roche Diagnostics

2. Inpatient Management Charles Reed MSN, RN, CNRN Patient Care Coordinator Surgical Trauma Intensive Care Unit University Hospital San Antonio, Texas

3. Objectives Identify metrics for measuring a glycemic control program Understand the importance of data in effectively managing a glycemic Identify barriers related to glycemic control

4. Background 24 Million people diagnosed with diabetes 57 Million with pre-diabetes $58 Billion in hospital costs 20-40% Longer LOS CDC Press Release 6/24/2008 ADA Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care, 2008;31(3):596-615

5. Background Diabetes & Hyperglycemia –Increased complications –Reduction in productivity EC PACU OR –EC Diversion / Canceled elective cases –Increased LOS PACU / ORs on hold –Ill-will between physician & hospital –Increased LOS due to bounce back –Increased healthcare costs

6. San Antonio Express News 9/9/07 “University's cramped ER illustrates the problem. It was expanded in the mid- 1980s to handle 35,000 patients a year. Today, it sees 70,000 in the same 44 beds.”

7. What can Healthcare Institutions do to maximize current resources?

8. Past Historically little attention paid to glucose control –Lack of benchmarks, guidelines, & evidence 1 Sliding scale insulin protocols –Glucose control started at >200 mg/dl –Minimal insulin used –Insulin drips rare –Fear of hypoglycemia 1 ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

9. Present Van den Berghe (2001) –Reduced Mortality 34%, sepsis 46%, renal failure, blood transfusions, polyneuropathy Van den Berghe (2006) –Reduced Mortality in those w/ LOS>3 days Van den Berghe et al. Intensive Insulin Therapy in the Critically Ill Patients. N Engl J Med. 2001;345:1359-1367 Van den Berghe et al. Intensive Insulin therapy in the medical ICU. N Engl J Med. 2006;354:449-461

10. Present Krinsley (2004) decreased mean blood glucose 152.3-130.7 –29% reduction in mortality, 75% reduction in new renal insufficiency Pittas (2004) Meta-analysis 35 clinical trials –Insulin therapy in the ICU decreased short-term mortality by 15% Krinsley J. Effect of Intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004;79(8):992-1000 ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

11. Present AMI and hyperglycemia –Predictor of mortality –Elevated infarct segments Cardiac Surgery and hyperglycemia –Independent predictor of infection –Reduction in mortality –Reduction in deep sternal wound infections ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

12. Present Yendamuri (2003) Hyperglycemia in trauma patients –Higher: LOS, Complications: UTI, Pneumonia, Wound Infection, Bacteremia, and Mortality Frontera (2006) Hyperglycemia after SAH –Associated with serious complications, increased LOS, and an increased risk of death or disability Yendamuri S. et al. Admission Hyperglycemia as a prognostic indicator in Trauma. J Trauma. 2003;555:33-38 Frontera J et al. Hyperglycemia After SAH Predictors, Associated Complications, and Impact on Outcomes. Stroke. 2006;37:199-203

13. Benefits of TGC Patient: –Sepsis –Wound Infection –Dialysis –Blood Transfusions –Polyneuropathy –Ischemic Brain Injury –Respiratory Failure –Pneumonia –Infarct Size of AMI & Stroke

14. Hyperglycemia Causes: –Pre-existing Diabetes –Medications –Nutrition –Surgery –Dialysis Solutions –Hypothermia –Anesthesia –Stress Induced Hyperglycemia

15. Implementing Tight Glycemic Control

16. STICU Timeline 2001 - 2002 Research published 2003 Implementation of TGC 2004 Multi-disciplinary development of TGC protocol 2005 Implementation of TGC Protocol, with titration grid 2006 Implementation of TGCM 2007 Implementation of TGC in all Adult ICUs

17. Strategies for Success Administrative support Multidisciplinary team Assessment of current practices Development of intervention –Order sets –Protocols –Algorithms –Education Metrics ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

18. Implementing TGC Support Identify Champions: –Administration –Physician –Nursing –Laboratory –Pharmacy –Dietary –Case management –Information Systems –Quality Dept. 1 ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

19. Current Practice (Physician) Clarify Clinical Triggers Automate the Orders Clarifying Transition Between Drip and S/S Defining Hyperglycemia

20. Current Practice (Nurse) Nurses Titrating Insulin Drips Physician Initiating Insulin Drip Physician Order Entry Continuing Insulin Drip Once on Regular Diet

21. Patient Doctor Policy / Protocol Facility / Equipment Nurse 1.Delay in receiving drip 2.Lack of real time value 3.Reactive Instead of Proactive 1.Dialysis 2.Bolus Feeds 3.Feeds Held for procedure 4.Regular Diet 1.MD won’t order protocol 2.Not all units have a protocol 3.No Standardized Policy 1.Fear Hypoglycemia 2.Lack of Value TGC 3.Nurse Avoids Drip 4.Reluctant to call MD 5.Does Not Follow Protocol 1.Fear Hypoglycemia 2.Personal Beliefs 3.Different Clinical Triggers 4.Lack of time/ too busy 5.Don’t know about protocol

23. Barriers Current Practice Cost Reduction in LOS Reduction in blood Reduction in dialysis Reduction in diversions Reduction in antibiotics Decrease in wait times Increased patient function

24. Barriers Current Practice Hypoglycemia NPO/Feeds held/Regular Diet IVF changed Dialysis Failure to change Insulin dosing Medication Error Infrequent blood glucose monitoring Orders not clearly written

25. Barriers Current Practice Organizational –Culture/Training –Workflow habits –Nursing time –Skepticism about benefits –Fear of hypoglycemia –Lack of knowledge –Lack of integration technology –Lack of ownership ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

26. No algorithm available to follow Difference in RN/MD belief for appropriate accucheck levels RN/MD fear of hypoglycemia Pump programming errors Reluctance to call MD regarding hyperglycemia/Inexperience Nurse avoiding initiation of IV drip Tight glycemic control not valued Knowledge deficit for switching from drip to sliding scale or vice versa Delays in starting protocol MD does not order protocol/drip MD avoids protocol Difficulty obtaining admission orders with protocol Protocol not followed at all Protocols differ per unit and per service Glycemic control driven by different trigger values Too many chiefs/no consensus on how to treat Order wrong/inadequate sliding scale or drip Lack of insulin availability Delayed delivery of drip from pharmacy Initiation of dialysis/Termination of dialysis Lack of real time accucheck report capability Patient preference/Patient refusal Inconsistent accucheck source (finger stick vs. blood draw vs. A-line) Conversion to Bolus feeds or PO diet Nurse deviates from protocol Survey Barriers Current Practice

28. Barriers by Unit Current Practice

29. Implementing TGC Interventions Standardization of tight glycemic control protocols mostly….

30. Implementing TGC Interventions Yale Leuven Portland Digami University of Washington Rush University Northwestern University Protocols

31. Implementing TGC Interventions

32. 1 Accucheck >150 Insulin Drip 2 Accuchecks >120 Implementing TGC Interventions

33. Develop protocol –Prompt users to initiates drip –Permits titration by ICU nurses –Ensure continuous administration of glucose –Specifies frequency glucose monitoring –Specify treatment plan for hypoglycemia. –Ensure nurses can handle increased burden of frequent glucose checks –Transition to subcutaneous insulin

34. Initial Infusion Rate Same BS defined as +/- 5. BS 111-140 Reg. Insulin 2 units IVP and start drip at 2 units/hr. BS 141-180 Reg. Insulin 4 units IVP and start drip at 2 units/hr. BS 181-250 Reg. Insulin 6 units IVP and start drip at 2 units/hr. BS 251-400 Reg. Insulin 8 units IVP and start drip at 4 units/hr. BS >400 Reg. Insulin 10 units IVP and start drip at 4 units/hr. Infusion Rate 1-3 units/hr Infusion Rate 4-6 units/hr. Infusion Rate 7-9 units/hr. Infusion Rate 10-12 units/hr. Infusion Rate 13-16 units/hr. Infusion Rate >16 units/hr. BS 0-50 Stop infusion. Call provider. Give 50ml D50. Recheck BS in 30mins.*** BS 51-70 Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous Stop infusion. Recheck BS in 30mins.*** When BS>110 restart@ 50% of previous BS 71-80 Decrease rate by 2 units/hr Decrease rate by 3 units/hr. Decrease rate by 4 units/hr. Decrease rate by 6 units/hr. Decrease rate by 8 units/hr. Decrease rate by 9 units/hr.

35. Implementing TGC Interventions Matheny (2007) –3616 diabetic patients 613 Lacking POC BG two days Colard 2004 –St. Lukes Hospital Kansas City MO –12,000 POC BG tests month 400-500 (up to 12.4%) 274 4.9% 102 1.7% 6.18% Matheny M et al. Treatment Intensification and Blood Glucose Control Among Hospitalized Patients. J Gen Intern Med. 2007;23(2):184-189 Colard D. Reduction in Patient Identification Errors Using Technology. 2004 Clinical Lab Expo AACC

36. Invalid POC Blood Glucose Monitoring

38. Implementing TGC Interventions Education –Physicians –Nurses –Techs Cook (2008) –S/S vs IV –Options/works? –Policies/protocols? –Target ranges? Cook B et al. Beliefs About Hospital Diabetes and Perceived Barriers to Glucose Management Among Inpatient Midlevel Providers. The Diabetes Educator. 2008;34(1):75-83

39. Implementing TGC Metrics Identify Program Goal –80-110, 80-140 –What are you comfortable with? Identify how to measure metrics/compliance –Who: QA department, bedside nurse, director, lab, POC office –How: Chart audits, crystal or lab report, data mining software –When: Per shift, daily, weekly, monthly, or quarterly Identify what to measure –Mean value (basic) good for trending –% values in range (basic) good for trending –% time in range –% time in range by patient (best)

40. Implementing TGC Metrics Goal: –Critically Ill patients 110mg/dl or as close as possible and generally<140mg/dl –Non-Critically Ill patients 126mg/dl fasting and all random 180-200 ADA. Standards of Medical Care in Diabetes-2008. Diabetes Care. 2008;31(1):S12-S54

41. Implementing TGC Metrics Monitor, assess, and reassess –Daily, Weekly, Monthly Share the results –E-mail –Bulletin board –Staff meeting

42. STICU Case Study

43. Insulin Usage Bags used –361 in 2003 –1063 in 2005 –2427 last 12 months Patient on Insulin drips –76 in 2003 (7%) –193 in 2005 (14.3%) –510 in last 12 months (33%)

44. Evaluation of Mean Blood Glucose 2003 156.1 2004 139.5 2005 130.8 2006 115.0

45. Evaluation of Mortality Compared to Published Studies Krinsley (2004) 29.3% reduction in mortality Van den Bergh (2001) 34% reduction in mortality Mortality % in STICU 2001 thru 2004 unchanged.

47. Evaluation of Mortality 2005 Mortality was reduced by: 30.2% Lives Saved 28

48. Journal of American College of Surgeons

49. Data Mining

50. Implementation Data Mining Software A TGC survey was developed to evaluate the nursing staff’s: –Knowledge of existing protocol. –Perceived percentage of effectiveness in achieving target range. –Perceived barriers to TGC. –Knowledge of available research literature on TGC. –Knowledge of benefits related to TGC. 60 nurses, 92.3% participated in the survey. –100% knew of the protocol and target range. –86% believed they achieved target range 50% to 90% –59% believed they achieved target range 70-90% of the time.

51. Implementation of Data Mining Software Pulled data from 5 consecutive quarters –Feb 2, 2006 - May 1, 2006 –May 2, 2006 - Aug. 1, 2006 –Implementation of Software Aug. 2, 2006 –Aug. 2, 2006 - Nov. 1, 2006 –Nov 2, 2006 - Feb 1, 2007 –Feb 2, 2007 - May 1, 2007

52. Implementation of Data Mining Software

53. Results p<0.001 Submitted to SCCM 91,536 glucose results collected

55. Managing Inpatients Continuous variable rate IV drip –Regular Insulin Premixed Insulin (Basal only) Basal-bolus –Long acting Insulin and rapid acting Insulin Oral hypoglycemic agents –Stable patients eating (stability in nutrition & condition) ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

56. Insulin Preparations Human –Rapid Acting Lispro Aspart Glulisine –Short Acting Regular –Intermediate Acting Lente NPH –Long Acting Insulin glargine analog Detemir Ultralente Human –Pre-mixed Humalog™ 75/25 Novolog Mix™ 70/30 Humulin™ 70/30 Novolin™ 70/30 Animal Source –Regular –NPH –Lente National Diabetes Education Program. Http://www.ndep.nih.gov/diabetes/wtmd/diabets_suppl_2.htm

57. Transitioning IV to SC Continue IV Insulin until patient tolerating food/feeds Continue IV Insulin at least 2 hrs after 1 st SC Insulin dose given (longer if basal Insulin) Regular insulin sliding scale – not effective Options to consider –Basal Insulin –Basal Bolus with supplemental Insulin Oral agents –not appropriate ACE/ADA Consensus Statement, Endocrine Practice.2006:12(4)459-468

58. Transitioning Home Inpatient Hyperglycemia –Stress Hyperglycemia (Temporary) Resolves, no further action needed –Previously Undiagnosed Diabetes Need to confirm Implement therapy & Education Outpatient follow-up –Previously Diagnosed Diabetes Evaluate level of control and compliance Adjust therapy if necessary Assess for complications Outpatient follow-up

59. Transitioning Home Discharge Checklist Diet Information Contact numbers –Resources –Follow-up appointments Treatment Goals Monitor and strips Prescription –Insulin & supplies “Survival Skills” training

60. “survival Skills” Training Target range for blood glucose How and when to monitor blood glucose How and when to take medication/Insulin Basics regarding meal planning How to treat hypoglycemia Sick day management Data and time of follow up appointment How to access other resources When should they call their healthcare provider

61. Case Studies: More than just a number Utilizing hyperglycemic episodes as a patient indicator for a worsening condition: –Bleeding –Sepsis Failure to Rescue –Careful surveillance and timely identification of complication –Initiating appropriate intervention and notifying the team

62. Clinical Case Study 1

63. Clinical Case Study 2

64. Patient in CT and Angio 00:20 Elevated ICPs MD Aware 03:15 MD made aware of poor ABG 03:19 Licox tissue oxygenation drops 04:00 MD making vent changes 05:15 Pt taken to CT Clinical Case Study 3

65. Clinical Case Study 4