Transcript Hershey Medical TGC

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
• 10–12% of all hospital discharges
• 29% of all cardiac surgery patients
• 1–3 days longer hospital stay
Hogan P, et al. Diabetes Care. 2003;26:917–932.
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 80–110 mg/dL
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
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;345:1359–1367.
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 80–110 mg/dL.
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
Copyright ©2001 Massachusetts Medical Society. All rights reserved.
Intensive Insulin Therapy in Critically Ill
Surgical Patients: Morbidity and Mortality
Benefits
N = 1,548
Mortality
Sepsis
Dialysis
Blood
Transfusion Polyneuropathy
0
-10
-20
Reduction
-30
(%)
-40
-50
34%
41%
46%
-60
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
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;345:1359–1367.
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 evidence—CABG
Evaluate Current Care
Identify the Stakeholders
Identify Barriers
Portland Diabetes Project:
Mortality
10
CII
8
Mortality
(%)
Patients with diabetes
6
Patients without
diabetes
4
2
0
87 88 89 90 91 92
93
94 95
96
97 98
99
00 01
Year
Reprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125:1007–1021 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;67:352–362.
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
Histogram of all glucose
levels in non-drip group and
insulin drip protocol
25%
No Drip
Drip
Percent
20%
15%
10%
5%
50
0
45
0
40
0
Glucose
35
0
30
0
25
0
20
0
15
0
10
0
50
0
0%
Our Analysis
• Financial data
• Costs incurred in 1999 normalized to the year 2000
(3% adjustment)
• Data collected from hospital’s 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 80–110 mg/dL.
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
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
121-140
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 re-check BG in 15-30
and re-check BG in 15-30
minutes. When BG >64 mg/dl, minutes. When BG >64 mg/dl,
re-start infusion at 50% lower
re-start infusion at 50% lower
rate.
rate.
Administer 25 ml of D50 IV, stop infusion, call physician, and
re-check BG in 15-30 minutes. When BG >64 mg/dl, re-start
infusion at 50% lower rate.
<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;27:553–591.
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