Inpatient Diabetes Management: Summary of International Hospital Diabetes Meeting

Affiliate Conference Call - Nov 17, 2010 Inpatient Diabetes Management: Summary of International Hospital Diabetes Meeting Presenter: Randi Kington, APRN, CDE

Participants: Brookwood - Linda Martin, Tom Wills W Penn - Marlene Sperl SNH - Cheryl Barry THOCC - Katie Tierney & Sue St Vincent – Roseann Anthony Floyd - Beth Ackerman & Pam Rake Upstate - Cindy DeBartolo Boston - J Giusti, C Mensing, E Sullivan, Ken Snow, MD, J Rizzotto and M Koen OSF Bloomington – Marvis Custer L&M – Barbara Corvello, Jan Amato, Rita Gonzalez, Lisa Gilmore, several students Frisbie - M Hall & M Kamill WV – Pat Swain & Mona Wilson

Types of people who attended this international conference: Internal Medicine, Endocrinologists, Hospitalists, FDA, JCAHO, Laboratory, educators. Most practice full time inpatient.

See detailed notes written by Randi and scanned agenda and list of presenters. Affiliates can contact speakers directly if interested in a particular topic in more detail.

Send protocols you want to share with affiliate colleagues to [email protected] and she will post on Affiliate to Affiliate Sharing section of the password protected Joslin website: http://www.joslin.org/affiliates/affiliate_to_affiliate_sharing.html

Joslin’s Manual Inpatient Care: Incorporating Diabetes/Hyperglycemia Care with CQI Principles is being revised. If you have things you want to contribute, please submit to Elaine Sullivan. If you want to be part of the team working on this manual, contact Elaine.

Conference attendee comments  Very few have drips on all floors  Options for insulin management in tube fed or TPN patients in transition from ICU insulin infusion to non-acute floors – low dose basal and regular q 6 hours – NPH q 12 hrs – NPH every 8 hours – NPH q 6 hours; – D10 backup if tube feeding held  Most important to prevent highs and lows, BG variability is biggest concern

Affiliate Approaches to Inpatient Management

 Brookwood – BG 140 pre CABG go on insulin drip  Upstate - drips on general floors but no set protocol – working on developing standard protocol; some units better than others at managing  L&M – nurse driven drips on all units convinced RNs they could do it based on fact they were already doing heparin drips by protocol; new problem is CT – Dept of Health resistance re nurse driven protocols – have to make more rigid, less nursing judgement; ongoing education required; newest L&M initiative is mandatory pre-op orders for all people with DM; Joslin is consulted; nurse gets daily report of low and high blood glucoses then follows up with hospitalists  OSF Bloomington – Target < 150 hospital wide with protocols  Boston – Ken Snow reported more flexibility in protocol worse glycemic control

Common Affiliate Problems  Nurse turnover – continuing education ongoing  Diabetes not primary concern

Pump Protocol  OSF Bloomington – educate general staff nurse to do assessment  Agreement with patient – signed or just verbal agreement  SNH – patient agreement is not called contract with patient; called safety checklist at request of risk management  Univ of Pittsburgh and Portland have published pump inpatient protocols  Decide who makes sure patient knows what they are doing – CDE gets involved & refers to outpt education post discharge; whoever doing BG management responsible to take patient off pump if unsafe

U500 – few at conference using U500 inpatient  L&M focus on lowering error rate; pharmacy pre-measures and 2 nurses co-sign before giving; No one on call is using U500 inpatient in pumps

Education on Nursing Unit  How to get time in RN Orientation – L&M focus on survival skills training and review all protocols – 75 minutes  Upstate – 450 beds and 1 educator; need to empower staff; not been able to get diabetes on orientation agenda

JCAHO – only 20 hospitals nationally  Most in audience at conference felt specific JCAHO certification for inpatient diabetes not necessary; want standard JCAHO survey to include focus on: reducing hyperglycemia, reducing hypoglycemia, following hypoglycemia protocol Monitoring on units  FDA – new rule clean monitors between each patients; Jan 2011 effective; based on data from extended care facility – hepatitis transmission; could add 7 minutes to each bedside glucose; not clear how hospitals will address this mandate; need to follow up with your hospital lab  In Critical care capillary glucose may not be accurate; recommendation to sample from only 1 site – either capillary, venous or arterial  CGM hold up on inpatient – will be long time coming for accuracy  Hematocrit 30-55mg/dL required for accuracy on BG meters  O2 can limit fingerstick glucose accuracy