HERSHEY MEDICAL CENTER EXPERIENCE WITH TIGHT GLYCEMIC CONTROL Robert Gabbay, M.D., Ph.D. Associate Professor of Medicine Co-Director, Penn State Diabetes Center Diabetes in Hospitalized Patients Fourth most common co-morbid condition among hospitalized patients 1012% of all hospital discharges 29% of all cardiac surgery patients 13 days longer hospital stay Hogan P, et al. Diabetes Care. 2003;26:917932. American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004. The Increasing Rate of Diabetes Among Hospitalized Patients Hospitalizations for Diabetes as a Listed Diagnosis 5 4 Hospital Discharges (millions) 3 48%
2 1 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Accessed June 15, 2004. Potential Benefits of Improving Glucose Control in the Hospital Improving inpatient glycemic control provides an opportunity to Reduce mortality Reduce morbidity Reduce costs of care Length of stay (LOS)
Cost of inpatient complications Fewer rehospitalizations Reduced extended care Intensive Insulin Therapy in Critically Ill Surgical Patients Setting: surgical intensive care unit in University Hospital, Leuven, Belgium Hypothesis: normalization of blood glucose levels with insulin therapy can improve prognosis of patients with hyperglycemia or insulin resistance Design: prospective, randomized, controlled study Conventional: insulin when blood glucose > 215 mg/ dL Intensive: insulin when glucose > 110 mg/dL and maintained at 80110 mg/dL
van den Berghe G, et al. N Engl J Med. 2001;345:13591367. Intensive Insulin Therapy in Critically Ill Surgical Patients Conventional Intensive Mean AM blood glucose achieved (mg/dL) 153 103
% receiving insulin 39% 100% % BG < 40 mg/dL 6 39 No serious hypoglycemic events. van den Berghe G, et al. N Engl J Med. 2001;345:13591367. Intensive Insulin Therapy in Critically
0 0 20 40 60 80 100 120 140 160 Days After Admission Conventional: insulin when blood glucose > 215 mg/dL.
Intensive: insulin when glucose > 110 mg/dL and maintained at 80110 mg/dL. van den Berghe G, et al. N Engl J Med. 2001;345:13591367. Copyright 2001 Massachusetts Medical Society. All rights reserved. Intensive Insulin Therapy in Critically Ill Surgical Patients: Morbidity and Mortality Benefits N = 1,548 0 Mortality Sepsis
46% -60 van den Berghe G, et al. N Engl J Med. 2001;345:13591367. 44% 50% IV Insulin Therapy in Critically Ill Surgical Patients: Safety A titration algorithm achieved and maintained blood glucose levels at < 110 mg/dL Insulin requirements were highest and most variable during first 6 hours of intensive care Normoglycemia was reached within 24 hours with
a mean daily insulin dose of 77 IU; maintained with 94 IU on day 7 Blood glucose was monitored every 4 hours by ABG Statistically significant, but clinically harmless, hypoglycemia was observed briefly van den Berghe G, et al. N Engl J Med. 2001;345:13591367. Keys to Van den Berghe succcess 1 nurse to 2 pts
Need IV glucose Benefit most for > 5 days in ICU (1/3) Number needed to treat = 29 Karnofsky scores better after 6 and 12 months Studies in Europe in NICU, PICU, MICU Indications for Intravenous Insulin Therapy: Summary Diabetic ketoacidosis Nonketotic hyperosmolar state Critical care illness (surgical, medical) Postcardiac surgery Myocardial infarction or
cardiogenic shock 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 American Association of Clinical Endocrinologists. Available at: http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
GETTING STARTED (1998) Define the problem Evaluate the evidenceCABG Evaluate Current Care Identify the Stakeholders Identify Barriers Portland Diabetes Project: Mortality
10 CII 8 Mortality (%) Patients with diabetes 6 Patients without diabetes
Year Reprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125:10071021 with permission from American Association for Thoracic Surgery. Rate of DSWI Rates With Different Ins Protocols 2.0 2.0% P = 0.01 1.5 Deep Wound 1.0 Infection
Rate (%) 0.8% 0.5 0.0 SQI SQI = subcutaneous insulin; CII = continuous insulin infusion. Anthony Furnary MD 1999 CCNM Furnary AP, et al. Ann Thorac Surg. 1999;67:352362. CII CURRENT STATE OF CARE
The infamous sliding scale Benign neglect Endocrinology consults on occasion Typical glucose monitoring every 4-6 hours IDENTIFY STAKEHOLDERS
CT Surgery Anesthesia Nursing Team Outcomes Research Team Endocrinology and Diabetes The hospital/payors IDENTIFY BARRIERS Glucose monitoring Who? How? Understanding the rationale Nursing time and effort
DEVELOPMENT OF THE INSULIN INFUSION GLYCEMIC CONTROL PROTOCOL (IGCP) Multidisciplinary team led by Endocrinology Glucose meters needed to be available Goal 120-200 mg/dL Grand rounds and educational programs Evaluate outcomes Endocrine Practice 10:112 (2004) HMC IGCP Intervention All pts undergoing CABG Start IV insulin when present to anesthesia
Continue IV insulin by protocol until taking po Endo consult to adjust insulin Multi-disciplinary team- nurses, anesthesia, CT surgery, outcomes research team, endo Endocrine Practice 2004 25% Histogram of all glucose levels in non-drip group and insulin drip protocol No Drip Drip Percent
20% 15% 10% 5% 0% 0 50 0
0 1 0 5 1 0 0 2 0 5 2 0
0 3 Glucose 0 5 3 0 0 4 0 5 4
0 0 5 Our Analysis Financial data Costs incurred in 1999 normalized to the year 2000 (3% adjustment) Data collected from hospitals cost accounting database and included following additional costs of IGCP: More frequent BG monitoring Pharmacy expenditures Routine endocrine consultation
COSTS Underestimated : Readmission Indirect costs, i.e., patient satisfaction, negative publicity and reduced referrals Risk of litigation Mean Variable No Drip (N=81) Drip (N=107 Total Cost $21,442
$21,076 Total LOS 8.64 8.25 LOS (Surgery to D/C) 5.98 5.48 4.94 %
4.63% DSWI CONCLUSIONS Mean blood glucose improved from 241 to 183 (first 48 hours) Average number glucose determinations was 23.8 vs. 8 Revenue neutral despite endocrine consults, pharmacy costs, pharmacy Cost offset by clinical improvement and overall cost savings Wide acceptance by nursing and docs EVERYTHING CHANGES
WITH THE VAN DEN BERGHE STUDY Intensive Insulin Therapy in Critically Ill Surgical Patients Improves Survival 100 Intensive treatment 96 92 Survival in ICU (%) 88
Conventional treatment 84 80 0 0 20 40 60 80
100 120 140 160 Days After Admission Conventional: insulin when blood glucose > 215 mg/dL. Intensive: insulin when glucose > 110 mg/dL and maintained at 80110 mg/dL. van den Berghe G, et al. N Engl J Med. 2001;345:13591367. Copyright 2001 Massachusetts Medical Society. All rights reserved. Getting to a Lower Goal GETTING LOWER
This should be easy? Shortcuts are not always shortcuts Better evidence Glucose monitoring a problem again Getting back to basics? HMC New insulin drip protocol Based on evidence based work from Van den Berghe (NEJM) Refined by multi-disciplinary team Key changes of new protocol Target BG range (80-120mg/dl) D10 NS at maintenance rate 50 ml/hour No automatic endo consult
Blood Glucose (BG) mg/dl Starting dose If Initial BG decreases by >50% >140 Regimen #1 For BG 110-219 mg/dl Usual insulin dose <30 units/day or patients using only oral agents whose
glycohemoglobin is <8 or current blood glucose 110-219 mg/dl or non-diabetics 2 units/hour Decrease to 1 unit/hour Regimen #2 For BG >220 mg/dl Usual insulin dose >30 units/day or patients using only oral agents whose glycohemoglobin is >8 or unknown or current blood glucose > 220 mg/dl 4 units/hour
Decrease to 2 units/hour Increase by 1unit/hour Increase by 2units/hour Increase by 0.5 unit/hour Increase by 1 unit/hour 80-120 Unchanged Unchanged
65-79 Reduce rate by 1 unit/hour Reduce rate by 1 unit/hour 40-64 Administer 12.5 ml of D50 IV, Administer 12.5 ml of D50 IV, stop infusion, call physician, stop infusion, call physician, and recheck BG in 1530 and recheck BG in 1530 minutes. When BG >64 mg/dl, minutes. When BG >64
restart infusion at 50% lower mg/dl, restart infusion at rate. 50% lower rate. Administer 25 ml of D50 IV, stop infusion, call physician, and recheck BG in 1530 minutes. When BG >64 mg/dl, restart infusion at 50% lower rate. 121140 <40 Coming to an ICU near you! Lessons Learned: Key things to think about
before you try this at home! The Ideal IV Insulin Protocol Easily ordered (signature only) Effective (gets to goal quickly) Safe (minimal risk of hypoglycemia) Easily implemented Protocol Implementation Multidisciplinary team Administration support
Pharmacy & Therapeutics Committee approval Forms (orders, flowsheet, med kardex) Education: nursing, pharmacy, physicians & NP/PA Monitoring/QA Bedside Glucose Monitoring Strong quality-control program essential! Specific situations rendering capillary tests inaccurate
Shock, hypoxia, dehydration Extremes in hematocrit Elevated bilirubin, triglycerides Drugs (acetaminophen, dopamine, salicylates) Clement S, et al. Diabetes Care. 2004;27:553591. Limitations of current system Nurse autonomy? GLUCOSE MONITORING Continuous Likely the first prototypes to be approved Closed loop Strengthening the business case for good glycemic control
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