Reducing/Preventing Hypoglycemic Risk Through Evidence-Based Practice

Abstract: Although sulfonylureas are useful in reducing blood glucose levels in the outpatient management of diabetes, continued use in the hospital is discouraged by professional organizations such as the American Diabetes Association (ADA), American Association of Clinical Endocrinologists (AACE), and Endocrine Society (Umpierrez, 2012) (Moghissi, 2009). This class of oral agents is well known to contribute to hypoglycemia, especially in patients with renal insufficiency and nutritional irregularities. The network’s DMQIT team would like to propose either the complete removal of sulfonylureas from inpatient formularies or consideration to limit the use for new starts as part of discharge planning. Background: One of the major concerns with sulfonylurea utilization in the hospital are their extremely long half-lives of 16-24 hours (dependent upon the sulfonylurea used), resulting in prolonged hypoglycemia (Barrueto, 2010). This is especially the case in patients with acute or chronic renal issues, and patients with altered nutritional intake (such as NPO and loss of appetite). Renal issues elongate the retention time the drug is in body, thereby extending the effect of the drug. Altered nutritional intake augments patient’s already low blood sugar with sulfonylureas (Vigersky, 2013) (Clement, 2013). One study spanning nearly 50 years reviewed 1418 cases of severe drug-induced hypoglycemia; recognizing that 63% of the cases were due to sulfonylureas (advanced age and fasting were others) (Seltzer, 1989). Duesenberry CM and colleagues completed a study observing adults who took a sulfonylurea during their hospitalization between November 1, 2008 and October 31, 2009. They found that 19% of patients ingesting a sulfonylurea also had one or more incidents of hypoglycemia during their stay (Duesenberry, 2012). Adrian Jennings did a similar study spanning six months in which 41 out of 203 hospital patients (20.3%) on a sulfonylurea experienced symptoms of hypoglycemia (Jennings, 1989). Significant data has been presented for the ADA to “suggest the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients with type 2 diabetes at the time of hospital admission for acute illness” (Umpierrez, 2012, 5). Through benchmarking it has been documented and confirmed that three other hospitals have officially removed sulfonylureas from their drug formularies to some degree. Memorial Sloan-Kettering Cancer Center, located in New York City with 469 inpatient beds, removed all sulfonylureas from their formularies more then 5 years ago. Spectrum Health System, located in Grand Rapids Michigan with 1048 inpatient beds, stopped all oral agents in May 2011. Additionally Redland Community Hospital, located in Redland California with 229 inpatient beds, has only one sulfonylurea still on formulary. Specifically all sulfonylureas are stopped upon entrance into the hospital, however upon discharge planning Glipizide (the only sulfonylureas still on formulary) may still be used. In addition, many other diabetes educators stated on the American Association of Diabetes Educators (AADE) website that their respective hospital was too in the process or planning on removing sulfonylurea from their drug formularies. The ADA has recognized this issue and stated “Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require therapy for hyperglycemia” (Moghissi, 2009,1127). Methods: The study was conducted in two major portions, literature reviews and data collection. The first step in the process was evaluating work that attempted to make the public mindful of the risks that are associated with sulfonylurea use in an hospital setting. Scholarly work on sulfonylurea-induced hypoglycemia was found by using ‘Google Scholar’, utilizing the search engine to find qualitative and quantitative research. Also, journals provided by the Inpatient Diabetes Team to the AADE, ADA, and Endocrine Society were an essential resource; providing assessments from professional organizations on sulfonylurea use in an inpatient setting. Subsequently, posts made by certified diabetes educators on the AADE website were examined, networking with those that encompassed the same concern. Personally reaching out and communicating with educators that have removed sulfonylureas from hospital formularies, or those in the process of doing so. Both the literature reviews and networking with diabetes educators created the foundation for the research. Providing a focus on the data and evidence that would be required in order to remove this drug off Lehigh Valley’s drug formularies. To proceed with the data collection the number of patients (with diabetes) fromLVHN that ingested a sulfonylurea during their inpatient stay was gathered. In addition, through the Lehigh Valley database one was able to locate all patients with diabetes that had at least one hypoglycemic event during there hospitalization. The number of days and events each patient was hypoglycemic was also provided. By the use of excel one was able to match patient account numbers between the two listed provided; patients with at least one hypoglycemic event and patients ingesting a sulfonylurea. This produced data on patients that were prescribed a sulfonylurea and experienced at least one hypoglycemic event, each respective patients’ days and events hypoglycemic were also included. Results: Since sulfonylureas lack flexibility when it comes to titrations, an essential asset to have in an acute care setting, then one would expect its use to increase inpatient hypoglycemia incidences (Clement, 2013). The data collected demonstrated this hypothesis. The ADA defines hypoglycemia as a blood glucose level less than 70 mg/dL (Moghissi, 2009). Both LVHN campuses, Cedar Crest and Muhlenberg, had a significantly high percent of patients with sulfonylurea-induced hypoglycemia, 18.7 and 16.2 respectively. Producing data that corresponds with Seltzer, Deusenberry, and Jennings work indicates that sulfonylurea-induced hypoglycemia is prevalent at Lehigh Valley Health Network. Additionally, both campus hospitals had substantial ratios of total days and events blood glucose less than 70 mg/dL stimulated by a sulfonylurea. At Cedar Crest campus these were 1.73 and 2.8 respectively, and 1.53 and 2.5 at Muhlenberg campus. Mechanism of Action Pancreatic Mechanism Sulfonylureas prevent the efflux of Potassium ions from Beta-cells of the pancreas. Resulting in the depolarization of the Beta-cells and consequently calcium channels (which are voltage-dependent), open and calcium ions flow into the cell. Proceeding in the exocytosis of insulin. Extra-Pancreatic Mechanism Decrease in glucagon levels. Exact mechanism is not known. * Source (DeRUITER) Sulfonylureas on Lehigh Valley Health Network Formulary Drug Contraindications Precautions Glimepiride (Amaryl) -Acknowledged hypersensitivity to this drug or any of the components that comprise it -Patients with history of allergic reaction to sulfonamide derivatives also have chance of reacting to Glimepiride -Hypoglycemia -Hypersensitivity reactions -Increased risk of cardiovascular mortality -Hemolytic Anemia Glyburide (Micronase/Diabeta) - Acknowledged hypersensitivity to this drug or components that comprises it - Type one diabetes, diabetic ketoacidosis (situation recommended to be treated with insulin) -Patients also treated with bosentan -Hypoglycemia -Hemolytic Anemia Glyburide micronized (Glynase) -Acknowledged hypersensitivity to this drug - Type one diabetes, diabetic ketoacidosis (situation recommended to be treated with insulin) - Treated also with bosentan -Hypoglycemia -Loss of control of BG -Hemolytic Anemia (with patients that have G6PD deficiency) Glipizide - Acknowledged hypersensitivity to this drug -Diabetic ketoacidosis (situation recommended to be treated with insulin) -Renal and Hepatic Disease -Hypoglycemia -Loss of control of blood glucose Glipizide XL - Acknowledged hypersensitivity to this drug or components that comprises it - Type one diabetes, diabetic ketoacidosis (situation recommended to be treated with insulin) -Renal and Hepatic Disease -GI disease -Hypoglycemia -Loss of control of BG -Hemolytic Anemia -Glipizide/Metformin - Renal disease or renal dysfunction -Acknowledged hypersensitivity to glipizide or metformin - Acute or chronic acidosis (situation recommended to be treated with insulin) -Hypoglycemia -Renal and Hepatic Disease -Hemolytic Anemia -Use of concomitant medication that alters renal function or disposal of metformin *Source: Daily Med Current Medication Information Data:*Data collected from LVHN inpatient admissions from July 2013-March 2014**All patients were 18 years of age or older, non-pregnant, and had diabetes Campus Cedar Crest Muhlenberg Adult Diabetes Patients Experiencing BG/dL 1310 485 Adult Patients Prescribed Sulfonylureas During Stay 566 105 Adult Patients Taking Sulfonylurea that had BG/dL During Stay 106 17 Total Days Adults Taking Sulfonylureas Had BG/dL During Stay 183 26 Total Events Adults Taking sulfonylureas Had BG/dL 302 42 Campus Cedar Crest Muhlenberg Percent Patients having Sulfonylureas Induced Hypoglycemia 18.7% 16.2% Total Days BG/dL per Sulfonylurea Induced Hypoglycemia 1.73 1.53 Total Events BG \u3c 70 mg/dL per Sulfonylurea Induced Hypoglycemia 2.85 2.5 Conclusion: The importance of this proposal is to reduce hypoglycemic risk. Hypoglycemia can be fatal, cause brain death, lead to confusion, loss of consciousness, and result in seizures (Vigersky, 2013). By removing and/or reducing sulfonylurea use in the hospital setting one may minimize this risk. Lehigh Valley has no restrictions on sulfonylurea use in the hospital setting (see above chart for available sulfonylureas at LVHN), and after identifying a relationship with ingestion of sulfonylurea and hypoglycemia, this proposal was crafted. The metrics derived above, as well as the associated literature, indicate that we are not maximizing the quality of care provided by keeping these drugs on formulary. Moreover, increased costs begin to become a concern when one episode of hypoglycemia increases the length of stay by 2.8 days (Turchin 2009). Consequently, two of the three “Triple Aim” aspects are not met while this drug is available for use. There are other medications that can reduce blood glucose levels more safely than sulfonylureas in the inpatient setting. For example, the ADA recommends “scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintain glucose control” (Moghissi 2009). Indeed, the use of sulfonylureas in hospital setting has decreased as more physicians are educated about the matter discussed in this proposal. Nonetheless, LVHN is still generating significantly high figures, indicating that sulfonylurea-induced hypoglycemia is still prevalent. Furthermore, removing sulfonylureas from the hospital formularies will directly contribute to reducing hypoglycemic rates, one of the network’s diabetes management quality improvement goals. Sources: Barrueto, F. (2010, August 19). Sulfonylureas. . Retrieved July 9, 2014, from https://umem.org/educational_pearls/1171/ Clement, S., Braithwaite, S., Magee, M., Ahmann, A., Smith, E., Schafer, R., et al. (2013, April). Management of Diabetes and Hyperglycemia in Hospitals. American Diabetes Association, 2,7, 553-591. Daily Med Current Medication Information. (n.d.). Food and Drug Administration . Retrieved July 14, 2014, from http://dailymed.nlm.nih.gov/dailymed/about.cfm DeRUITER, J. (n.d.). OVERVIEW OF THE ANTIDIABETIC AGENTS. Retrieved July 8, 2014, from http://www.auburn.edu/~deruija/endo_diabetesoralagents.pdf Deusenberry CM, Coley KC, Korytkowski MT, Donihi AC. (2012, May). Hypoglycemia in hospitalized patients treated with sulfonylureas. Pharmacotherapy 2012, 32. Jennings, A., Wilson, M., & Ward, J. Symptomatic Hypoglycemia in NIDDM Patients Treated With Oral Hypoglycemic Agents. 1989, March. American Diabetes Association, 12 (3), 203-208. Moghissi, E., Korytkowski, M., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I., et al. (2009, June) American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. American Diabetes Association , 32 (6), 1119-1131. Seltzer, HS. Drug-induced hypoglycemia. A review of 1418 cases. (1989, March) Endocrinology and Metabolism Clinics of North America, 18 (1), 83-163. Retrieved July 7, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/2645125 Turchin, A., Scanlon, J., Matheny, M., Shubina, M., Greenwood, B., & Pendergrass, M. (2009, July). Hypoglycemia and Clinical Outcomes in Patients with Diabetes Hospitalized in the General World. American Diabetes Association, 32(7), 1153-1157. Umpierrez, G., Hellman, R., Korytkowski, M., Kosiborod, M., Maynard, G., Montori, V., et al. (2012, January). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. The Journal of clinical Endocrinology and Metabolism, 97(1), 16-38. Vigersky, R., Seaquist, E., Anderson, J., Childs, B., Cryer, P., Dagogo-Jack, S., et al. (2013, May). Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society. Diabetes Care, 32(5), 1384-1395

Improving Safety of Insulin Administration

Improving Safety of Insulin Administration Melissa Tucker Joyce Najarian, RN, MSN, CDE Inpatient Diabetes Team, Department of Medicine, Lehigh Valley Health Network Abstract: Managing inpatient glycemic control is a challenge. With the rising prevalence of diabetes in the United States, there is an emerging importance for health care providers to have a thorough knowledge of the disease process and treatments. The Inpatient Diabetes Team at Lehigh Valley Health Network has put forth many efforts to improve inpatient care of patients with diabetes. This paper delineates the efforts to provide education to health care providers, improve inpatient insulin delivery, and assist patients after discharge whom have added insulin to their medication regimen. Results of these projects include a pocket reference card that goes into extensive details for each insulin product, a comprehensive analysis of a survey taken by Registered Nurses on perceived barriers to delivering insulin in an appropriate time frame, a post discharge follow up phone questionnaire for future use in the Inpatient Diabetes Team. Keywords: diabetes management, insulin, safety, administration Background: Insulin is a medication used as the main therapy in Type 1 diabetes and often used in therapy for Type 2 diabetes. With current statistics indicating that 29.1 million people in the United States have diabetes, there should be an emphasis on healthcare providers understanding the disease process and proper treatment. Focusing on just Lehigh Valley Health Network, about 30% of admitted patients have a diagnosis of diabetes. A common barrier to proper inpatient diabetes care is the fear of hypoglycemia related to insulin use. Some of the apprehensions may originate from situations where hypoglycemia was the result; but it was not the medication dose, rather the timing of the medication that was the root cause. The standard of care states that any insulin dose covering high blood glucose must be given within 30 minutes in order to be appropriate. From a survey conducted in LVHN in May 2015, only 47.68% of RNs admitted to “Almost always” giving the dose within the correct time frame. Of the remaining participants, an alarming 43.71% selected “About half the time.” Based on these results, there is a need to examine the current practice and possible resolutions. The addition of insulin to a treatment regimen can be a result of many situations. A new diagnosis of Type 1 diabetes will always include the need for insulin. Unlike Type 1, a new diagnosis of Type 2 will not always necessitate an insulin regimen. Furthermore, a patient with a new or pre-existing diagnosis of Type 2 diabetes may need insulin to control their chronic disease. Since insulin is an injectable medication that may cause a severe side effect, education is a necessity for successful transition onto the medication. The Institute for Safe Medicine Practices lists insulin as a high-alert medication. These factors also increase the importance of regular visits to a physician who can assist the patient in managing their disease correctly. The transition for a patient leaving the hospital new to this medication requires education on the disease, precise instructions on administration, the correct materials, and intent to follow up with a provider. Objective: The overall purpose of this project is to assist in improving the safety of insulin administration. There are three sub-projects that aim at more specific goals. First, the intent is to provide updated and vital information on each type of insulin to healthcare professionals via pocket cards along with developing weekly interactive case based education. Second, to provide insight from RNs as to the barriers they face when insulin cannot be administered in an appropriate time frame. The final objective is to assist in the transition from hospitalization to home for patients who need insulin added to their home medication regimen after being discharged. Methodology: The first sub-project involved collecting and analyzing data from a survey that was created by the Diabetes Management Quality Improvement Team that focused on identifying the perceived barriers to timely deliverance of insulin as well as suggestions to aid in improvement. Four hundred and sixty one Registered Nurses completed the survey from all three Lehigh Valley Health Network campuses. Additional quantitative analysis as well as themed analysis responses provided a complete breakdown of the challenges faced while “on the floor.” Targeting and listening to the professionals who are in constant patient contact is of high importance for safe inpatient use of insulin. Evaluation to determine the presence of a knowledge deficit related to insulin administration involved correcting, entering, and analyzing Insulin Knowledge Assessment tests given to a group of 40 people including medical students, residents, and general medicine faculty. The assessment was created to assess baseline knowledge of medical residents on 5K. The average percent correct on the 17 question assessment was 63.82%. Once a deficit in knowledge was confirmed, research into product information and current practice was conducted to update previous materials from the Inpatient Diabetes Team for creation of a pocket card. Most assistance was provided in formatting and reorganization of the material. In order to generate a foundation for a questionnaire for phone calls following up with patients discharged new to insulin, staff interviews and research from other teams who conduct disease specific post-discharge phone calls (i.e. Community Care Teams). With assistance from these resources, a ten question phone survey was created that would take place one business day after discharge and a second call one week from the first phone call. Prior to conducting the phone call, the patient’s vital information is recorded on the survey form. If the patient is being followed by a physician who utilized the Community Care Team, then the follow up is handled by CCT. Once the need for follow up is established, a systematic review of the Discharge Instructions (DCI) is conducted to gather what medications, prescriptions, supplies, appointments, and instructions they had been sent home with. After all relevant information was collected; then the patient would be called using the survey as a guide for questions. An algorithm is used to determine actions taken by the person making the phone call. The piloted results were recorded and then reported to Joyce Najarian, Program Manager of Inpatient Diabetes, immediately following the conclusion of the phone calls. Discussion: Results from the survey “Barriers to Timely Delivery of Insulin” indicate the specific problem areas that can be addressed. At 46.21%, the highest perceived barrier is that the nurse has too many other responsibilities. Among the other responses, communication between the RN, technical partner, and dietary staff proves to be another issue with regards to insulin delivery. Fourty-two percent of respondents indicate that they “rarely get communication that my patient’s tray has arrived,” and 26.44% say that they do not get communication from the TP that the pre-meal blood glucose has been taken. The last question of the survey allowed respondents to type in suggestions. Among those themed responses, some of the top indicated suggestions are as follows: increasing staff and lowering patient to nurse ratio, scheduled mealtimes for patients with diabetes, improved communication with technical partner, improved communication with dietary staff, and education on diabetes, insulin, and mealtimes. The information for the pocket card was derived from interviews with Joyce Najarian, resources provided by the Inpatient Diabetes Team, and package inserts for each insulin product. Once all the information was accounted for, the next task was to organize the information in an easy to understand manner. The insulin products that are commonly used for inpatient care are on one side and the uncommon inpatient insulin products are on the other. While formatting and organizing this education tool, the content became more familiar. There is now a higher comfort level with my knowledge of insulin products because of this. The questions of the survey were specific to discharge planning with regards to diabetes care. The first question asks if the patient has made or attended an appointment with a doctor who will manage their diabetes. Through a series of ten questions, it explores if the patient had any trouble obtaining their medications, using their glucose-testing meter, or using their insulin. Several phone calls occurred after the completion of the piloted questionnaire. Results will be tracked, including refusals, to identify potential safety issues or other opportunities to ensure safe discharge on insulin. Future Implications: A comprehensive report of the survey result was compiled and distributed on July 2, 2015. The report was shared with a group of Lehigh Valley Health Network Nurse Administrators in hopes to draw attention to these perceived barriers. Consequently, the attention may assist in the development of solutions to improve patient safety and decrease RN frustration on the floor. Additionally, a group of Nurse Residents are in communication with Joyce Najarian in order to potentially implement some interventions to improve insulin timing at the LVHN Muhlenberg campus. The pocket reference cards have been submitted to be printed. The intent is to distribute these pocket cards to Residents, RNs and any other professionals who can benefit from the information. Moving forward, the follow up phones are planned to continue for patients who are discharged new to insulin. Through experience, the survey will be adapted and updated to better fit the responses from these phone calls. Many useful outcomes are intended to come of this. For example, if a patient expresses concern about injecting insulin correctly, there will be a systematic way to refer the patient to an outpatient education appointment. The algorithm will continue to exist based on the needs to the patients. The intent remains to ensure that patients are safely using their insulin at home and comfortable doing so. References: Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, 2014. ISMP, (2014). ISMP List of High-Alert Medications in Acute Care Settings. Retrieved from http://www.ismp.org/Tools/highalertmedications.pdf. Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch I. B., … Umpierrez, G. E. (2009). AACE and ADA Consensus Statement on Inpatient Gycemic Control. Endocrine Practice, 15 (4) 7-8. Retrieved from http://lvhwebcontent.lvh.com/upload/docs/Diabetes%20Mgmt%20Site/inpatientglycemiccontrolconsensusstatement.pdf. Inpatient Diabetes, Department of Medicine, LVHN. (2015). Barriers to Timely Delivery of Insulin: Survey Summary. Allentown, PA: Najarian, J., Tucker, M. Pre-test results from Insulin Knowledge Test given to Residents and Medical Students rotating through 5K unit at LVHCC as part of a Diabetes Quality Improvement Project

Improving Glycemic Control in the Acute Care Setting Through Nurse Education

Patients with a primary or secondary diagnosis of diabetes present unique challenges during an inpatient hospital stay to treat an acute or chronic illness. Upon review of current hospital practice, an interprofessional team embarked on a performance improvement project to improve outcomes for the complex medical-surgical diabetic patient. The methods detailed herein—a comprehensive education plan, preceptorship and peer accountability, active engagement and support by the unit nursing leadership team, and interprofessional collaboration—offer strategies any organization can implement to positively impact diabetes care