1. Diabetes Pathway Pitfalls: Cased-Based Problem Solving Fran R. Cogen, MD, CDE Director, Diabetes Services Director, Washington Nationals Diabetes Care Complex Professor of Pediatrics Children’s National Health System National Institutes of Health, 3.19.15

2. Disclosures 1. Type 1 expert blogger for www.healthcentral.com www.healthcentral.com 2. Associate editor, Diabetes Spectrum 3. Consultant, DEXCOM 4. Examination Committee chair, National Certification Board for Diabetes Educators (NCBDE)

3. Learning Objectives 1.To become proficient in managing type 1 diabetes and Diabetic ketoacidosis 2.To identify potential pitfalls during treatment 3.To recognize and prevent errors in hospital management of diabetes. ***Overall goal: to decrease, fix and prevent errors in our diabetes patients

4. Case Presentation Chief Complaint: respiratory distress and vomiting for 12 hours. HPI: JW is a 3 year old female who was previously well until 6 days prior to admission when Mom noted a rash over her diaper area and lower abdomen as well as increased drinking and urination. There was a 5 lb weight loss over the past month. On the morning of admission, JW had difficulty breathing and 2 episodes of vomiting presented to the PCP. Patient was transferred to an outside hospital where she was found to be listless and in respiratory distress. Patient was given Normal Saline Boluses and transferred to CNMC after CBC demonstrated elevated WBC and blood glucose of 534. Prior to CNMC transfer, cultures were obtained and 1 dose of Vancomycin administered. Patient was admitted to ED prior to transfer to PICU for further diagnostic work-up and treatment.

5. Case presentation continued Family History: positive history of cardiovascular disease and type 2 diabetes in maternal grandparents. History of “low thyroid” in maternal aunt. Personal and Social History: JW lives with her mother and 2 siblings and attends Daycare in Bowie, Md. Mother works full- time as an administrative assistant for a rental car company.

6. Case Presentation continued Physical Examination (in ED): Vital Signs: BP=91/53, HR=133, RR=50, Temp-35.6, weight=12.5 kg, mottled skin, lungs clear to auscultation, equal breath sounds, labored breathing, cardiovascular regular rate and rhythm, poor capillary refill abdomen: ? tenderness, mild rebound, +/- bowel sounds, neurological: confused and irritable.

7. Case presentation: laboratory evaluation Glucose324 mg/dl VBG: pH7.00 pCO218 HCO34 Urine4+ glucose/ large ketones Serum acetonepositive Electrolytes: Na131 K4.1 Cl99 BUN40 Cr1.3 C-peptidepending Hb A1c10.2 CBC: WBC25,200 hb/hct9.8/30 88% polys GAD-65 antibodiespending TSH and Serum tissue Transglutaminase deferred 9 © 2011

8. Patient Summary 3 y.o. girl p/w with 6 day history h/o polydipsia, polyuria, and weight loss Found to be in respiratory distress with profound dehydration and alteration of mental status, hyperglycemic and acidotic with a blood glucose of 324, pH of 7.00, HCO3 of 4, and UA with 4+ glucose and large ketones. –Newly diagnosed diabetes, admitted to PICU in DKA

9. Most common sources of errors 1.Insulin 2.Communication 3.Fluids 4.Discharge 5.Nutrition –Reflect on the treatment of JW as you proceed through his hospital course

10. Hospital Course JW was given 30 cc/kg IV NS bolus in ED, then admitted to the PICU  tx initiated for DKA –Regular insulin drip started at 0.1 units/kg/hr –HCO3 bolus given for pH of 7.00 –IVF started with ½ NS at 1.5 x maintenance –Blood glucose trended down to 275 after 3 hours  D5 added to IVF –BMP at that time showed K level of 2.2  IV K bolus given –By 5:30 p.m., acidosis resolved (BG 252, pH 7.37, HCO3 21)  insulin drip d/c’d –Prior to dinner at 7 p.m., her blood glucose is 386. She is given 10 units of SQ humalog insulin (Weight 12.5 kg)

11. Hospital Course With DKA resolved, JW is transferred to 7East at 9 p.m. –At 10 pm, JW’s blood sugar drops to 20 and 15 grams of carbohydrates are given x 3 to raise blood sugar >70 mg/dl –At 1:30 a.m., the night intern is informed by the bedside nurse that JW did not receive her bed time dose of Lantus in the PICU and the dose has just arrived to the floor  2 units of Lantus given at 1:45am. –Knowing that JW will not be eating overnight, the intern continues her on D5 ½ NS at 1x maintenance IV fluids –Morning glucose check reveals a BG of 450 and UA shows large ketones –Breakfast is served at 7 a.m., JW gets a morning insulin injection prior to breakfast (9 units of humalog) –At 9:30 a.m., JW, becomes “irritable and shaky,” the intern asks for a stat blood glucose  BG is 50 –JW is given 4 ounces OJ (15 grams) and BG improves to 102 @ 11 am

12. Hospital Course JW and her family will need to be taught survival skills and the basics of diabetes management –They go to the family teaching room, but the diabetes educator has not arrived. –The PICU team had paged Endocrinology when the patient cleared her acidosis/DKA to ask about SQ insulin recommendations. This was the only time ENDO heard about the patient. –The diabetes educators finally arrive at 11 am and the teaching is complete by 6 p.m. –After the teaching is complete, JW is given 2 units of humalog insulin prior to dinner. 1 hour later JW’s blood sugar is 64 and the dinner tray finally arrives. –At 10:30 p.m., the night intern gets paged by JW’s nurse asking if the discharge paper work is complete –The intern writes the Discharge Summary and JW and her family head home to Bowie, Maryland.

13. So what do you think of the JW’s care? Have you identified any errors? Under what category would they fit? –Communication, Insulin, Fluids, Nutrition, Discharge How could these problems be prevented?

14. References 1.Diabetes Pathway, Children’s National Health System 2. Goldman E, Shah K, Greenberg L, Cogen F. A pediatric resident diabetes curriculum that targets different learning styles. Diabetes Spectrum 2012;25(1):45–48. 3. DeSalvo DJ, Greenberg LW, Henderson CL, Cogen FR. A learner-centered diabetes management curriculum: reducing resident errors on an inpatient diabetes pathway. Diabetes Care 2012;35(11):2188–2193. 4. Cogen, F & Greenberg, L, Teaching trainees to prevent medical errors may decrease the need for disclosure. Academic Medicine 2014:89(3): p372.

15. QUESTIONS???