Glycemic control in hospitalized patients with diabetes mellitus as a secondary diagnosis admitted to the medical floor of SOCH 7/2013 7/2014

Transcription

1 Glycemic control in hospitalized patients with diabetes mellitus as a secondary diagnosis admitted to the medical floor of SOCH 7/2013 7/2014 Erlin J. Marte

2 Introduction About 25% of patients with type 1 and 30% of patients with type 2 diabetes mellitus (DM) are admitted each year for treatment of conditions other than diabetes. These patients tend to have a higher A1C value. Moss SE, Klein R, Klein BE. Risk factors for hospitalization in people with diabetes. Arch Intern Med. 1999;159(17):2053.

3 Introduction In hospital hyperglycemia is considered an important independent marker of poor clinical outcome and mortality. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE: Hyperglycemia: an independent marker of in hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87: , 2002

4 Introduction In non critically ill patients and patients post non cardiac surgery, elevated mean glucose values have been associated with adverse outcomes, such as increased length of stay (LOS), rate of complications and mortality. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in non cardiac surgery. Diabetes care. 2010;33: Baker EH, Janaway CH, Philips BJ, et al. Hyperglycemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease. Thorax. 2006;61: McAlister FA, Majumdar SR, Blitz S, Rowe BH, Romney J, Marrie TJ. The relation between hyperglycemia and outcomes in 2471 patients admitted to the hospital with community acquired pneumonia. Diabetes care. 2005;28:

5 Introduction Main goals in patients with diabetes requiring hospitalization are: To minimize disruption of the metabolic state. Prevent an untoward result. Return the patient to a stable glycemic balance as quickly as possible.

6 Introduction There is adequate experimental and observational data to recommend avoidance of marked hyperglycemia in patients with or at risk for infection, although the precise glycemic target or threshold for non critically ill patients has not yet adequately been determined. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB, Hirsh IB, American Diabetes Association Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, Bistrian BR. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr. 1998;22(2):77.

7 Introduction The Randomized study of Basal Bolus Insulin Therapy (RABBIT) 2 trial showed a lower frequency of the composite outcome of perioperative complications, including wound infection, pneumonia, bacteremia, respiratory failure, and acute kidney injury in patients treated with basal bolus therapy, with better glycemic control achieved compared with the use of sliding scale only.

8 A 2012 meta analysis concluded that there is potential benefit of glycemic control in the range of 100 to 180 mg/dl in patients hospitalized in non critical care setting. Murad MH, Coburn, JA, Coto Yglesias F, et al. Glycemic control in non critically ill hospitalized patients: systematic review and meta analysis. J Clin Endocrinol Metab. 2012;97:49 58.

9 The consensus statement by the ADA/AACE and the clinical practice guideline of the endocrine society recognizes the lack of evidence for specific glycemic goals in noncritically ill patients and suggests Pre meal glucose goals of <140 mg/dl (7.8 mmol/l) for general hospitalized patients. All random glucoses <180 mg/dl (10.0 mmol/l) Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail Beigi F, Kirkman MS, Umpierrez GE, American Association of Clinical Endocrinologists, American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, Van den Berghe G, Endocrine Society. Management of hyperglycemia in hospitalized patients in non critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab Jan;97(1):16 38.

10 Other recommendations Measurement of HbA1c on admission. Frequent revision of scheduled insulin therapy. Nutritional assessment.

11 Despite these recommendations, there is increasing evidence suggesting suboptimal management of DM in noncritically ill hospitalized patients. Knecht LA, Gauthier SM, Castro JC, et al. Diabetes care in the hospital: is there clinical inertia? J hosp Med. 2006; 1: Thomann R, Lenherr C, Keller U. Glycemic control in hospitalized patients at the university hospital basel in 2002 and in Swis Med Wkly. 2009; 139: Cook CB, Castro JC, Schmidt RE, et al. Diabetes care in hospitalized noncritically ill patients: more evidence for clinical inertia and negative therapeutic momentum. J Hosp Med. 2006;1: Schnipper JL, Barsky EE, Shaykevich S, Fitzmaurice G, Pendergrass ML. Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital. J Hosp Med. 2006;1:

12 The aim of this study is to: Describe the glycemic control of non ICU hospitalized diabetic patients admitted to our Institution. To describe current clinical practices being applied to the care of this population (i.e. therapeutic strategies being implemented and their modifications in response to elevated or low glucose values). Adherence to current recommendations.

13 Methods This is a retrospective observational study conducted at Sisters of Charity between 07/01/2013 and 07/01/2014.

14 Inclusion Criteria Patients between the ages of 18 and 80 years admitted to the Internal Medicine team with an international classification of disease, ninth revision, clinical modification (ICD 9) diagnoses code for diabetes as a secondary diagnoses. Patients with LOS of at least 3 days but no more than 7days

15 Exclusion Criteria Patients admitted for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and gestational diabetes. Patients requiring steroid therapy during admission. Patients transferred to the medical, surgical, or neurosurgical ICU. Patients with criteria for ICU setting.

16 Data Collection Record review Clinical data were extracted for the first 3 days of admission and for the last 24 hours prior discharge. In order to maintain confidentiality a numeric code was used for each patient.

17 Sorian Data Collection Patient demographics Race Age Gender Weight Height Type of diabetes Medications before admission. Medical comorbidities, History of DM complications HbA1c FHx of DM Primary admission diagnoses

18 Primary outcome Prevalence of hyperglycemia (glucose > 180 mg/dl) and hypoglycemia (glucose < 70 mg/dl) among non critically ill hospitalized patients.

19 Secondary Outcomes Process of Care: # of Glucose fingertip measurements Hemoglobin A1C Nutritional Evaluation.

20 Measurements Bedside fingertip blood Glu Recorded Mean Glucvalue per patient Calculated 1 st 24 hours 1 st 3 days Last 24 hours documented

21 Glucose management was classified as Insulin Therapy Oral Agents Only. Oral Agents plus Insulin. Long Acting Formulation Only. Short acting formulation only. Long and short acting combination Sliding Scale (SSI) Only Note: The amount of insulin administered during the first 24 hours was compared to the amount of insulin administered on the last 24 hours to assess changes in dosing.

22 Patient classification Controlled: Mean BG < 180 and > 70 mg/dl) Uncontrolled Mean BG > 180 mg/dl

23 7/2013 to 7/ patients were admitted with DM as secondary diagnosis. 100 patients who met the inclusion/exclusion criteria were randomly selected

24 Baseline Characteristics Age 62 +/ 11 Gender Male: 43 Female: 57 Type of DM Type I: None Type II: 100

25 Baseline Characteristics HbA1c / 2.4 BMI / 8.9 Mean glucose value on admission

26 Most common comorbidities HTN 91% DL 29.5% CHF 9.1 %

27 Process of Care HbA1c on admission ordered for 87% Median # of Glu figertips measurements/day 4 (first 3 days) 2 (On discharge) Nutrition assessment 7%

28 Mean bedside glucose value 1 st 24 hours 2 nd day of H 3 rd day of H Last 24 hours Mean Glucose

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30 Controlled (<180) Uncontrolled (>180) 1 st 24 hours 38% (Mean Glucose 140) 2 nd day of H 38% (Mean Glucose 142.5) 3 rd day of H 51% (Mean Glucose 150) Last 24 hours 67% (Mean Glucose 152.5) 62% (Mean Glucose 239.7) 62% (Mean Glucose 209.7) 49% (Mean Glucose 199.9) 33% (Mean Glucose 189.9)

31

32 Long acting SSI Long/Short acting SSI SSI Only Controlled 1 st 24 hours 28.9% 2.6% 68.5% 2 nd day 47% 7.8% 45.2% 3 rd day 53% 12% 35% Last 24 hours 68% 31% 1% Uncontrolled 1 st 24 hours 69% 8.2% 22.8% 2 nd day 74% 10.2% 15.8% 3 rd day 53% 14% 33% Last 24 hours 57% 16% 27%

33 Pv: 0.03, 0.11, 0.89, 0.17

34 Discussion Management of noncritically ill diabetic patients is still suboptimal. In the Mayo clinic study, they found that throughout admission, 20 to 25% of patients were hyperglycemic. In our case is as high as 63% with an average of 51% Cook CB, Castro JC, Schmidt RE, et al. Diabetes care in hospitalized noncritically ill patients: moreevidence for clinical inertia and negative therapeutic momentum. J Hosp Med. 2007;2:

35 Discussion This is due to Inappropriate insulin choice (type/combination): The use of SSI as treatment instead of as a correction factor. The relative minimal use of a combination of short/long acting Insulin. The lack of intensification of therapy Possible concern hypoglycemia.

36 Conclusion This study provides a descriptive overview of the current state of glycemic control in our institution and also provides interesting insights into the therapeutic strategies being applied. New strategies need to be applied to achieve adequate glycemic targets and avoid adverse outcomes related to sustain hyperglycemia.

37 Recommendations Familiarize yourself with the CHS Glucose control protocol. Which makes temporal relationship between glucose level and amount of insulin given. Do not use SSI as a sole therapeutic method Calculate the amount of insulin needed on a daily basis and do not be afraid of hypoglycemia.

38 Limitations Source of data Chart review depends of proper documentation. Unable to evaluate the rationale in therapy. Unable to determine if glucose values represented premeal or postmeal state. Relatively small sample size.

39 Other references Moss SE, Klein R, Klein BE. Risk factors for hospitalization in people with diabetes. Arch Intern Med. 1999;159(17):2053. Ahmann A. Comprehensive management of the hospitalized patient with diabetes. Endocrinologist. 1998;8:250. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18(6):870. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in non cardiac surgery. Diabetes care. 2010;33: Baker EH, Janaway CH, Philips BJ, et al. Hyperglycemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease. Thorax. 2006;61: McAlister FA, Majumdar SR, Blitz S, Rowe BH, Romney J, Marrie TJ. The relation between hyperglycemia and outcomes in 2471 patients admitted to the hospital with community acquired pneumonia. Diabetes care. 2005;28: Umpierrez GE, Smiley D, Jacobs E, et al. Randomized study of basal lolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes care. 2011;34: Murad MH, Coburn, JA, Coto Yglesias F, et al. Glycemic control in non critically ill hospitalized patients: systematic review and meta analysis. J Clin Endocrinol Metab. 2012;97: Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail Beigi F, Kirkman MS, Umpierrez GE, American Association of Clinical Endocrinologists, American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, Van den Berghe G, Endocrine Society. Management of hyperglycemia in hospitalized patients in non critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab Jan;97(1): Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail Beigi F, Kirkman MS, Umpierrez GE, American Association of Clinical Endocrinologists, American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119.

40 Acknowledgement Howard Lippes, MD Advisor and Mentor Henri Woodman, MD

41 Comments/Questions