1. 1 Challenges and Opportunities In Managing Diabetes and Hyperglycemia Module 2 Diabetes Special Interest Group Georgia Hospital Association

2. 2 Module no.Topic 1Hyperglycemia and hospital outcomes 2Challenges and opportunities for care improvement 3Initial recognition, triaging, and management 4Pharmacologic management: Insulin 1 5Pharmacologic management: Insulin 2 6Review of policies and procedures 7Getting patients ready for discharge This module will describe current knowledge of our hospital diabetes care and ongoing efforts to improve Learning Modules

3. 3 Objectives Discuss the challenges to managing hyperglycemia in the hospitalized patient Describe the current status of diabetes management Use operational definitions for inpatient glucose control

4. 4 Challenges to Managing Hyperglycemia in the Hospital Type of hyperglycemic patients –Patients with preexisting diabetes –Patients with undiagnosed diabetes –Patients with stress hyperglycemia Types of hospitalized patients –Short stay –Elective/Urgent/Emergent –Post-surgical –Critically ill The patient population with hyperglycemia is heterogeneous.

5. 5 Challenges to Control Variables exacerbating hyperglycemia –Increased counter-regulatory hormones –Decreased insulin secretion –Decreased insulin sensitivity –Accelerated glucose production Increased protein catabolism Increased lipolysis Medications (steroids, vasopressors)

6. 6 Other Things to Consider Care-related issues –Incorrect classification of diabetes –Problem overlooked or not addressed –Fear of hypoglycemia –Nutrition Type of nutritional support Missed injections/missed meals Mismatching of insulin with meals –Unpredictable timing of procedures

7. 7 Let’s Look at One Hospital’s Data To identify barriers to glucose control To encourage you to identify the barriers to care at your facility

8. 8 Distribution of Diabetes Cases, by Discharge Service, at X Community Hospital

9. 9 Distribution (%) of bedside glucose, non-ICU, 2001 to 2004 at X community hospital Overall average First 24h average (n=2,408) Last 24h average (n=2,318) Admitted hyperglycemic Staying hyperglycemic Discharged hyperglycemic X needs to do a better job treating hyperglycemia 42% of patients were admitted with poor control (  200 mg/dl) and remained in poor control at time of discharge

10. 10 X needs to develop a consensus of what hyperglycemia is and establish common goals. X = 140 mg/dL Results of similar survey regarding operational definitions of hyperglycemia among attending physicians at X hospital

11. 11 Frequency of Hypoglycemia and Hyperglycemia Hypoglycemia is rare at X. Hyperglycemia is common. Which is the bigger problem? No. events/person/100 measurements Hypoglycemia frequency Hyperglycemia frequency

12. 12 Units of insulin delivered, last vs. first 24 hours of hospitalization Hospital X has clinical inertia (failure to intensify treatment). Tertile of BedGluc av Mean glucose 129165218 It also has negative therapeutic momentum (decrease in treatment despite hyperglycemia).

13. 13 Documentation of Diabetes Diabetes or hyperglycemia in daily progress note Diabetes or hyperglycemia in discharge note Diabetes in admission note Need for diabetes or hyperglycemia follow-up Diabetes is often overlooked after admission. N= 90 charts reviewed

14. 14 Diabetes and Assessment of Inpatient Glucose Control Bedside glucose values recorded in progress notes Assessment of glucose control Beside glucose measurements ordered Bedside glucose is frequently ordered, but often is not tracked.

15. 15 X is not the only hospital with opportunities for improvement.

16. 16 A Quality and Safety Concern! Insulin is one of the five highest risk medications in the hospital setting Common sources of error include –Uncoordinated feedings and medication administration leading to mistiming of insulin action –Insufficient glucose monitoring frequency –Unrecognized need for changes in insulin requirements Strategies to reduce errors include –Written protocols –Improved communication between caregivers, especially in transitions of care including discharge

17. 17 Overcoming System Barriers and Challenges Cultural change is needed –Long-standing practice patterns need to change –Processes of care need to be coordinated –Work-flow habits need to be adjusted Increased nursing time and effort is needed Skepticism about benefits of inpatient glycemic control persists Fear of hypoglycemia exists Lack of “ownership” of glycemia management Lack of diabetes education

18. 18 Final Summary Hyperglycemia is common in hospitalized patients — you will see these patients Good glycemic control is essential for good outcomes There is room to improve inpatient diabetes care at most hospitals Glucose control requires a team effort between, physicians, nurses, pharmacists and food service employees.