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

0

1

2

3

4

5

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Hospital Discharges (millions)

48%

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/dLvan den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

Intensive Insulin Therapy in Critically Ill Surgical Patients

van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

No serious hypoglycemic events.

Conventional Intensive

Mean AM blood glucose achieved (mg/dL)

153 103

% receiving insulin 39% 100%

% BG < 40 mg/dL 6 39

Intensive Insulin Therapy in Critically Ill Surgical Patients Improves

Survival

van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.Copyright ©2001 Massachusetts Medical Society. All rights reserved.

Conventional: insulin when blood glucose > 215 mg/dL.Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL.

Survival in ICU (%)

100

96

92

88

80

0

84

0 20 40 60 80 100 120 140 160

Intensive treatment

Conventional treatment

Days After Admission

Intensive Insulin Therapy in Critically Ill Surgical Patients: Morbidity and Mortality

Benefits

van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

-60

-50

-40

-30

-20

-10

0

Reduction(%)

Mortality Sepsis Dialysis PolyneuropathyBlood

Transfusion

34%

46%41%

44%50%

N = 1,548

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

Reprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125:1007–1021 with permission from American Association for Thoracic Surgery.

CII

10

8

6

4

0

Mortality(%)

87 88 89 90 91 92 93 94 98 99 00

Year

Patients with diabetes

Patients withoutdiabetes

2

95 96 97 01

Anthony Furnary MD 1999 CCNM

0.0

0.5

1.0

1.5

2.0

SQI CII

Deep Wound Infection Rate (%)

Furnary AP, et al. Ann Thorac Surg. 1999;67:352–362.

2.0%

0.8%

P = 0.01

SQI = subcutaneous insulin; CII = continuous insulin infusion.

Rate of DSWI Rates With Different Ins Protocols

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

0%

5%

10%

15%

20%

25%

0 50 100

150

200

250

300

350

400

450

500

Glucose

Per

cen

t

No Drip

Drip

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

DSWI 4.94 % 4.63%

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

van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.Copyright ©2001 Massachusetts Medical Society. All rights reserved.

Conventional: insulin when blood glucose > 215 mg/dL.Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL.

Survival in ICU (%)

100

96

92

88

80

0

84

0 20 40 60 80 100 120 140 160

Intensive treatment

Conventional treatment

Days After Admission

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

Regimen #1For BG 110-219 mg/dl

Usual insulin dose <30 units/day orpatients using only oral agents whose glycohemoglobin is <8 or current blood glucose 110-219 mg/dl or

non-diabetics

Regimen #2For BG >220 mg/dl Usual insulin dose >30 units/day or patients using only oral agents whose glycohemoglobin is >8 or unknown orcurrent blood glucose > 220 mg/dl

Starting dose 2 units/hour 4 units/hour

If Initial BG decreases by

>50%

Decrease to 1 unit/hour Decrease to 2 units/hour

>140 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, stop infusion, call physician, and re‑check BG in 15‑30 minutes. When BG >64 mg/dl, re‑start infusion at 50% lower rate.

Administer 12.5 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 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.

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