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Slide 2 Presented by: CAPT Christine Chamberlain, PharmD, BCPS, CDE Multidisciplinary Approach to Inpatient Blood Glucose Management Slide 3 2 Slide 4 1,500 studies currently in progress. Most Phase 1 & 2 trials. 240 inpatient beds, 82 day hospital stations, and outpatient clinics. 3 Slide 5 List important factors that were considered in the design of blood glucose management service (BGMS) Explain the design of electronic medical record to support the service Implement new strategies for managing inpatients requiring insulin efficiently in similar environments 4 Slide 6 All patients seen at NIH are on a clinical research protocol Some investigational drugs may affect glucose or insulin action Some research protocols require steroids Minimizing serious adverse events of glycemia related to protocol 5 Slide 7 Patients come from all 50 states and other countries as often we are studying rare diseases Many foreign languages Many without insurance 6 Slide 8 7 n engl j med 355;18 www.nejm.org november 2, 2006 Slide 9 No consistency Changing management guidelines New drugs to use in controlling blood glucose Late endocrine consults Delay in implementing consult recommendations Discharge planning Disjointed patient education 8 Slide 10 Members Attending Fellows Pharmacist Dietitian Nurse Practitioner Nurse Social Worker as needed 9 Slide 11 Attending Physician Champion Expert Training Liaison 10 Slide 12 Fellow Initial visit and history Orders On-call 11 Slide 13 Dietitian Patient teaching Participation in daily rounds Determination of diet/TPN 12 Slide 14 Nurse Ambassador Daily visits with patient Participate in daily meetings, report Documentation in electronic record Discharge teaching with patients Staff training Back up on call Fellow 13 Slide 15 Nurse Practitioner Ambassador Daily visits with patient Participate in daily meetings, report Documentation in electronic record Discharge teaching with patients Staff training Back up on call Fellow Facilitate order entry 14 Slide 16 Pharmacist Ambassador Daily visits with patient Participate in daily meetings, report Documentation in electronic record Discharge teaching with patients Staff training Back up on call Fellow Medication Profile review 15 Slide 17 Multidisciplinary team consult service Provide around the clock responsibility for blood glucose management for referred patients. Manage only inpatients receiving insulin Team will participate in multidisciplinary rounds each working day and a fellow during weekends Team interdisciplinary notes will be recorded daily in the EMR Insulin orders will be entered in the EMR rather than a recommendation in a note Resources: laptops, pager, conference room, supervisor support 16 Slide 18 Report Discussion Orders Discharge planning 17 Slide 19 January 8, 2007 Piloted on one unit initially Medical executive committee endorsement Hospital wide at 7 months 18 Slide 20 Census form Occurrences Daily Rounds log Monthly on-call schedule 19 Slide 21 20 Slide 22 21 Slide 23 Flowsheet ( Eclipsys electronic medical record) 22 Slide 24 23 Slide 25 BGMS team pager Appropriate education for each patient care unit Sufficient beta-testing of the EMR systems, including: The BG flowsheet- worklist link and System for recording daily BGMS progress notes Stamp for the BGMS fellow to place a note in each patients medical record indicating the service is following that patient, and where progress notes can be found (On service note) 24 Slide 26 Consult Note (structured note) 25 Slide 27 Consult Note (structured note) 26 Slide 28 27 Slide 29 Consult Note (structured note) 28 Slide 30 Consult Note (structured note) 29 Slide 31 Consult Note (structured note) 30 Slide 32 Consult Note (structured note) 31 Slide 33 Report Discussion Orders Discharge planning 32 Slide 34 We are following Mr/Mrs ________ whose primary diagnosis underlying their hospitalization is _______. Our present blood glucose management orders for him/her are ________. Issues today that may have influenced the BGs you can see on the flowsheet include _____ (and examples may be infections, alterations in his/her diet, procedures, new medications like glucocorticoids). Upcoming plans for his/her hospitalization that may effect his/her blood glucose control include ____ (and examples may include alterations in his/her diet, procedures, new medications like glucocorticoids, plans for discharge). State pertinent lab values for that day 33 Slide 35 Quoting Lennon and McCartney, I have to admit its getting better, a little better all the time. 34 Slide 36 Prepare for home regimen Prepare for insulin pump or adjust setting if admitted on pump Transition to outpatient 35 Slide 37 36 Slide 38 37 Slide 39 38 Slide 40 Slide 41 Established rules for initial insulin dosing Created treatment plans specific to glycemia issue Created Standard operating procedures Created insulin ordering templates Insulin drip High concentration insulin Insulin subcutaneous pump 40 Slide 42 Pre-meal goal Critically ill 140-180 mg/dl Non critically ill pre-mealSlide 43 Weight based regular insulin Regular insulin 0.2-0.5 units/kg/day divided four times daily with meals or every 6 hr if not eating 30%-25%-25%-20% for breakfast, lunch, dinner and bedtime snack plus correction regular insulin based on BG level Basal/ bolus Continue home regimen or weight based Insulin glargine or detemir 50% TDD Lispro insulin with meals 50% of TDD Correction with lispro 42 Slide 44 43 Slide 45 44 Regular insulin QID schedule will have overlap Slide 46 45 Slide 47 On admission obtain insulin pump program settings Patient must have an order that includes specific pump settings, self administer, and using own supplies If patient needs MR,I pump needs to be suspended (MD to order a bolus) Nurse assess patients competence for insulin pump use self administration Monitor labs, and blood glucose pre-meal and bedtime Review with patients s/s of hypoglycemia to report Validate emergency medications available glucagon, 50% dextrose Site, tubing and cartridge are changed every 3 days Patient to communicate with nurse bolus amount and time 46 Slide 48 47 Documentation on Flowsheet Specific for insulin pump Slide 49 Oral Corticosteroids prednisone, dexamethasone, methylprednisolone, hydrocortisone Budesonide (drug interaction/systemic effect) NPH insulin single dose in morning and correction with regular insulin Regular insulin 4 times/day (30%-25%- 25%-20%) 48 Slide 50 Add in correction amount given over past 24 hr Increase dose by 10-15% if not at target Reduce dose by 50% if episode of hypoglycemia Reduce dose by 15-20% for below target blood glucose levels 49 Slide 51 NPO guidelines Reduce insulin dose by 50% if on regular insulin regimen Basal bolus regimen stop mealtime insulin Give basal insulin or decrease dose by 20% Prevention of hypoglycemia due to good communication and quickly adjusted medication orders 50 Slide 52 Laboratory Postprandial Nursing orders Insulin Stat orders Nutrition Medications (insulin orders, ID bracelet) OGTT orders Slide 53 Slide 54 Slide 55 Gradually increase dextrose content in TPN Initiate 0.1 units of regular insulin per gm of dextrose in TPN infusion Our maximum insulin dose in TPN is 0.3 units/gm of dextrose in TPN Correction dose of short acting insulin based on blood glucose level every 6 hours Continuous insulin infusion if cannot achieve goal 54 Slide 56 Computerized order set Four algorithms per insulin sensitivity Blood glucose monitoring required hourly initially Medical floor with adequate staffing ICU if hemodynamically unstable Transition to subcutaneous insulin when the event resolves 55 Slide 57 Regular insulin 100 units in a total volume of 100ml of sodium chloride 0.9% for final concentration of 1 unit/ml Additional instructions: See ORDER DETAILS for dosing algorithm. Notify BGMS on call physician (102-12200) when blood glucose result is above 180mg/dL and glucose does not decrease by at least 60mg/dL within 1 hour of a rate change. Page 102-12200 for all blood glucose/insulin related issues. Slide 58 Slide 59 Slide 60 Slide 61 Patients requiring more than 200u/day-severe insulin resistance More than 100U/day by insulin pump is also high dose requirement Pediatrics-more than 2-3U/kg/day Typically seen in patients with severe forms of insulin resistance Increased incidence of high dose insulin requirements related to obesity epidemic Other forms of diabetes: Genetic defects in insulin secretion or action Autoantibodies to insulin receptor Endocrinopathies-Cushings and Acromegaly Most common- corticosteroid induced diabetes 60 Slide 62 What is influencing insulin requirements Influenced by type of diabetes Influenced by energy intake - Insulin requirements when fasting - Insulin requirements after bariatric surgery Influenced by device/mechanical issues: -Pumps with bolus rate limits of 1 unit per 40 seconds, maximum bolus of 25-30 units, and cartridge that holds 180-300 units - Pens with maximum amount of 60 unit or 80 unit bolus - Cost and insurance Slide 63 Use of U-500 Insulin inpatient setting Hospital Policy For use Slide 64 63 Slide 65 64 Slide 66 Multidisciplinary approach Consistent plan of care Continuous endocrinology input Quick response to medication errors Training for staff Discharge instructions for patients Electronic communication Data-driven blood glucose targets 65 Slide 67 David Harlan, MD Rana Malek, MD Kathryn Feigenbaum, RN, CDE Elaine Cochran, CRNP, BC-ADM Pamela Brooks, CNP Mahfuzul Khan, MD Christine Salaita, RD Allison McLean- Adams, RN Ann McNemar RN, IT specialist NIDDK Diabetes Branch Support Staff NIDDK and NICHD Endocrine Fellows Clinical Center Nursing Staff 66 Slide 68 Mean bg prior to our consult Median BG with range prior to consult Fasting BG on discharge % days at goal 67