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HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL Robert Gabbay, M.D., Ph.D. Associate Professor of Medicine Co-Director, Penn State Diabetes.

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Presentation on theme: "HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL Robert Gabbay, M.D., Ph.D. Associate Professor of Medicine Co-Director, Penn State Diabetes."— Presentation transcript:

1 HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL Robert Gabbay, M.D., Ph.D. Associate Professor of Medicine Co-Director, Penn State Diabetes Center

2 Diabetes in Hospitalized Patients Fourth most common co-morbid condition among hospitalized patients 10–12% of all hospital discharges 29% of all cardiac surgery patients 1–3 days longer hospital stay Hogan P, et al. Diabetes Care. 2003;26:917–932. American Association of Clinical Endocrinologists. Available at: Accessed March 17, 2004.

3 The Increasing Rate of Diabetes Among Hospitalized Patients 48% Available at: Accessed June 15, 2004.

4 Potential Benefits of Improving Glucose Control in the Hospital Improving inpatient glycemic control provides an opportunity to –Reduce mortality –Reduce morbidity –Reduce costs of care Length of stay (LOS) Cost of inpatient complications Fewer rehospitalizations Reduced extended care

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6 Intensive Insulin Therapy in Critically Ill Surgical Patients Setting: surgical intensive care unit in University Hospital, Leuven, Belgium Hypothesis: normalization of blood glucose levels with insulin therapy can improve prognosis of patients with hyperglycemia or insulin resistance Design: prospective, randomized, controlled study Conventional: insulin when blood glucose > 215 mg/dL Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

7 Intensive Insulin Therapy in Critically Ill Surgical Patients van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367. No serious hypoglycemic events. ConventionalIntensive Mean AM blood glucose achieved (mg/dL) % receiving insulin39%100% % BG < 40 mg/dL639

8 Intensive Insulin Therapy in Critically Ill Surgical Patients Improves Survival van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367. Copyright ©2001 Massachusetts Medical Society. All rights reserved. Conventional: insulin when blood glucose > 215 mg/dL. Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL. Survival in ICU (%) Intensive treatment Conventional treatment Days After Admission

9 Intensive Insulin Therapy in Critically Ill Surgical Patients: Morbidity and Mortality Benefits van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367. Reduction (%) MortalitySepsisDialysisPolyneuropathy Blood Transfusion 34% 46% 41% 44% 50% N = 1,548

10 IV Insulin Therapy in Critically Ill Surgical Patients: Safety A titration algorithm achieved and maintained blood glucose levels at < 110 mg/dL Insulin requirements were highest and most variable during first 6 hours of intensive care Normoglycemia was reached within 24 hours with a mean daily insulin dose of 77 IU; maintained with 94 IU on day 7 Blood glucose was monitored every 4 hours by ABG Statistically significant, but clinically harmless, hypoglycemia was observed briefly van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

11 Keys to Van den Berghe succcess 1 nurse to 2 pts Need IV glucose Benefit most for > 5 days in ICU (1/3) Number needed to treat = 29 Karnofsky scores better after 6 and 12 months Studies in Europe in NICU, PICU, MICU

12 Indications for Intravenous Insulin Therapy: Summary Diabetic ketoacidosis Nonketotic hyperosmolar state Critical care illness (surgical, medical) Postcardiac surgery Myocardial infarction or cardiogenic shock NPO status in Type 1 diabetes Labor and delivery Glucose exacerbated by high-dose glucocorticoid therapy Perioperative period After organ transplant Total parenteral nutrition therapy American Association of Clinical Endocrinologists. Available at: Accessed March 17, 2004.

13 GETTING STARTED (1998) Define the problem Evaluate the evidenceCABG Evaluate Current Care Identify the Stakeholders Identify Barriers

14 Portland Diabetes Project: Mortality Reprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125:1007–1021 with permission from American Association for Thoracic Surgery. CII Mortality (%) Year Patients with diabetes Patients without diabetes

15 Anthony Furnary MD 1999 CCNM Deep Wound Infection Rate (%) Furnary AP, et al. Ann Thorac Surg. 1999;67:352– % 0.8% P = 0.01 SQI = subcutaneous insulin; CII = continuous insulin infusion. Rate of DSWI Rates With Different Ins Protocols

16 CURRENT STATE OF CARE The infamous sliding scale Benign neglect Endocrinology consults on occasion Typical glucose monitoring every 4-6 hours

17 IDENTIFY STAKEHOLDERS CT Surgery Anesthesia Nursing Team Outcomes Research Team Endocrinology and Diabetes The hospital/payors

18 IDENTIFY BARRIERS Glucose monitoring –Who? –How? Understanding the rationale Nursing time and effort

19 DEVELOPMENT OF THE INSULIN INFUSION GLYCEMIC CONTROL PROTOCOL (IGCP) Multidisciplinary team led by Endocrinology Glucose meters needed to be available Goal mg/dL Grand rounds and educational programs Evaluate outcomes

20 Endocrine Practice 10:112 (2004)

21 HMC IGCP Intervention All pts undergoing CABG Start IV insulin when present to anesthesia Continue IV insulin by protocol until taking po Endo consult to adjust insulin Multi-disciplinary team- nurses, anesthesia, CT surgery, outcomes research team, endo Endocrine Practice 2004

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26 Histogram of all glucose levels in non-drip group and insulin drip protocol

27 Our Analysis Financial data Costs incurred in 1999 normalized to the year 2000 (3% adjustment) Data collected from hospitals cost accounting database and included following additional costs of IGCP: –More frequent BG monitoring –Pharmacy expenditures –Routine endocrine consultation

28 COSTS Underestimated : Readmission Indirect costs, i.e., patient satisfaction, negative publicity and reduced referrals Risk of litigation

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31 CONCLUSIONS Mean blood glucose improved from 241 to 183 (first 48 hours) Average number glucose determinations was 23.8 vs. 8 Revenue neutral despite endocrine consults, pharmacy costs, pharmacy Cost offset by clinical improvement and overall cost savings Wide acceptance by nursing and docs

32 EVERYTHING CHANGES WITH THE VAN DEN BERGHE STUDY

33 Intensive Insulin Therapy in Critically Ill Surgical Patients Improves Survival van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367. Copyright ©2001 Massachusetts Medical Society. All rights reserved. Conventional: insulin when blood glucose > 215 mg/dL. Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL. Survival in ICU (%) Intensive treatment Conventional treatment Days After Admission

34 Getting to a Lower Goal

35 GETTING LOWER This should be easy? Shortcuts are not always shortcuts Better evidence Glucose monitoring a problem again Getting back to basics?

36 HMC New insulin drip protocol Based on evidence based work from Van den Berghe (NEJM) Refined by multi-disciplinary team

37 Key changes of new protocol Target BG range (80-120mg/dl) D10 NS at maintenance rate 50 ml/hour No automatic endo consult

38 Blood Glucose (BG) mg/dl Regimen #1 For BG mg/dl Usual insulin dose <30 units/day or patients using only oral agents whose glycohemoglobin is <8 or current blood glucose mg/dl or non-diabetics Regimen #2 For BG >220 mg/dl Usual insulin dose >30 units/day or patients using only oral agents whose glycohemoglobin is >8 or unknown or current blood glucose > 220 mg/dl Starting dose2 units/hour4 units/hour If Initial BG decreases by >50% Decrease to 1 unit/hourDecrease to 2 units/hour >140Increase by 1unit/hourIncrease by 2units/hour Increase by 0.5 unit/hourIncrease by 1 unit/hour Unchanged 65-79Reduce rate by 1 unit/hour 40-64Administer 12.5 ml of D50 IV, stop infusion, call physician, and re check BG in 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 minutes. When BG >64 mg/dl, re start infusion at 50% lower rate.

39 Coming to an ICU near you!

40 Lessons Learned: Key things to think about before you try this at home!

41 The Ideal IV Insulin Protocol Easily ordered (signature only) Effective (gets to goal quickly) Safe (minimal risk of hypoglycemia) Easily implemented

42 Protocol Implementation Multidisciplinary team Administration support Pharmacy & Therapeutics Committee approval Forms (orders, flowsheet, med kardex) Education: nursing, pharmacy, physicians & NP/PA Monitoring/QA

43 Bedside Glucose Monitoring Strong quality-control program essential! Specific situations rendering capillary tests inaccurate –Shock, hypoxia, dehydration –Extremes in hematocrit –Elevated bilirubin, triglycerides –Drugs (acetaminophen, dopamine, salicylates) Clement S, et al. Diabetes Care. 2004;27:553–591.

44 Limitations of current system Nurse autonomy? GLUCOSE MONITORING –Continuous Likely the first prototypes to be approved Closed loop Strengthening the business case for good glycemic control


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