Presentation on theme: "HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL"— Presentation transcript:
1HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL Robert Gabbay, M.D., Ph.D.Associate Professor of MedicineCo-Director, Penn State Diabetes Center
2Diabetes in Hospitalized Patients Fourth most common co-morbid condition among hospitalized patients10–12% of all hospital discharges29% of all cardiac surgery patients1–3 days longer hospital stayDiabetes in Hospitalized PatientsDiabetes is the fourth most common comorbid condition complicating all hospital discharges. In 1997, diabetes was present in 9.5% of all hospital discharges and in 29% of patients undergoing cardiac surgery.Diabetes causes a 2- to 4-fold increase in rates of hospitalizations and increases hospital stay by 1–3 days, depending on the diagnosis on admission.Direct medical and indirect expenditures attributable to diabetes in 2002 were estimated at $132 billion. Direct medical expenditures alone totaled $91.8 billion and comprised $23.2 billion for diabetes care, $24.6 billion for chronic complications attributable to diabetes, and $44.1 billion for excess prevalence of general medical conditions. Inpatient days (43.9%), nursing home care (15.1%), and office visits (10.9%) constituted the major expenditure groups by service settings.17 million hospital days for patients with diabetes mellitusInpatient contribution of healthcare expenditures attributable to diabetes$40.3 billion43% of total direct expenditures in diabetesAnnual per capita inpatient costsDiabetes = $6,309Without diabetes = $1,289 ($2,971 adjusted)Furthermore, recent studies clearly show that hyperglycemia in hospitalized patientscomplicates numerous illnesses and is an independent risk factor for adverse outcomes.Hogan P, Dall T, Nikolov P. Economic costs of diabetes in the US in Diabetes Care. 2003;26:917–932.American Association of Endocrinologists. Accessed March 17, 2004.Hogan P, et al. Diabetes Care. 2003;26:917–932.American Association of Clinical Endocrinologists. Available at:Accessed March 17, 2004.
3The Increasing Rate of Diabetes Among Hospitalized Patients 48%The Increasing Rate of Diabetes Among Hospitalized PatientsData regarding the burden of diabetes among hospitalized patients is somewhat difficult to determine because diabetes is reflected in multiple codes in the International Classification of Diseases, Ninth Revision. In the 1990s the number of hospital discharges with diabetes as the first-listed diagnosis began increasing.Accessed June 15, 2004.Available at: Accessed June 15, 2004.
4Potential Benefits of Improving Glucose Control in the Hospital Improving inpatient glycemic control provides an opportunity toReduce mortalityReduce morbidityReduce costs of careLength of stay (LOS)Cost of inpatient complicationsFewer rehospitalizationsReduced extended carePotential Benefits of Improving Glucose Control in the HospitalImproving inpatient glycemic control provides an opportunity toReduce mortalityReduce morbidityReduce costs of careLength of stay (LOS)Cost of inpatient complicationsFewer rehospitalizationsReduced extended care
6Intensive Insulin Therapy in Critically Ill Surgical Patients Setting: surgical intensive care unit in University Hospital, Leuven, BelgiumHypothesis: normalization of blood glucose levels with insulin therapy can improve prognosis of patients with hyperglycemia or insulin resistanceDesign: prospective, randomized, controlled studyConventional: insulin when blood glucose > 215 mg/dLIntensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dLIntensive Insulin Therapy in Critically Ill Surgical PatientsRecently, the concept that stress hyperglycemia was beneficial to critically ill patients was challenged by the results of a large, prospective, randomized, controlled trial, which studied the effects if intensive insulin therapy to manage hyperglycemia on morbidity and mortality.This landmark study evaluated whether the normalization of blood glucose levels with insulin therapy improves the prognosis for patients with hyperglycemia or insulin resistance.On admission to the intensive care unit, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg/dL [4.4 and 6.1 mmol/L]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg/dL [11.9 mmol/L] and maintenance of glucose at a level between 180 and 200 mg/dL [10.0 and 11.1 mmol/L]).van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
7Intensive Insulin Therapy in Critically Ill Surgical Patients ConventionalIntensiveMean AM blood glucose achieved (mg/dL)153103% receiving insulin39%100%% BG < 40 mg/dL639Intensive Insulin Therapy in Critically Ill Surgical PatientsIt was feasible to achieve and maintain blood glucose levels at < 110 mg/dL by using a titration algorithm in all patients in the intensively treated group.Insulin requirements were highest and most variable during the first 6 hours of intensive care (mean, 7 IU/h; 10% of patients required > 20 IU/h). Between days 7 and 12, insulin requirements decreased by 40% on stable caloric intake (data not shown).With nutritional intake increasing from a mean of 550 to 1,600 calories/day during the first 7 days of intensive care, normoglycemia was reached within 24 hours, with a mean daily insulin dose of 77 IU and maintained with 94 IU on day 7 (data not shown).No serious hypoglycemic events were reported.van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.No serious hypoglycemic events.van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
9Intensive Insulin Therapy in Critically Ill Surgical Patients: Morbidity and Mortality Benefits SepsisDialysisBlood TransfusionPolyneuropathyN = 1,548Reduction (%)Intensive Insulin Therapy in Critically Ill Surgical Patients: Morbidity andMortality BenefitsIntensive insulin therapy also reduced overall in-hospital mortality by 34%, bloodstream infections by 46%, acute renal failure requiring dialysis or hemofiltration by 41%, the median number of red-cell transfusions by 50%, and critical-illness polyneuropathy by 44%. Patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than 5 days (20.2% with conventional treatment vs. 10.6% with intensive insulin therapy, P = 0.005).The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus.van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.34%41%44%46%50%van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
10IV Insulin Therapy in Critically Ill Surgical Patients: Safety A titration algorithm achieved and maintained blood glucose levels at < 110 mg/dLInsulin requirements were highest and most variable during first 6 hours of intensive careNormoglycemia was reached within 24 hours with a mean daily insulin dose of 77 IU; maintained with 94 IU on day 7Blood glucose was monitored every 4 hours by ABGStatistically significant, but clinically harmless, hypoglycemia was observed brieflyIV Insulin Therapy in Critically Ill Surgical Patients: SafetyIt was feasible and safe to achieve and maintain blood glucose levels at < 110 mg/dL by using a titration algorithm. Stepwise linear regression analysis identified body mass index, history of diabetes, reason for intensive care unit admission, at-admission hyperglycemia, caloric intake, and time in intensive care unit as independent determinants of insulin requirements.Insulin requirements were highest and most variable during the first 6 hours of intensive care (mean, 7 IU/h; 10% of patients required > 20 IU/h). Between days 7 and 12, insulin requirements decreased by 40% on stable caloric intake.With nutritional intake increasing from a mean of 550 to 1,600 calories/day during the first 7 days of intensive care, normoglycemia was reached within 24 hours, with a mean daily insulin dose of 77 IU and maintained with 94 IU on day 7.Brief, clinically harmless hypoglycemia occurred in 5.2% of intensive insulin-treated patients on median day 6 (2–14) vs. 0.8% of conventionally treated patients on day 11 (2–10). It is Important to decrease insulin infusion when patients begin enteral feeding.van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
11Keys to Van den Berghe succcess 1 nurse to 2 ptsNeed IV glucoseBenefit most for > 5 days in ICU (1/3)Number needed to treat = 29Karnofsky scores better after 6 and 12 monthsStudies in Europe in NICU, PICU, MICU
12Indications for Intravenous Insulin Therapy: Summary Diabetic ketoacidosisNonketotic hyperosmolar stateCritical care illness (surgical, medical)Postcardiac surgeryMyocardial infarction or cardiogenic shockNPO status in Type 1 diabetesLabor and deliveryGlucose exacerbated by high-dose glucocorticoid therapyPerioperative periodAfter organ transplantTotal parenteral nutrition therapyIndications for Intravenous Insulin Therapy: SummaryAmerican Association of Clinical Endocrinologists. Available at: Accessed March 17, 2004.
13GETTING STARTED (1998) Define the problem Evaluate the evidence—CABG Evaluate Current CareIdentify the StakeholdersIdentify Barriers
14Portland Diabetes Project: Mortality 10CII86Patients with diabetesMortality (%)Patients without4diabetesPortland Diabetic Project: MortalityAll patients with diabetes undergoing CABG (N = 3,554) were treated aggressively with either subcutaneous insulin (1987–1991) or continuous insulin infusion (1992–2001) for hyperglycemia in this nonrandomized, prospective study.Observed mortality and glucose control were both significantly better with continuous insulin infusion than with subcutaneous insulin therapy.Continuous insulin infusion independently reduced perioperative absolute mortality by 57% and risk-adjusted mortality by 50%. Improved survival was attributed to a reduction in cardiac-related deaths.Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007–1021.2878889909192939495969798990001YearReprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125:1007–1021 with permission from American Association for Thoracic Surgery.
15Rate of DSWI Rates With Different Ins Protocols 2.0%P = 0.01Deep Wound Infection Rate (%)0.8%Portland Diabetic Project: Rate of Deep Sternal Wound Infection RatesWith Different Insulin ProtocolsAfter previously showing that elevated postoperative blood glucose levels are a predictor of deep sternal wound infection in diabetic patients, the investigators hypothesized that aggressive intravenous pharmacologic control of postoperative blood glucose levels would reduce the incidence of deep sternal wound infection.This was a prospective study of 2,467 consecutive patients with diabetes who underwent open heart surgical procedures between 1987 and 1997; perioperative blood glucose levels were recorded every 1 to 2 hours. Patients were classified into 2 sequential groups: The control group included 968 patients treated with sliding-scale–guided intermittent subcutaneous insulin (SQI) injections; the study group included 1,499 patients treated with a continuous intravenous insulin infusion in an attempt to maintain a blood glucose level of less than 200 mg/dL.Compared with subcutaneous insulin injections, continuous intravenous insulin infusion induced a significant reduction in perioperative blood glucose levels, which led to a significant reduction in the incidence of deep sternal wound infection in the continuous intravenous insulin infusion group (0.8% [12 of 1,499]) versus the intermittent subcutaneous insulin injection group (2.0% [19 of 968], p = by the χ2 test).Multivariate logistic regression revealed that continuous intravenous insulin infusion induced a significant decrease in the risk of deep sternal wound infection (p = 0.005; relative risk, 0.34), whereas obesity (p < 0.03; relative risk, 1.06) and use of an internal thoracic artery pedicle (p = 0.1; relative risk, 2.0) increased the risk of deep sternal wound infection.Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352–360; discussion 360–362. SQI = subcutaneous insulin; CII = continuous insulin infusion.Anthony Furnary MD CCNMFurnary AP, et al. Ann Thorac Surg. 1999;67:352–362.
16CURRENT STATE OF CARE The infamous sliding scale Benign neglect Endocrinology consults on occasionTypical glucose monitoring every 4-6 hours
17IDENTIFY STAKEHOLDERS CT SurgeryAnesthesiaNursing TeamOutcomes Research TeamEndocrinology and DiabetesThe hospital/payors
18IDENTIFY BARRIERS Glucose monitoring Who? How? Understanding the rationaleNursing time and effort
19DEVELOPMENT OF THE INSULIN INFUSION GLYCEMIC CONTROL PROTOCOL (IGCP) Multidisciplinary team led by EndocrinologyGlucose meters needed to be availableGoal mg/dLGrand rounds and educational programsEvaluate outcomes
21HMC IGCP Intervention All pts undergoing CABG Start IV insulin when present to anesthesiaContinue IV insulin by protocol until taking poEndo consult to adjust insulinMulti-disciplinary team- nurses, anesthesia, CT surgery, outcomes research team, endoEndocrine Practice 2004
26Histogram of all glucose levels in non-drip group and insulin drip protocol
27Our Analysis Financial data Costs incurred in 1999 normalized to the year 2000 (3% adjustment)Data collected from hospital’s cost accounting database and included following additional costs of IGCP:More frequent BG monitoringPharmacy expendituresRoutine endocrine consultation
28COSTS Underestimated : Readmission Indirect costs, i.e., patient satisfaction, negative publicity and reduced referralsRisk of litigation
31CONCLUSIONSMean blood glucose improved from 241 to 183 (first 48 hours)Average number glucose determinations was 23.8 vs. 8Revenue neutral despite endocrine consults, pharmacy costs, pharmacyCost offset by clinical improvement and overall cost savingsWide acceptance by nursing and docs
32EVERYTHING CHANGES WITH THE VAN DEN BERGHE STUDY
35GETTING LOWER This should be easy? Shortcuts are not always shortcuts Better evidenceGlucose monitoring a problem againGetting back to basics?
36HMC New insulin drip protocol Based on evidence based work from Van den Berghe (NEJM)Refined by multi-disciplinary team
37Key changes of new protocol Target BG range (80-120mg/dl)D10 NS at maintenance rate 50 ml/hourNo automatic endo consult
38Blood Glucose (BG) mg/dl Regimen #1For BG mg/dlUsual insulin dose <30 units/day orpatients using only oral agents whose glycohemoglobin is <8 or current blood glucose mg/dl or non-diabeticsRegimen #2For BG >220 mg/dlUsual insulin dose >30 units/day or patients using only oral agents whose glycohemoglobin is >8 or unknown orcurrent blood glucose > 220 mg/dlStarting dose2 units/hour4 units/hourIf Initial BG decreases by >50%Decrease to 1 unit/hourDecrease to 2 units/hour>140Increase by 1unit/hourIncrease by 2units/hour121‑140Increase by 0.5 unit/hourIncrease by 1 unit/hour80-120Unchanged65-79Reduce rate by 1 unit/hour40-64Administer 12.5 ml of D50 IV, stop infusion, call physician, and re‑check BG in 15‑30 minutes. When BG >64 mg/dl, re‑start infusion at 50% lower rate.<40Administer 25 ml of D50 IV, stop infusion, call physician, and re‑check BG in 15‑30 minutes. When BG >64 mg/dl, re‑start infusion at 50% lower rate.
40Key things to think about before you try this at home! Lessons Learned:Key things to think about before you try this at home!
41The Ideal IV Insulin Protocol Easily ordered (signature only)Effective (gets to goal quickly)Safe (minimal risk of hypoglycemia)Easily implementedThe Ideal IV Insulin ProtocolIn addition to specifying insulin dose, protocols should include specific guidelines for identifying patients at risk for hypoglycemia and actions to be taken to prevent and treat hypoglycemia.
42Protocol Implementation Multidisciplinary teamAdministration supportPharmacy & Therapeutics Committee approvalForms (orders, flowsheet, med kardex)Education: nursing, pharmacy, physicians & NP/PAMonitoring/QAProtocol ImplementationUtilizing the team approach to inpatient care has been shown to reduce length of stay and improve clinical outcomes in patients with diabetes.
43Bedside Glucose Monitoring Strong quality-control program essential!Specific situations rendering capillary tests inaccurateShock, hypoxia, dehydrationExtremes in hematocritElevated bilirubin, triglyceridesDrugs (acetaminophen, dopamine, salicylates)Bedside Glucose MonitoringImplementing intensive glycemic control in the hospital setting requires frequent and accurate blood glucose data. Capillary tests have the advantage over laboratory tests of providing rapid “point of care” information. However, there are situations in which these tests are rendered inaccurate and in which laboratory testing of venous glucose testing is required.Clement S, Braithwaite SS, Magee M, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553–591.Clement S, et al. Diabetes Care. 2004;27:553–591.
44Limitations of current system Nurse autonomy?GLUCOSE MONITORINGContinuousLikely the first prototypes to be approvedClosed loopStrengthening the business case for good glycemic control