Melanie Mabrey

Implementation of a new intravenous insulin method on intermediate-care units in hospitalized patients.

Good blood glucose control in hospitalized adults leads to reduced mortality. Intravenous (IV) insulin has been shown to be an effective way to achieve tight control of blood glucose. Managing IV insulin is a labor-intensive task for nurses and is generally done in intensive care units with high nurse-to-patient ratios. In this 3-month study, intermediate-care general medicine units with a nurse-to-patient ratio of 1 to 5 or 6 were evaluated for effectiveness of monitoring IV insulin. The project, which relied on intensive in-service education, an audit tool, and continuous positive feedback for nurses, yielded positive results.

Comparison of an Electronic Glycemic Management System Versus Provider-Managed Subcutaneous Basal Bolus Insulin Therapy in the Hospital Setting

Background: American Diabetes Association (ADA) guidelines recommend a basal bolus correction insulin regimen as the preferred method of treatment for non–critically ill hospitalized patients. However, achieving ADA glucose targets safely, without hypoglycemia, is challenging. In this study we evaluated the safety and efficacy of basal bolus subcutaneous (SubQ) insulin therapy managed by providers compared to a nurse-directed Electronic Glycemic Management System (eGMS). Method: This retrospective crossover study evaluated 993 non-ICU patients treated with subcutaneous basal bolus insulin therapy managed by a provider compared to an eGMS. Analysis compared therapy outcomes before Glucommander (BGM), during Glucommander (DGM), and after Glucommander (AGM) for all patients. The blood glucose (BG) target was set at 140-180 mg/dL for all groups. The safety of each was evaluated by the following: (1) BG averages, (2) hypoglycemic events <40 and <70 mg/dL, and (3) percentage of BG in target. Result: Percentage of BG in target was BGM 47%, DGM 62%, and AGM 36%. Patients’ BGM BG average was 195 mg/dL, DGM BG average was 169 mg/dL, and AGM BG average was 174 mg/dL. Percentage of hypoglycemic events <70 mg/dL was 2.6% BGM, 1.9% DGM, and 2.8% AGM treatment. Conclusion: Patients using eGMS in the DGM group achieved improved glycemic control with lower incidence of hypoglycemia (<40 mg/dL and <70 mg/dl) compared to both BGM and AGM management with standard treatment. These results suggest that an eGMS can safely maintain glucose control with less hypoglycemia than basal bolus treatment managed by a provider.

Assessing electronic health record phenotypes against gold-standard diagnostic criteria for diabetes mellitus.

Objective: We assessed the sensitivity and specificity of 8 electronic health record (EHR)-based phenotypes for diabetes mellitus against gold-standard American Diabetes Association (ADA) diagnostic criteria via chart review by clinical experts. Materials and Methods: We identified EHR-based diabetes phenotype definitions that were developed for various purposes by a variety of users, including academic medical centers, Medicare, the New York City Health Department, and pharmacy benefit managers. We applied these definitions to a sample of 173 503 patients with records in the Duke Health System Enterprise Data Warehouse and at least 1 visit over a 5-year period (2007–2011). Of these patients, 22 679 (13%) met the criteria of 1 or more of the selected diabetes phenotype definitions. A statistically balanced sample of these patients was selected for chart review by clinical experts to determine the presence or absence of type 2 diabetes in the sample. Results: The sensitivity (62–94%) and specificity (95–99%) of EHR-based type 2 diabetes phenotypes (compared with the gold standard ADA criteria via chart review) varied depending on the component criteria and timing of observations and measurements. Discussion and Conclusions: Researchers using EHR-based phenotype definitions should clearly specify the characteristics that comprise the definition, variations of ADA criteria, and how different phenotype definitions and components impact the patient populations retrieved and the intended application. Careful attention to phenotype definitions is critical if the promise of leveraging EHR data to improve individual and population health is to be fulfilled.

Managing hyperglycemia and diabetes in patients receiving enteral feedings: A health system approach

Abstract Evidence of poor outcomes in hospitalized patients with hyperglycemia has led to new and revised guidelines for inpatient management of diabetes. As providers become more aware of the need for better blood glucose control, they are finding limited guidance in the management of patients receiving enteral nutrition. To address the lack of guidelines in this population, Duke University Health System has developed a consistent practice for managing such patients. Here, we present our practice strategies for insulin use in patients receiving enteral nutrition. Essential factors include assessing the patients’ history of diabetes, hyperglycemia, or hypoglycemia and timing and type of feedings. Insulin practices are then designed to address these issues keeping in mind patient safety in the event of abrupt cessation of nutrition. The outcome of the process is a consistent and safe method for glucose control with enteral nutrition.

Patient Self-Management of Diabetes Care in the Inpatient Setting: Pro.

Patients should be allowed to manage their diabetes in the hospital. Diabetes mellitus is a common and sometimes difficult to control medical issue in hospitalized patients. Oftentimes patients who have been controlling their diabetes well as an outpatient are not allowed to continue this management on the inpatient setting, which can lead to hypo- and hyperglycemia. Involving the patient in his or her diabetes care, including self-management in select patients, may provide a safe and effective way of improving glycemic control and patient satisfaction. This may particularly benefit the dosing and coordination of meal-time

Effectively Identifying the Inpatient With Hyperglycemia to Increase Patient Care and Lower Costs

Abstract Recent years have seen an increased focus on merging quality care and financial results. This focus not only extends to the inpatient setting but also is of major importance in assuring effective transitions of care from hospital to home. Inducements to meld the 2 factors include tying payment to quality standards, investing in patient safety, and offering new incentives for providers who deliver high-quality and coordinated care. Once seen as the purview of primary care or specific surgical screening programs, identification of patients with hyperglycemia or undiagnosed diabetes mellitus now presents providers with opportunities to improve care. Part of the new focus will need to address the length of stay for patients with diabetes mellitus. These patients are proven to require longer hospital stays regardless of the admission diagnosis. With reducing length of stay as a major objective, efficiency combined with improved quality is the desired outcome. Even with the mounting evidence supporting the benefits of improving glycemic control in the hospital setting, institutions continue to struggle with inpatient glycemic control. Multiple national groups have provided recommendations for blood glucose assessment and glycated hemoglobin testing. This article identifies the key benefits in identifying patients with hyperglycemia and reviews possible ways to identify, monitor, and treat this potential problem area and thereby increase the level of patient care and cost-effectiveness.

IV Insulin Infusions: How to Use an “Insulin Drip”

Several clinical scenarios mandate the use of an IV insulin infusion (often informally referred to as an “insulin drip”). Any inpatient with diabetic ketoacidosis (DKA) requires an IV insulin infusion for proper management; simply continuing subcutaneous injections is not the standard of care in the hospital. Also, a patient with hyperosmolar nonketotic hyperglycemia should be initially managed with IV insulin.

Safely Converting an Entire Academic Medical Center From Sliding Scale to Basal Bolus Insulin via Implementation of the eGlycemic Management System

Objective: Hyperglycemia is common in the inpatient setting and providers frequently rely on sliding scale insulin. This case study reviews the experience of one hospital moving from high utilization of sliding scale to basal bolus insulin therapy. Method: This Retrospective Quality Improvement Study describes the journey of clinicians at a 580-bed hospital to convert from high usage of SSI to BBI. Hyperglycemic adult patients prescribed insulin, with/without a diagnosis of diabetes, were included. Results: Data over the first year showed that patients treated with Glucommander (GM) spent more time in the target range of 70-180 mg/dL than patients treated with non-Glucommander (non-GM), with 2,434 fewer hypoglycemic events and 40,589 fewer hyperglycemic events. Prior to implementation of GM, SSI was close to 95%, BBI at 5%. Within the first month of use, 96% usage of BBI was achieved. Reduction of hypoglycemic events (% of BG < 70 mg/dL) by 21% with 2.16% non-GM compared to GM at 1.74% and severe Hypoglycemia (% of BG < 50 mg/dL) by 50% in the ICU 3% non-GM compared to GM at 1.5%. In addition, patients treated with GM had a shorter LOS than patients treated with non-GM by 3.18 days and used 47.4% less point of care tests per patient. Conclusion: Glycemic management improved with use of eGMS. The conversion from SSI to BBI enhanced overall patient safety, eliminated the time and effort otherwise required when manually titrating insulin and reduced overall cost of care for patients on insulin therapy.

Letter: Comment on Unger J. Modern Medicine Nearly Killed Me. [Editorial] Clinical Diabetes 2016;34:22–24

As a diabetes nurse practitioner and consulting associate faculty member in the Duke University School of Nursing nurse practitioner program, I read this article with great interest. I have practiced in inpatient diabetes care as an acute care nurse practitioner since 2001; I have been a nurse since 1993 and was a ward clerk in the early 1980s, when patients were admitted for respite care. Care has changed dramatically over those years. Unfortunately, I could see any of the things that happened to Dr. Unger during his hospitalization happening at almost any hospital (academic or otherwise) today. I am completely dismayed at times by the quality of education related to diabetes care, comprehensive history taking, review of systems, and physical examinations, as well as by the lack of …