Glucose Management University of Colorado Hospital
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- Barrie Mathews
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1 Glucose Management University of Colorado Hospital Bridget Everhart, MSN, NP, CDE Inpatient Diabetes Educator M F Pager
2 UCH Diabetes Program Michael McDermott MD Diabetes Program Director Carolee Whitehill RN MS Diabetes Program Administrator Advisory Committee: Michael McDermott MD Reenie Zaccardi RN MSN NP Mary Krugman RN PhD FAAN Steve Ringel MD Carolee Whitehill RN MS Bridget Everhart Inpatient Diabetes Educator Jenny Madrid Outpatient Diabetes Education Coordinator Connie Zachrich Clinical Data Specialist
3 SCOPE ~25% of Inpatients DM diagnosis Hyperglycemia Pregnancy with DM or GDM ~5000 Outpatients Primary Care & Endocrine
4 Inpatient Diabetes Educator Program Development Order sets, data collection, revisions, focused PI Staff Education Patient Education high risk patients Staff RN responsible for DM education for most pts Clinical Recommendations
5 Target BG and A1C Goals Outpatient A1C <7% Pre-prandial mg/dL Post-prandial <180mg/dL Inpatient Non-ICU: pre-meal < 140mg/dL random < 180mg/dL More stringent if stable and previous tight control Less stringent if severe comorbidities ICU: treat persistent hyperglycemia ( 180) with insulin. BG goal mg/dL ((UCH IV Insulin Infusion BG Goal = mg/dL)) American Diabetes Association, Diabetes Care January 2010 Vol 33, S43
6 Unit-Based Glycemic Report Example POC BG Values 2008/2009 Orthopedics (BONE) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 26% 31% 35% 34% 28% 72% 67% 63% 63% 70% 1% 1% 2% 3% 2% Jan-Mar 08 Mean BG 157 Apr-Jun 08 Mean BG 167 Jul-Sept 08 Mean BG 167 Oct-Dec 08 Mean BG 164 Jan-Mar 09 Mean BG mg/dl mg/dl 70 mg/dl
7 UCH Glucose Management Practices NO Regular insulin Sliding Scale (SSI) Use Basal / Bolus insulin - protocols (ie 24hr basal insulin + rapid acting insulin) UCH Formulary Insulins Glargine, Lispro, 70/30, Regular Avoid Orals Inpatient
8 UCH Glucose Management Practices Type 1 DM = long acting AND short acting ALL times DKA develops in hospital is hospital acquired condition that is at risk for loss of reimbursement Most patients who need insulin need BOTH basal and short acting Start basal early OR add basal if 2 or more BGs >180mg/dL Order A1C If not available in last 60 days (Joint Commission expectation) A1C can be used for DM diagnosis Diabetes Meal Plan: order diabetes diet AND calories
9 Insulin Orders Main Order sets **SQ Glargine / Lispro SQ NPH / Lispro SQ Insulin for TPN & Tube Feedings **IV Insulin Infusion Additional Insulin Order Sets Continuous Subcutaneous Insulin Infusion (CSII) Pumps. Also see the detailed policy DKA / HHS orders IV Insulin Infusion for L&D Intensive SQ Insulin Orders used in OB, CFRD
10 Insulin Orders: Basal Glargine ORDER BASAL INSULIN: units Glargine subcutaneous in abdomen at 0800 daily OR 2200 (Common starting dose: patient s weight in kg X 0.2 units = units of Glargine. Refer to guidelines on back) Partial dose Glargine to cover until daily dose is due, give units NOW subcutaneous in abdomen (see partial dose guidelines on back) Discontinue IV Insulin Infusion 2 hours after giving Glargine Total Daily Dose of insulin is best allocated as 50% long acting and 50% rapid acting for most patients
11 Insulin Orders: Rapid-Acting Lispro for Meals & Correction Blood Glucose mg/dl Sensitive to Insulin Type 1 DM Stress Hyperglycemia Normal body weight Resistant to Insulin Type 2 DM Steroids Overweight / Obese Extra Resistant to Insulin Blood Glucose uncontrolled by Resistant to Insulin Table Customized 70 Implement Hypoglycemia orders Implement Hypoglycemia orders Implement Hypoglycemia orders Implement Hypoglycemia orders Receiving Calories No Calories Receiving Calories No Calories Receiving Calories No Calories Receiving Calories No Calories units No Insulin 6 units No Insulin 10 units No Insulin units units units No Insulin 7 units 1 unit 11 units 1 unit units units units 1 unit 8 units 2 units 12 units 2 units units units units 2 units 10 units 4 units 14 units 4 units units units units 3 units 12 units 6 units 16 units 6 units units units units 4 units 14 units 8 units 18 units 8 units units units units 5 units 16 units 10 units 20 units 10 units units units 400 Call MD Call MD Call MD Call MD Sensitive C:I=15:1 & 45gm/meal 50:1 Correction, BG goal 100 Resistant C:I=10:1 & 60gm/meal 25:1 Correction, BG goal 100 Extra Resistant C:I=6:1 & 60gm/meal 25:1 Correction, BG goal 100
12 Insulin Pump Patients (CSII) Keep pump inpatient if patient A&O, able to operate it Consult Glucose Management Team ORDERS and CONSENT required Patient keeps BG records If pump removed give IV or SQ insulin See detailed policy online
13 Resources: UCH DM website
14 Glucose Mgt Review Screen
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