how should we manage blood sugar in the hospital? ihs leadership symposium april 20, 2010
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How Should We Manage Blood Sugar in the Hospital? IHS Leadership Symposium April 20, 2010. Nate Brady MD, MPH Assistant Medical Director Center for Clinical Transformation Iowa Health System [email protected]. Current Diabetes Facts. 7% of Americans are diabetic Age 20 years or older: 9.6% - PowerPoint PPT PresentationTRANSCRIPT
How Should We Manage Blood How Should We Manage Blood Sugar in the Hospital?Sugar in the Hospital?
IHS Leadership SymposiumIHS Leadership SymposiumApril 20, 2010April 20, 2010
Nate Brady MD, MPHNate Brady MD, MPHAssistant Medical DirectorAssistant Medical Director
Center for Clinical TransformationCenter for Clinical TransformationIowa Health SystemIowa Health System
[email protected]@ihs.org
Source: www.Diabetes.orgSource: www.Diabetes.org
Current Diabetes FactsCurrent Diabetes Facts
7% of Americans are diabetic7% of Americans are diabetic
Age 20 years or older: 9.6%Age 20 years or older: 9.6%
Age 60 years or older: 20.9%Age 60 years or older: 20.9%
Prevalence has risen 5% annually since Prevalence has risen 5% annually since 19901990
Type II DM makes up 90-95% of casesType II DM makes up 90-95% of cases
70% is thought due to weight (???)70% is thought due to weight (???)
0
1
2
3
4
5
6
7
1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06
Year
Per
cen
t w
ith
Dia
bet
es
0
2
4
6
8
10
12
14
16
18
20
Nu
mb
er w
ith
Dia
bet
es (
Mil
lio
ns)Percent with Diabetes
Number with Diabetes
Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Age-adjusted percentage of adults aged ≥20 years with diagnosed diabetes, 2007
MMWR 58:1259-1263, 2009
Age-adjusted percentage of adults aged ≥20 years who are obese, 2007
MMWR 58:1259-1263, 2009
IDPH Annual Report BRFSS 2008IDPH Annual Report BRFSS 2008
Diabetes in IowaDiabetes in Iowa
7% of adults over 20 yrs old7% of adults over 20 yrs old
99thth lowest rate in the nation (2008) lowest rate in the nation (2008)
17% of those over 65 yrs old17% of those over 65 yrs old
29% on insulin at home29% on insulin at home
73% on oral medications73% on oral medications
Has stabilized over timeHas stabilized over time
Diabetes in Iowa Health Diabetes in Iowa Health SystemSystem
20-40% of hospitalized patients20-40% of hospitalized patients
Varies by diagnosisVaries by diagnosis
41% of COPD patients41% of COPD patients
No consistent approachNo consistent approach
Conflicting evidence for best practiceConflicting evidence for best practice
Conflicting EvidenceConflicting Evidence
2001 van den Bergh NEJM:2001 van den Bergh NEJM:
intensive glucose control decreases intensive glucose control decreases mortality by 42% in ICU patientsmortality by 42% in ICU patients
2002 Umpierrez J Clin Endo Metab:2002 Umpierrez J Clin Endo Metab:
Hyperglycemia increase risk of death Hyperglycemia increase risk of death 4X4X
~2x
Mort
ality
Rate
(%
)
Mean Glucose Value (mg/dL)
Krinsley JS. Mayo Clin Proc. 2003;78:1471-1478.
N=1826 ICU patients.
0
5
10
15
20
25
30
35
40
45
80-99 100-119 120-139 140-159160-179180-199 200-249 250-299 >3000
5
10
15
20
25
30
35
40
45
0
5
10
15
20
25
30
35
40
45
Hyperglycemia and MortalityHyperglycemia and Mortalityin the ICU (mixed medical/surgical)in the ICU (mixed medical/surgical)
~4x~3x
Umpierrez GE et al. J Clin Endocrinol Metabol. 2002;87:978-982.
Hyperglycemia: An Independent Hyperglycemia: An Independent Marker of In-Hospital OutcomeMarker of In-Hospital Outcome
Length of stay higher (9.0 Length of stay higher (9.0 vs 4.5 and 5.5 days, vs 4.5 and 5.5 days, respectively) for new respectively) for new hyperglycemia than for hyperglycemia than for normoglycemic or known normoglycemic or known DM DM
New hyperglycemia more New hyperglycemia more likely to require ICU than likely to require ICU than normoglycemic or known normoglycemic or known DM (29% vs 9% vs 14%, DM (29% vs 9% vs 14%, respectively), and to need respectively), and to need transitional care after transitional care after dischargedischarge
Trend toward higher rate Trend toward higher rate of infections and of infections and neurologic events in the neurologic events in the two hyperglycemia groupstwo hyperglycemia groups
KnownDiabetes
Normoglycemia NewHyperglycemia
10% 11%
31%*ICU Mortality
Mort
ality
(%
) 30
20
10
0
*P<0.01
KnownDiabetes
Normoglycemia NewHyperglycemia
0.8% 1.7%
10%*
Non ICU Mortality
Mort
ality
(%
) 30
20
10
0
KnownDiabetes
Normoglycemia NewHyperglycemia
1.7% 3.0%
16%*
Total Inpatient Mortality
Mort
ality
(%
) 30
20
10
0
SH, significant hypoglycemia: <2.2 mmol/L; <40 mg/dL.
Krinsley JS et al. Crit Care Med. 2007;35:2262-2267.
Mortality rate (%) among patients with significant hypoglycemia, matched controls, and no
hypoglycemia
0
10
20
30
40
50
60
SH Controls No SH
Significant hypoglycemia was associated significantly with an increased risk of mortality (OR, 2.28; 95% CI, 1.41-3.70; P=0.0008)
Severe HypOglycemia in Critically Severe HypOglycemia in Critically Ill Patients: Risk Factors and Ill Patients: Risk Factors and
OutcomesOutcomesM
ort
alit
y R
ate
(%
)
IHS Campaign to stop SSIIHS Campaign to stop SSI
BrochuresBrochures
LecturesLectures
PostersPosters
Local experts engagedLocal experts engaged
Order set development and launchOrder set development and launch
Adoption of order setAdoption of order set
Conflicting Evidence, contConflicting Evidence, cont
2008 JAMA Wiener et al:2008 JAMA Wiener et al:Benefits and Risks of tight glucose Benefits and Risks of tight glucose control. Meta-analysis showed no control. Meta-analysis showed no difference between intensive vs. good difference between intensive vs. good controlcontrol
2009 NICE-SUGAR NEJM:2009 NICE-SUGAR NEJM:Intensive vs. good glucose control Intensive vs. good glucose control shows slight INCREASED risk of deathshows slight INCREASED risk of death
Diabetes Care, vol. 33, Supp. I JanDiabetes Care, vol. 33, Supp. I Jan. 2010. 2010
Current RecommendationsCurrent Recommendations
Glucose TargetsGlucose Targets
Critically ill: 140-180 mg/dLCritically ill: 140-180 mg/dL
All others: < 140 mg/dL premeal, All others: < 140 mg/dL premeal, <180mg/dL other times.<180mg/dL other times.
Diabetes Care, vol. 33, Supp. I JanDiabetes Care, vol. 33, Supp. I Jan. 2010. 2010
Current RecommendationsCurrent Recommendations
Critically ill:Critically ill:
Insulin infusion preferred methodInsulin infusion preferred method
All others: All others:
Subcutaneous insulin, basal-bolus-Subcutaneous insulin, basal-bolus-correctional preferred methodcorrectional preferred method
Diabetes Care, vol. 33, Supp. I JanDiabetes Care, vol. 33, Supp. I Jan. 2010. 2010
Current RecommendationsCurrent Recommendations
““A topic that deserves particular A topic that deserves particular attention is the persistent overuse attention is the persistent overuse of…sliding scale insulin…prolonged of…sliding scale insulin…prolonged therapy with sliding scale insulin is therapy with sliding scale insulin is ineffective."ineffective."