Patricia A. Mackey

Transitioning Insulin Pump Therapy from the Outpatient to the Inpatient Setting: A Review of 6 Years' Experience with 253 Cases

Background: We reviewed the care of a large cohort of patients with diabetes mellitus on insulin pump therapy who required an inpatient stay. Methods: Records were reviewed of patients hospitalized between January 1, 2006, and December 31, 2011. Results: A total of 136 patients using insulin pumps had 253 hospitalizations. Mean (standard deviation) patient age was 55 (16) years, diabetes duration was 29 (15) years, and pump duration was 6 (5) years. Insulin pump therapy was continued in 164 (65%) hospitalizations. Adherence to core process measures improved over time: by 2011, 100% of cases had an endocrinology consultation, 100% had the required insulin pump order set completed, and 94% had documentation of the signed agreement specifying patient responsibilities for continued use of the technology while hospitalized. Documentation of the insulin pump flow sheet also increased but could still be located in only 64% of cases by the end of 2011. Mean glucose was not significantly different among patients who remained on insulin pump therapy compared to those for whom it was discontinued (p > .1), but episodes of severe hyperglycemia (>300 mg/dl) and hypoglycemia (<40 mg/dl) were significantly less common among pump users. No pump site infections, mechanical pump failures, or episodes of diabetic ketoacidosis were observed among patients remaining on therapy. Conclusions: With appropriate patient selection and usage guidelines, most patients using insulin pumps can safely have their therapy transitioned to the inpatient setting. Further study is needed to determine whether this approach can be translated to other hospital settings.

Care directed by a specialty-trained nurse practioner or physician assistant can overcome clinical inertia in management of inpatient diabetes

OBJECTIVE The studys objective was to determine the impact of care directed by a specialty-trained nurse practitioner (NP) or physician assistant (PA) on use of basal-bolus insulin therapy and glycemic control in a population of noncritically ill patients with diabetes. METHODS A retrospective review of diabetes patients evaluated between July 1, 2011 and December 31, 2011 was conducted. Patients cotreated by a specialty-trained NP/PA were compared with patients who did not receive such care. RESULTS In total, 171 patients with 222 hospitalizations were cotreated by an NP/PA and 543 patients with 665 hospitalizations were not. Patients with NP/PA involvement were younger, and had more frequent hyperglycemia, and had greater corticosteroid use than patients without NP/PA involvement (P<.01 for all). Basal-bolus insulin therapy was administered to 80% of patients with NP/PA involvement and 34% of patients without it (P<.01). After adjustment for age, sex, hyperglycemia measures, and corticosteroid use, the odds of basal-bolus insulin therapy being administered were increased significantly through NP/PA care (odds ratio, 3.66; 95% confidence interval, 2.36-5.67; P<.01). After adjustment for these variables and insulin regimen, NP/PA care was significantly correlated with lower mean point-of-care glucose levels at 24 hours before discharge (P = .042). CONCLUSION Diabetes care assisted by an NP/PA trained in inpatient diabetes management results in greater use of recommended basal-bolus insulin therapy and is correlated with lower mean glucose levels before discharge. Adapting this model for use outside an endocrinology consult service needs to be explored so that the expertise can be brought to a broader inpatient population with diabetes.

Insulin Pump Therapy in the Perioperative Period: A Review of Care after Implementation of Institutional Guidelines

Background: An institutional policy was previously established for patients with diabetes on insulin pump therapy undergoing elective surgical procedures. Method: Electronic medical records were reviewed to assess documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of care. Results: Twenty patients with insulin pumps underwent 23 procedures from March 1 to December 31, 2011. Mean (standard deviation) age was 58 (13) years, mean diabetes duration was 28 (17) years, and mean duration of insulin pump therapy was 7 (6) years. Nearly all cases (86%) during the preoperative phase had the presence of the device documented—an improvement over the 64% noted in data collected before the policy. Intraoperatively, 13 cases (61%) had the presence of the pump documented, which was higher than the 28% before implementation of the policy. However, documentation of pump status was found in only 38% in the PACU and was actually less than the 60% documented previously. Over 90% of cases had glucose checked in the preoperative area and the PACU, and only 60% had it checked intraoperatively, which was nearly identical to the percentages seen before policy implementation. No adverse events occurred when insulin pump therapy was continued. Conclusions: Although some processes still require improvement, preliminary data suggest that the policy for perioperative management of insulin pumps has provided useful structure for care of these cases. The data thus far indicate that insulin pump therapy can be continued safely during the perioperative period.

Update on a Quality Initiative to Standardize Perioperative Care for Continuous Subcutaneous Insulin Infusion Therapy.

Objective: The objective of the analysis was to review the effectiveness of a care process model (CPM) developed to guide management of patients on insulin pump therapy undergoing elective surgical procedures. Methods: Electronic medical records were reviewed to assess the impact of the CPM on documentation of insulin pump status, glucose monitoring, and safety during the perioperative phase of care. Post-CPM care was compared with management provided before CPM implementation. Results: We reviewed 45 cases on insulin pump therapy in the pre-CPM cohort and 106 in the post-CPM cohort. Demographic characteristics, categories of surgery, and perioperative times were not significantly different between the 2 groups. Recommended hemoglobin A1c monitoring occurred in 73% of cases in the pre-CPM cohort but improved to 94% in the post-CPM group (P < .01). There was a higher frequency of documentation of the insulin pump during the preoperative, intraoperative, and postanesthesia care unit segments of care in the post- vs pre-CPM periods (all P < .01). The number of cases with intraoperative glucose monitoring increased (57% pre-CPM vs 81% post-CPM; P < .01). Glycemic control was comparable between the 2 CPM periods. Hypoglycemia was rare, with only 3 episodes in the pre-CPM group and 4 in the post-CPM. No adverse events associated with perioperative insulin pump use were observed. Conclusions: This analysis adds to previous data on use of insulin pump therapy during the perioperative period. Some processes require additional attention, but data continue to indicate that a standardized approach to care can lead to a successful and safe transition of insulin pump therapy throughout the perioperative period.

Hyperglycemia during the immediate period following liver transplantation

Aim: High blood glucose levels in the hospital are common among transplant recipients. Methods: Retrospective analysis, stratified by diagnosis of pretransplant diabetes mellitus (DM). Results: Of 346 patients, 96 had pretransplant DM (insulin, n = 60; no insulin, n = 36) and 250 did not. Patients with pretransplant DM had higher inpatient mean glucose levels and more hyperglycemia and hypoglycemia (all p < 0.01). For patients without pretransplant DM, the need for insulin at discharge increased 23% for every 5-year age increase (odds ratio: 1.23; 95% CI: 1.06–1.44; p = 0.007) and 51% for every five units of glucose measurements >180 mg/dl (OR: 1.51; 95% CI: 1.23–1.95; p < 0.01). Conclusion: Inpatient hyperglycemia was common in liver transplant recipients. Hospital practitioners must anticipate the need to teach self-management skills to liver transplant recipients.

NICOTINE-SUBSTITUTE GUM-INDUCED MILK ALKALI SYNDROME: A LOOK AT UNEXPECTED SOURCES OF CALCIUM

OBJECTIVE This report describes a 64-year-old woman with recurrent hypercalcemia. Her laboratory evaluation was consistent with milk-alkali syndrome. It was eventually discovered that the source of the excessive calcium consumption was nicotine-replacement chewing gum and carbonated water. METHODS An extensive literature search was performed to see if milk-alkali syndrome due to nicotine-replacement gum and carbonated water has been previously reported. RESULTS No prior report describing the association of milk alkali syndrome with nicotine-replacement gum and carbonated water was found. CONCLUSION We present a unique case of milk-alkali syndrome due to nicotine-replacement gum and carbonated water. It serves as a lesson to evaluate other sources besides calcium supplements as the cause of excessive calcium intake.