System Change and Inpatient Diabetes Management

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System Change and Inpatient Diabetes Management

• Paul E. Stander, MD, FACP
• Chief Medical Officer
• Banner Good Samaritan Medical Center

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Historical Perspective

• Joslin/Banner proposal
• Diabetes at Good Sam
• 20 of all hospital inpatients
• Approx 17K annual patient days
• Avg 1 day longer LOS for matched DRGs
• Large financial incentive to improve DM mgt

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Glucose Mgt - CABG

• BGSMC 600 open heart surg per yr
• Excellent mortality results OE 0.6
• Suboptimal complication rates
• incr deep sternal wound infections
• aggressive blood sugar mgt implemented
• normoglycemia in immed periop period
• deep sternal wounds virtually eliminated

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ICU Glucose Mgt

• NEJM article shows tight control improves ICU
  mortality
• CABG protocol implemented in MICUs
• FAILURE!!!!
• Nurse driven IV insulin protocol now achieving
  normoglycemia in gt 50 patients
• Outcomes???

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Non-ICU Glucose Mgt

• Nurse Practitioner led effort with
  multidisciplinary team
• Goals
• Reduce use of sliding scale
• Increase use of routine long-acting and pre- meal
  short-acting insulin regimen
• Reduce hypoglycemia episodes
• Reduce LOS and complications

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Non-ICU Glucose Mgt

• Lessons Learned Many Obstacles
• Nursing education about DM and insulin preps
• Data collection is difficult
• Sliding scale is entrenched
• Physician reluctance to cede control
• Insulin protocols are complex to implement
• Dietary coordination is difficult

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ICU Glucose Control April 05

• Surgical ICU Drip vs SS
• Drip() SS()
• lt 60 3 (1) 0
• 61-110 147 (42) 23 (21)
• 111-140 136 (38) 42 (39)
• 141-180 44 (12) 24 (22)
• 181-250 17 (5) 15 (14)
• gt250 7 (2) 3 (3)

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ICU Glucose Control April 05

• Medical ICU Drip vs SS
• Drip() SS()
• lt60 10 (2) 1 (0)
• 61-110 203 (45) 45 (17)
• 111-140 150 (33) 64 (25)
• 141-180 56 (12) 81 (31)
• 181-250 26 (6) 48 (18)
• gt250 4 (1) 21 (8)