1. Module 3 Initial Recognition, Triaging, and Management of Hyperglycemia Diabetes Special Interest Group Georgia Hospital Association

2. The highlighted topic is what is covered in this module Learning Modules Module no.Topic 1Hyperglycemia and hospital outcomes 2Challenges and opportunities for care improvement 3Initial recognition, triaging, and management 4Principles of pharmacologic management: Insulin 1 5Principles of pharmacologic management: Insulin 2 6Review of policies and procedures 7Getting patient ready for discharge

3. Summary Of Key Points From Previous Modules The numbers of diabetes cases seen in the hospital are rising Hyperglycemia in the hospital is associated with worse patient outcomes Controlling glucose in the hospital can lead to better patient outcomes There is room to improve diabetes care at most facilities With this module we will begin to discuss management strategies

4. Module 3 Objectives Understand the phases of inpatient glucose management Differentiate types of hyperglycemic patients you will encounter in the hospital Initiate appropriate management steps according to: –Type of diabetes –Severity of hyperglycemia

5. Phases of Inpatient Hyperglycemia Care Admission First 24 hours Recognition and triage Initial treatment plan Continued care Ongoing monitoring Education Treatment adjustment Discharge planning What therapy? What is the follow-up? Do patients know what to do? Education provided? This module will focus on the first 24 hours of management We will conceptually divide inpatient hyperglycemia care into three phases

6. Types of Hyperglycemic Patients in the Hospital Patients with pre-existing diabetes Have a history of diagnosed diabetes May be on pharmacotherapy Patients with stress hyperglycemia Hyperglycemia that develops in response to the acute illness or medications Require therapy during hospital stay if their blood glucose is above target range for their unit (ICU 80-110 mg/dL, Med Surg and Peri-Op 90-140 mg/dL Patients with undiagnosed diabetes Often have unequivocal hyperglycemia (glucose  200 mg/dL) on admission

7. Minimum Admission Actions Patients with diabetes/hyperglycemia, or who are at risk of developing hyperglycemia (e.g. transplant patients, patients starting steroids) should have at admission a minimum: –Bedside glucose monitoring ac, hs, & 3AM if eating or every 6 hours if NPO –Hemoglobin A1c if none available from past 60 days –Documentation in admission note about the presence or risk of hyperglycemia –Therapeutic strategy outlined Remember to include the problem of diabetes/hyperglycemia in your problem list!

8. Initial Management Decisions Should be based on the type of diabetes and severity of hyperglycemia Half of the patients with diabetes are undiagnosed. Patients without a known diagnosis of diabetes but who exhibit hyperglycemia on admission likely have diabetes and should be treated as such.

9. Triaging Patients Without Known Diabetes *All insulin deficient patients, especially type 1 diabetes, must have insulin Patient admitted DKA Hyperglycemic Crisis Labor and Delivery Obtain HbA1c Begin IV Insulin Protocol Glucose Monitoring Hourly No previous Diabetes Diagnosis Elevated Admission Glucose <200 mg/dL Obtain HbA1c, Begin BG Monitoring, Correct with rapid Insulin any BG > 140 mg/dL Bedside glucose  140 mg/dL two consecutive measurements Start basal-bolus insulin protocol Consult diabetes education team Bedside glucose occasionally 140 to 199 mg/dL Continue to monitor Start correctional insulin Consider basal bolus in cardiac pts. Unequivocal hyperglycemia (glucose  200 mg/dL, not DKA/hyperglycemic crisis or labor) Obtain HbA1c Begin glucose monitoring Start scheduled insulin therapy

10. Patient admitted Determine if insulin requiring Type 1 or Insulin Requiring Type 2 or Gestational Obtain HbA1c Start monitoring Continue and adjust insulin regimen Type 2 Diabetes or Gestational Not Using Insulin Was taking oral agents* Obtain HbA1c Start monitoring Start insulin if needed No previous pharmacotherapy Obtain HbA1c Start monitoring Start insulin if needed *Should usually be discontinued in acutely ill patients Initial Management for Patients With Known Diabetes

11. Case Scenario A 75 year old lean woman with a 5 year history of diabetes is admitted for elective knee replacement. She has always needed insulin to control hyperglycemia. She is currently on short acting insulin with meals and a long acting insulin in the evening. You place her only on a sliding scale program. Her blood glucoses start to rise pretty quickly into 300’s and 400’s, and you desperately call the Endocrine service. What went wrong? She has Type 1 Diabetes and needs a basal – bolus insulin program. Not every person who develops diabetes in older years has Type 2 diabetes. Be certain to correctly classify your patient’s diabetes and never withhold basal insulin from someone with Type 1 diabetes.

12. When a patient with pre-existing diabetes is admitted to the hospital… Determine if they are insulin requiring –Type 1 Diabetes patients ALWAYS need a long acting (basal) insulin even if they are fasting. They also need meal bolus insulin based on the carbohydrate they consume at each meal. If patients are already on outpatient insulin, chances are they were on it because they needed it—at the very least keep them on basal insulin until you are sure they don’t need it

13. Module Summary Hyperglycemic inpatients are diverse—be sure you know who you are managing Identify hyperglycemic patients early Apply appropriate therapy early