1. Achieving Glycemic Control in the Hospital Setting 143357 Part 4 of 4

2. What Does It Take to Achieve Effective Glycemic Control for Hospitalized Patients?

3. Reasons for Deterioration of Glucose Control During Hospitalization Adapted from Metchick LN et al. Am J Med. 2002;113(4):317-323. Hyperglycemic influences “Stress” hyperglycemia Concomitant therapy Decreased physical activity Medication omissions Fear of hypoglycemia Overutilization of sliding scales Hypoglycemic influences Decreased caloric intake Acute illness (eg, gastrointestinal) Monitored compliance Delayed/missed meals Altered cognition Overutilization of sliding scales

4. Challenges of Prandial Dosing Patient’s variable nutritional schedule 1 Appetite 1 Unexpected patient transfers 1 Lab tests 1 Procedures 1 NPO 2 1. Hellman R. Endocr Pract. 2004;10(suppl 2):100-108. 2. Clement S et al. Diabetes Care. 2004;27(2):553-591. Online Appendix 1.

5. Components of a Successful Program to Improve Inpatient Glycemic Control Administrative support – The program must be given priority by the institution A multidisciplinary steering committee – Drives initiative development Assessment of current processes, quality of care, and barriers to practice change – Systematically track glucose control data Development and implementation of interventions – Standardized order sets, protocols, policies, and algorithms with associated educational components – Educate both patients and staff – Implement an inpatient-to-outpatient transition plan Metrics for evaluation to drive continuing process improvement The ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006;29:1955-1962.

6. Discharge Planning A plan for transitioning to the outpatient setting should be established at the time of admission to the hospital A successful transition to the outpatient setting requires patient education, discharge planning, and communication with outpatient providers Poor explanation of instructions to the patient during discharge has been associated with medication errors and adverse drug events Successful coordination of transition requires a team approach that may involve physicians, nurses, certified diabetes educators, medical assistants, dietitians, case- managers, and social workers Moghissi ES et al. Endocr Pract. 2009;15(4):353-369.

7. Predischarge Checklist Treatment goals How and when to take medication/insulin How and when to monitor blood glucose How to treat hypoglycemia Prescriptions for/supplies of medications and insulin and monitoring supplies Basics regarding meal plan Sick-day management Date of next appointment with clinician How to access further diabetes education as an outpatient When to call health care team Contact phone numbers “Survival skills” training Clement S et al. Diabetes Care. 2004;27(2):553-591.

8. Continuity of Care: Transitioning to Effective Outpatient Glycemic Management Lavernia F. Treating hyperglycemia and diabetes with insulin therapy: transition from inpatient to outpatient care. Medscape J Med. 2008;10(9):216. Patient Physician Dietician Podiatrist Social worker or psychologist Exercise physiologist Eye doctor Diabetes educator

9. Conclusions Hyperglycemia is associated with poor clinical outcomes across many disease states in the hospital setting Despite inconsistencies in clinical trial results, good glucose management is imperative in hospitalized patients Beneficial outcomes may be derived from higher glucose targets than previously proposed More conservative glucose targets are assumed to result in lower hypoglycemia rates

10. Conclusions (cont’d) In the non–ICU setting, insulin therapy should be tailored to meet physiologic requirements and targeted glucose levels – Sliding-scale insulin alone is ineffective and should not be used – Clinical judgment and ongoing assessment of glucose levels by the healthcare team must be incorporated into day-to-day decisions regarding glycemic management – Post-discharge patient follow-up is necessary for ongoing glycemic management Discharge planning, patient education, and clear communication with outpatient providers are critical for a safe and successful transition to outpatient care ©2011 Novo Nordisk, Inc. 143357 January 2011