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Diabetes Update: Think like your patient to better assess.

Best practices on how to use simple flash animations in combination with prezi Path and Frames - to achieve a strong narrative.
by

Amber Wilhoit

on 26 July 2013

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Transcript of Diabetes Update: Think like your patient to better assess.

Best Advice:
1.
Exercise
2.
It's okay to keep it SIMPLE.
3.
Repeat and Reinforce when able.
--Key teachable moment--
If you come across as someone wanting to help instead of someone with a lecture, you can win over the patient who (thinks they) know it all already.
4.
Diabetes is Epidemic
Chances are it will affect you or someone you love in your lifetime.
The patient has fallen. Someone somewhere or many someones and many somewheres led to this. Always ask the patient home doses taken. Do not rely on insulin or medication Rxs.
How can you empower this patient?
Diagnosable Diabetes:
Be aware of visual disturbances due to hyperglycemia or retinopathy. Large font and pictures can help.
Every Diabetic patient on insulin, a sulfonylurea (Glipizide, glyburide, glimepiride), or meglitinides (prandin) should have the Rule of 15 for hypoglycemia management reviewed.
Many people with Diabetes have limitations due to back or knee problems, so a pool or stationary bike may be their only option. Exercise helps increase glucose uptake and can have a marked improvement in blood sugar numbers.
It can also cause hypoglycemia.
Omnipod
Animas
Medtronic
Diabetes Assessment
Artificial Pancreas
Think twice before using the descriptor Non-compliant with Patients with Diabetes.
Be on the lookout for chances to help as all help is needed.
A vial of insulin is 1000 units (10 mL).
An insulin pen is 300 units (3 mL) and comes in a box of 5 pens for a total of 1500 units (15 mL).
Insulin in use can be stored at room temperature
"No one ever explained it like that before"
"I wish I had known that 20 years ago"
"I can have rice and pasta now.
I just have to watch my portion size.
"
"When I was told I couldn't eat this and I couldn't eat that. I was scared to eat anything. Eventually, I just said to heck with it."
"When my blood sugar is low, I won't take any insulin before meals."
"A low for me is around 100.
If I get below 100, I am going to eat something fast."
"I just take it twice a day like I was told"
"I am not sure if I have Type I or Type II"
"I can't have fruits. They run my sugar too high"
"My insurance won't cover Lantus"
Said by a male patient, "I don't miss my shots. I inject into my arm and the top of my leg every day."
"I have a cooler that I keep my insulin in all the time"
"My Lantus lasts me about three months"
Sweets are no more “off limits” to people with diabetes than they are to people without diabetes.
"She obviously isn't taking care of her Diabetes if she is on insulin"
"I take my insulin after I know what I am going to eat"
"When I have a low, I will grab a soda or a piece of hard candy"
183
142
119
86
fasting plasma Glucose Result (mg/dL)
Diagnosis
99 or below -- Normal
100 to 125--Prediabetes (impaired FBG)
126 or above -- Diabetes*
*Confirmed by repeating the test on a
different day.
2-Hour Plasma Glucose Result (mg/dL)
Diagnosis
139 and below -- Normal
140 to 199 -- Prediabetes (IGTT)
200 and above -- Diabetes*
*Confirmed by repeating the test on a
different day.
A1C
Pre-diabetes 5.7%-6.4%
Diabetes 6.5% or higher
No disease has had such an evolution of therapy in the past 80 years as type 1 diabetes. From certain death to the discovery of insulin, from impure animal insulin preparations to purified human insulins, from once daily long-acting insulin to CSII, from urine glucose testing to real-time continuous glucose sensors, treatments continue to emerge that improve the lives of people with type 1 diabetes. Our current challenges remain teaching the providers how to best use these new tools, directing our medical systems to allow us to best utilize these therapies, and perhaps most importantly, transferring these new technologies to the patients who can best apply them. Although the future is exciting, we need to first master the use of our current tools before we can successfully move forward. Hopefully, in the near future the successful management of type 1 diabetes will become a reality for all with this disease.
Medications
Insulin
Lantus (glargine)/ Levemir (detemir)
Humalog (lispro)/ Novolog (aspart)/ Apidra (glulisine)
Humulin N/ Novolin N
Humulin R/ Novolin R
Humulin or Novolin 70/ 30
Humalog or Novolog 75/ 25
Humalog 50/50

Basal Bolus
50%
50%
Breakfast
Lunch
Supper
How long have you been diagnosed?
What, if any, medications do you take for your diabetes?
You said before...what did you mean by that?
What do you drink when you are thirsty?
Have you heard of a lab called an A1C?
How many times per day do you eat?
Metformin/ Glucophage
Improves insulin sensitivity; supresses the release of glucose from the liver overnight.

Contraindications:
acute illness, GI or hepatic disease, renal dysfunction, CHF, hypoxic states or alcohol abuse; Cr>1.4; withold in IV contrast dye procedure; small incr. risk of lactic acidosis
Dipeptidyl peptidase-4 Inhibitor
Easily ordered (signature only)
Effective (gets to goal quickly)
Maintains BG within a defined target range
Includes an algorithm for making temporary corrective increments or decrements of insulin infusion rate
Safe (minimal risk of hypoglycemia)
Easily implemented
Can be executed by nursing staff in response to a single physician order
An Optimal IV Insulin Protocol
Starting dose = 0.5 x wt in kg
0.5 x 100 kg = 50 U
Basal dose = 40%-50% of starting dose at bedtime
50% of 50 U = 25 U at hs
Total bolus dose = 50%-60% of starting dose evenly distributed 1/3 at each meal
25 U ÷ by 3 meals = 8 U before meals (tid)
Give after meals as rapid-acting analog if food intake is in doubt
Do not skip correction dose even if no food eaten
Adjust upwards daily by adding 50% of correction doses to basal and bolus doses
Starting MDI in 100-kg Person
with Moderate Insulin Resistance
Converting IV to SC Insulin: Practical Guidelines
D/C drip 2-4 h after first SC dose of insulin
(Longer if long-acting basal insulin is started)
Continue IV insulin until patient is able to tolerate solid food intake
Continue IV insulin at least 2 h after the first SC insulin injection is given
Don’t use only basal insulin in patients with an A1C greater than 8.5% on 2 or more oral agents
Don’t switch to only oral agents from IV insulin in patients with type 2 diabetes
Arrange for outpatient follow-up of patients placed on insulin in the hospital
Transition from IV To SC Insulin
Transition from IV to SQ Insulin
Bedside glucose monitoring technique
Critical and target BG values
Insulin administration technique
Optimum timing of subcutaneous insulin shots
Hypoglycemia prevention and treatment
BG and insulin dose documentation
Basic patient education (ability to teach patient “survival skills”)
Core Competencies for Nurses
Impact of BG on hospital outcomes
Institutional targets for BG
Terminology: basal/nutritional/correction
Insulin product knowledge
Hypoglycemia prevention and treatment
Core Knowledge for Physicians
Education
Education
Education
Needs to be provided on a regular basis and can be given through a variety of approaches
Lectures
Presence on rounds
Online (available 24/7)
Pocket tools for house staff (laminated cards)
Education is Key to Success
Management of Hyperglycemia
in the ICU Setting
Published Guidelines for Conversion from IV to SQ
Establish 24 h insulin requirement
Extrapolate from average over last 4-8 h if stable
Give 1/2 amount as basal
Give ac boluses
Based on CHO intake (1 U of insulin for 10 grams of CHO)
Remaining 50% given 1/3 before each meal
Monitor ac, tid, hs, and 3 AM
Correction bolus for all BG >140 mg/dL
Recommendations for Converting
IV to SC Insulin: Basal or MDI
Resumption of prior insulin regimens
Initiation of basal insulin
Initiation of basal/bolus MDI
Initiation of premixed insulin
Therapeutic Options to Consider
When Converting to SC Insulin
Is the patient eating? If so, what and when?
What are the concomitant therapies?
Glucocorticoids?
Inotropes?
Vasoconstrictors?
Will resolution of the illness(es) or change in concomitant therapies reduce insulin needs?
Additional Questions to Consider When Converting to SC Insulin
Garg R, et al. J Hosp Med. 2007;2:258-60.
Retrospective analysis of response to insulin-induced hypoglycemia
Mean BG at the time of dextrose administration for hypoglycemia was 52 mg/dL (range 31-68)
While insulin dose was held at the time of the hypoglycemic episode in all 52 patients, changes were subsequently made in the treatment of only 40% patients
Poor Provider Response to Insulin-Induced Hypoglycemia in Hospitalized Patients
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468.
Advanced age
Decreased oral intake
Chronic renal failure
Liver disease
Beta-blockers
Common Features Increasing Risk of Hypoglycemia in an Inpatient Setting
Prevention of Hospital Hypoglycemia
Clement S, et al. Diabetes Care. 2004;27:553-591.
Concentrations should be standardized throughout the hospital
Regular insulin in concentrations of 1 U/mL or 0.5 U/mL
Infusion controller adjustable in 0.1-U doses

Accurate bedside blood glucose monitoring done hourly (and if stable, every 2 hours)

Potassium should be monitored and given if necessary
Components of IV Insulin Therapy
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-68.
A system to track hospital glucose data on an ongoing basis can be used to
Assess the quality of care delivered
Allow for continuous improvement of processes and protocols
Provide momentum
Metrics for Evaluation
American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control.
Endocr Pract. 2004;10:77-82.
Champion(s)
Administrative support
Multidisciplinary steering committee to drive the development of initiatives
Medical staff, nursing and case management, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, administration
Assessment of current processes, quality of care, and barriers to practice change
Successful Strategies for Implementation
Several published protocols for intravenous insulin infusions exist
each may be suitable for different patient populations
The ideal protocol is the one that will work in a given institution
However, all protocol implementation will require multidisciplinary interaction and education
Other protocols needed to make inpatient glucose management a success include
Protocols to manage hypoglycemia
Protocols to guide the transition from intravenous to subcutaneous therapy
Key Points
Model from a Tertiary Care Center
DeSantis AJ, et al. Endocr Pract. 2006;12:491-505.
Example 2. Estimating Insulin Doses When No Intravenous Insulin Therapy has Been Given
Calculate estimated total daily dose of insulin as follows:
Type 2 diabetes (known): 0.5 to 0.7 U/kg
Type 1 diabetes (known): 0.3 to 0.5 U/kg
Unknown 0.3 to 0.5 U/kg
Divide total daily dose of insulin into 50% basal as glargine and 50% prandial as aspart, lispro, or glulisine
Divide prandial insulin into 3 equal doses to be given with meals.
DeSantis: Transition from Intravenous Insulin Infusion to Subcutaneous Therapy
American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control.
Endocr Pract. 2004;10:77-82.
Transportation off ward causing meal delay
New NPO status
Interruption of any of the following:
Intravenous dextrose
TPN
Enteral feedings
Continuous renal replacement therapy
Triggering Events for Hypoglycemia
USP Patient Safety CapsLink July 2003. Available at: http://www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01.pdf Accessed 5 8.07
Use of “sliding scale” insulin in the absence of regularly scheduled insulin
Use of “U” for units being misread as a number
Similar names of products, manufacturer’s labeling
Accessibility as floor stock
Non-standard compounded IV solutions and infusion rates
Factors Increasing Risk of Medication Errors with Insulin
USP Patient Safety CapsLink July 2003. Available at: http://www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01.pdf Accessed 5 8.07
JCAHO considers insulin to be 1 of the 5 highest-risk medicines in the inpatient setting
Primarily because the consequences of errors with insulin therapy can be catastrophic
Analysis of data reported to USP’s MEDMARX reporting program over a 2 yr period uncovered a total of 4,764 insulin errors with approximately 6.6% (n = 320) of these causing harm to the patient.
Historically, the average harm threshold for error reports submitted to MEDMARX has been about 2.8%, indicating that when an insulin product is involved, it may be twice as likely to result in harm
Omission errors (leading to hyperglycemia) and Improper dose/quantity (leading to hyper or hypoglycemia) were the two most frequently reported types of error associated with insulin
Insulin Therapy
Goldberg PA, et al. Diabetes Care. 2004;27:461-467.
Insulin infusion: Mix 1 U regular human insulin per 1 mL 0.9% NaCl
Administer via infusion pump in increments of 0.5 U/h
Bolus and initial infusion rate:
Divide initial BG by 100, round to nearest 0.5 U for bolus and initial infusion rates
Example: Initial BG = 325 mg/dL: 325/100 = 3.25, round up to 3.5: IV bolus = 3.5 u start infusion at 3.5 U/h
Subsequent rate adjustments:
Changes in infusion rate are determined by the current infusion rate
and the hourly rate of change from the prior BG level; see table for
instructions
Example: Yale Insulin Infusion Protocol
Yale protocol
Markovitz protocol
Leuven protocol
Portland protocol
DIGAMI
University of Washington
Luther Midelfort Mayo Health System
Brigham and Women’s Hospital insulin protocol
Various IV Insulin Protocols Exist
Wilson M, et al. Diabetes Care 30:1005-1011 Goldberg PA, et al. Diabetes Care. 2004;27:461-467; Furnary AP, et al. Endocr Pract. 2004;10:21-33; Krinsley J. Mayo Clin Proc. 2004;79:992-1000; Ku SY, et al. Jt Comm J Qual Patient Saf. 2005;31:141-147; Malmberg K, et al. Circulation. 1999;99:2626-2632; Malmberg K, et al. Eur Heart J. 2005;26:650-66; Markovitz LJ, et al. Endocr Pract. 2002;8:10-18; van den Berghe G, et al. N Engl J Med. 2001;345:1359-1367.
Clement S, et al. Diabetes Care. 2004;27:553-591.
Kanji S, et al. Crit Care Med. 2005;33:2778-85.
Strong quality-control program essential
Specific situations rendering capillary tests inaccurate
Shock, hypoxia, dehydration
Extremes in hematocrit
Elevated bilirubin, triglycerides
Drugs (acetaminophen, dopamine, salicylates)
Point-of-care measurement
Most practical and actionable for guiding treatment
But need to consider limitations in accuracy
Indications for Bedside Glucose Monitoring
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-68.
Multidisciplinary team
Administration support
Pharmacy & Therapeutics Committee approval
Forms (orders, flowsheet, med kardex)
Education: nursing, pharmacy, physicians & NP/PA
Monitoring/Quality Assurance
Requirements for Protocol Implementation
American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control.
Endocr Pract. 2004;10:77-82.
Standardized order sets
-BG measurement
-Treatment of hyperglycemia AND hypoglycemia
Protocols, algorithms
Policies
Educational programs (physicians and nurses)
Glycemic Management Clinical Team
Metrics for evaluation
Development and Implementation
Furnary AP, Braithwaite SS. Am J Cardiol. 2006;98:557-564.
More likely to experience increasing blood glucose or increased complications on early transition to subcutaneous insulin
Underwent complex heart surgeries
At high risk for mediastinitis in ICU
Receiving pressors
Require intra-aortic balloon pump
Receiving corticosteroids
BG >130 mg/dl while receiving insulin infusion
With type 1 diabetes
Basal insulin dose projected to be >48 U/d while receiving insulin drip
Basal insulin infusion rate >2 U/h to maintain BG <130 mg/dl
More likely to successfully transition without a loss of glycemic control
Underwent uncomplicated CABG and/or valve surgery and discharged from ICU extubated
Taking liquids/regular meals,
Following house/ADA diet
Stable renal function
Observed for 6–8 h before breakfast to determine basal insulin requirement
With type 2 diabetes or hospitalization-related hyperglycemia
Receiving ≤2 U/h insulin infusion with concomitant BG <130 mg/dl
Basal insulin dose ≤48 U/d while receiving insulin drip
Proposed Predictors for Successful Transition
from Intravenous Insulin Infusion to Subcutaneous Insulin Therapy
Furnary AP, Braithwaite SS. Am J Cardiol. 2006;98:557-564.
Conversion protocol
Initiate prandial doses of rapid-acting analogue with the first dietary trays, even if patient is receiving IV insulin infusion
Find a 6- to 8-h interval during IV insulin infusion when the following conditions are met:
Out of the ICU
No oral intake (e.g. nighttime)
No IV dextrose administration
Use the average insulin infusion rate during this interval to project an average 24-h based insulin requirement (6-h total dose X 4; 8-h total dose X 3, and so forth)
Calculate the initial insulin glargine dose at 80% of the 24-h basal insulin requirement during the previous time interval
Stop IV infusion of insulin 2 h after first insulin glargine dose
Monitor blood glucose perprandially, at bedtime, and at 3:00am
Order a correction dose algorithm for use of a rapid-acting analogue to treat hyperglycemia to start after IV insulin infusion is terminated
Revise total 24-h dose of insulin daily
Revise the distribution of basal and prandial insulin daily to approach 50% basal and 50% prandial
Furnary: Transition from Intravenous Insulin Infusion to Subcutaneous Therapy
Model from a Tertiary Care Center
DeSantis AJ, et al. Endocr Pract. 2006;12:491-505.
Example
1. Conversion From Intravenous Insulin Therapy
Intravenous insulin drip rate averaged 1.8 U/h with final glucose level 98 mg/dL
Calculate average insulin infusion rate for last 6 h = 2.1 U/h and multiply x 24 to get total daily insulin requirement (2.1 x 24 = 50 U/24 h)
Multiply this 24-h dose (50 U) x 80% to obtain glargine dose = 40 U, which is given and the infusion is stopped
Multiply the glargine dose by 10% to give as a rapid-acting insulin (e.g., aspart, lispro, or glulisine) at the time the glargine is given and the infusion is stopped
Give 10% of the glargine dose as prandial doses before each meal
DeSantis: Transition from Intravenous Insulin Infusion to Subcutaneous Therapy
Example
* BG = blood glucose; CF = correction factor; IV = intravenously; SC = subcutaneous; TDD = total daily dose
Bode BW, et al. Endocr Pract. 2004;10 Suppl 2:71-80.
Patient has received an average of 2 U/h IV during previous 6 h. Recommended doses are as follows:
SC TDD is 80% of 24-h insulin requirement:
80% of (2 U/h x 24) = 38 U
Basal dose is 50% of SC TDD:
50% of 38 U = 19 U of long-lasting analogue
Bolus total dose is 50% of SC TDD:
50% of 38 U = 19 U of total prandial rapid-acting analogue or ~6 U with each meal
Correction dose is actual BG minus target BG divided by the CF, and CF is equal to 1,700 divided by TDD:
CF = 1,700 ÷38 = ~40 mg/dL
Correction dose = (BG – 100) ÷ 40
Bode: Transition from Intravenous Insulin
Infusion to Subcutaneous Therapy
Garg R et al. J Hosp Med. 2009;4(6):E5-7.
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468.
Lack of coordination between dietary and nursing leads to mistiming of insulin dosage with respect to food
Inadequate glucose monitoring
Inadequate insulin dose adjustment
Lack of coordination between transportation and nursing
Unsafe work environment
Indecipherable orders
Factors Increasing Risk of Hypoglycemia in an Inpatient Setting
American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control.
Endocr Pract. 2004;10:77-82.
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
Diabetic ketoacidosis
Nonketotic hyperosmolar state
Critical care illness (surgical, medical)
Postcardiac surgery
Myocardial infarction or cardiogenic shock
Indications for Intravenous Insulin Therapy
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-68; NICE-SUGAR, NEJM; Mar 26, 2009; 360;1283-97
Significant improvements in mortality and morbidity with intensive glycemic management have been demonstrated

In some randomized controlled trials “Before and after” comparisons
Cost analyses have documented substantial cost savings with this therapy

Adverse consequences of hyperglycemia exist even in patients without known diabetes (and may be even worse)

The largest randomized trial (NICE-SUGAR) showed increased mortality with tight glycemic control (80-110 mg/dl, mean glucose 115 mg/dl) in the ICU when compared with good glycemic control (140-180, mean glucose 144 mg/dl).
Overview: Glycemic Control
in Critically Ill Patients
Kosiborod M, et al. Circulation 2008:117:1018.
Reference: Mean BG 100-110 mg/dL
Moghissi E et al., Diabetes Care 2009;32:1344; Moghissi E et al., Endocrine Practice 2009;15:353
AACE-ADA Consensus Statement on Inpatient Glycemic Control: ICU
Start IV insulin at threshold no higher than 180 mg/dl.

Glucose target = 140-180 mg/dl
? Greater benefit at lower end
Lower target ( 110-140 mg/dl ) acceptable in selected patients if hospital achieving this successfully.
Moghissi E et al., Diabetes Care 2009;32:1344; Moghissi E et al., Endocrine Practice 2009;15:353
Start IV insulin at threshold no higher than 180 mg/dl.

Glucose target = 140-180 mg/dl
? Greater benefit at lower end
AACE-ADA Consensus Statement on Inpatient Glycemic Control: ICU
Lower target ( 110-140 mg/dl ) acceptable in selected patients if hospital achieving this successfully.
Moghissi E et al., Diabetes Care 2009;32:1344; Moghissi E et al., Endocrine Practice 2009;15:353
AACE-ADA Consensus Statement on Inpatient Glycemic Control: ICU
Start IV insulin at threshold no higher than 180 mg/dl.

Glucose target = 140-180 mg/dl
? Greater benefit at lower end
Tighter targets ( <110 mg/dl ) not safe; >180 mg/dl not acceptable.
Now In PrezivisionN TM
Mean Glucose & In-Hospital Mortality In 16,871 Patients with Acute MI
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