Transcript Achieving Glycemic Control in the Hospital Setting

Achieving Glycemic Control
in the Hospital Setting
Part 4 of 4
143357
What Does It Take to Achieve
Effective Glycemic Control
for Hospitalized Patients?
Reasons for Deterioration of Glucose
Control During Hospitalization
Hyperglycemic influences
Hypoglycemic influences
• “Stress” hyperglycemia
• Decreased caloric intake
• Concomitant therapy
• Acute illness
(eg, gastrointestinal)
• Decreased physical activity
• Medication omissions
• Fear of hypoglycemia
• Overutilization of
sliding scales
Adapted from Metchick LN et al. Am J Med. 2002;113(4):317-323.
• Monitored compliance
• Delayed/missed meals
• Altered cognition
• Overutilization of
sliding scales
Challenges of Prandial Dosing
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Patient’s variable nutritional schedule1
Appetite1
Unexpected patient transfers1
Lab tests1
Procedures1
NPO2
1. Hellman R. Endocr Pract. 2004;10(suppl 2):100-108.
2. Clement S et al. Diabetes Care. 2004;27(2):553-591. Online Appendix 1.
Components of a Successful Program
to Improve Inpatient Glycemic Control
• Administrative support
– The program must be given priority by the institution
• A multidisciplinary steering committee
– Drives initiative development
• Assessment of current processes, quality of care, and barriers
to practice change
– Systematically track glucose control data
• Development and implementation of interventions
– Standardized order sets, protocols, policies, and algorithms
with associated educational components
– Educate both patients and staff
– Implement an inpatient-to-outpatient transition plan
• Metrics for evaluation to drive continuing process improvement
The ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006;29:1955-1962.
Discharge Planning
• A plan for transitioning to the outpatient setting should
be established at the time of admission to the hospital
• A successful transition to the outpatient setting
requires patient education, discharge planning, and
communication with outpatient providers
• Poor explanation of instructions to the patient during
discharge has been associated with medication errors
and adverse drug events
• Successful coordination of transition requires a team
approach that may involve physicians, nurses, certified
diabetes educators, medical assistants, dietitians, casemanagers, and social workers
Moghissi ES et al. Endocr Pract. 2009;15(4):353-369.
Predischarge Checklist
• Treatment goals
• How and when to take
medication/insulin
• How and when to monitor
blood glucose
• How to treat hypoglycemia
• Prescriptions for/supplies of
medications and insulin and
monitoring supplies
• Basics regarding meal plan
Clement S et al. Diabetes Care. 2004;27(2):553-591.
• Sick-day management
• Date of next appointment
with clinician
• How to access further
diabetes education as
an outpatient
• When to call health
care team
• Contact phone numbers
• “Survival skills” training
Continuity of Care: Transitioning to
Effective Outpatient Glycemic
Management
Patient
Physician
Diabetes
educator
Eye doctor
Dietician
Exercise
physiologist
Podiatrist
Social worker or
psychologist
Lavernia F. Treating hyperglycemia and diabetes with insulin therapy: transition from inpatient to outpatient care.
Medscape J Med. 2008;10(9):216.
Conclusions
• Hyperglycemia is associated with poor clinical outcomes
across many disease states in the hospital setting
• Despite inconsistencies in clinical trial results, good
glucose management is imperative in hospitalized patients
• Beneficial outcomes may be derived from higher glucose
targets than previously proposed
• More conservative glucose targets are assumed to result
in lower hypoglycemia rates
Conclusions
(cont’d)
• In the non–ICU setting, insulin therapy should
be tailored to meet physiologic requirements and
targeted glucose levels
– Sliding-scale insulin alone is ineffective and should
not be used
– Clinical judgment and ongoing assessment of glucose
levels by the healthcare team must be incorporated
into day-to-day decisions regarding glycemic management
– Post-discharge patient follow-up is necessary for ongoing
glycemic management
• Discharge planning, patient education, and clear
communication with outpatient providers are critical
for a safe and successful transition to outpatient care
©2011 Novo Nordisk, Inc.
143357
January 2011