Tutorial: How to Use the Glucose Optimizer

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Tutorial How to Use the Glucose Optimizer
Press the arrow ? Key on your Keyboard to Proceed
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This Tutorial will take about 15 minutes to
complete
Press the Forward arrow ? Key on your Keyboard to
proceed forward or the Back arrow ? to go back
one step in this tutorial
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How to Access the Glucose Optimizer
Open the UMMC Intranet page click on Patient
Care Resources
Go to
Click On
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The program may take 20 to 30 seconds to load,
during which you may see this image
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• This is the Opening screen of the program
• Press the arrow ? Key on your Keyboard to Proceed
  forward

NOTE The buttons that you see during this
TUTORIAL are simply screen shots of the actual
program. Hence you CANNOT CLICK them using the
MOUSE. Instead use the arrow keys ? to advance
thru this tutorial
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You can also access the Online Tutorial or Help
from here
This tutorial will now focus on TITRATE PHASE of
GLUCOSE OPTIMIZER! Prescribers may choose to use
the INITIATION and TRANSITION PHASES of the
GLUCOSE OPTIMIZER OR They may follow their
respective UNIT policies for INITITION
TRANSITIONING OFF Insulin drip using UNIT
SPECIFIC POWERPLANS built into the CPOE system
The INITIATE button is used to begin a NEW
patient on Insulin Protocol
The TITRATE button is used to adjust Insulin rate
for a patient ALREADY on Insulin Protocol
The TRANSITION button is used for a patient who
is ready to come off Insulin drip- this is only a
guideline- Please use Diabetic Management
powerplan

• The Support button is used for
• Online Tutorial
• Phone Support

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Lets now access the TITRATE section of the
Glucose Optimizer program for a patient WHO IS
ALREADY ON INSULIN DRIP
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• 3 entries are required for the Titration Phase
• Current BG,
• Current Insulin Drip rate
• Previous BG

Remember, the first Entry Box is always your MOST
CURRENT BG level
The current BG is graphically displayed here
CAUTION ! Do not interchange Current BG with
Previous BG
... Current Insulin rate
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Enter Previous BG Level
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Next, this button is clicked to see the new
recommendations
89
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Before the new recommendations are displayed, you
are asked to confirm the Current Previous BG
entries
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Next your are required to confirm the correct
INSULIN dose by re-entering it
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RECOMMENDATIONS are then displayed in this area
Recommended NEW INSULIN DRIP RATE is shown here
In the current example the recommendation is to
increase from 4 to 5.5 Units/hour
Recommended interval for the next BG level check
is shown here
Special instructions are shown here
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Lets have a look at the Glucose Optimizer
recommendations when patient is Hypoglycemic
Administer Dextrose 50 STAT IV. The volume of
D50W is shown here
INSULIN infusion should be STOPPED IMMEDIATELY!
A repeat BG MUST BE CHECKED in 15 minutes!
Notice In this example, the Current BG is 30 !
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How to Prevent Hypoglycemia

• Most importantly ALWAYS CHECK Blood Glucose
  level at the CORRECT INTERVAL RECOMMENDED BY THE
  PROGRAM!
• The recommended interval for BG check varies
  from
• 1 hour (most of the patients on Insulin drip)
• 2 hours (if BG and Insulin drip stable for 4
  hours)
• 15 minutes (if BG is less than 60 mg/dl)
• 30 minutes (if BG is decreasing very rapidly or a
  high insulin dose needs to be decreased rapidly)
• (Note, the program indicates when you can go to
  q2h BG checks)
• STAT BG level at ANY time you suspect
  hypoglycemia
• (e.g. Tachycardia, sweating, seizures, altered
  mental status)

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How to Prevent Hypoglycemia

• Check Insulin drip to confirm that the
  concentration is 1 unit/ml, it has been
  correctly programmed into the pump
• Label the drip the pump clearly
• Be alert for factors that cause BG to drop
  quickly such as decrease in TPN or feeds,
  reduction in steroids dose, reduction in inotrope
  drips

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When Can I do q 2hr FS check?
Note In this example, both the Current
Previous BG values are in target range (80 to
120) Insulin dose is NOT VERY HIGH (upto 4
units/hr)
Lets now click on this button
Note the instructions that appear in this pop-up
box CAREFULLY
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Whereas this patient is not ready for q2h BG
checks
Notice, the Current BG is greater than target
range (80 to 150 AND Insulin dose recommended is
an increase from 4 to 9 units/hour
Clicking on this button ..
Notice, also that the q2h button in NOT GREEN
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Lets now look at the -INITIATE Phase of the
program
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For INITIATING Insulin Drip, simply answer the 4
questions below
1) Insulin Drip is ONLY indicated for patients
expected to stay in the ICU for gt 12 to 24 hours
are CRITICALLY ILL
IMPORTANT ! Your Unit may use different
indications to INITIATE a patient on TGC. In
that case, please follow your own INITIATION
GUIDELINES rather than using the INITIATE section
in Gluc Optimizer. In either case INITIATE orders
must be entered in powerchart by MD/NP
e.g. if the most recent BG was 138, then click
the 121-150 range box
2) A recent BG level is required before
initiating insulin drip.
Once all questions are answered, Recommendations
are displayed for initiating Insulin Drip in this
box
3) Indicate the most recent BG level, by
clicking on the appropriate range box
4) and if the prior BG was 168 then click the
151-200 range box
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Review the recommendations for INITIATING Insulin
Drip in the box below
IMPORTANT ! Please advise MD/NP to Enter
Order using TGC powerplan (Insulin Drip, Finger
sticks, and D50W for hypoglycemia) in Power chart
as shown in next slide (see GLYCEMIC CONTROL)
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IMPORTANT ! 1) Orders need to be Entered in power
chart by MD/NP before initiating insulin
infusion
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Once you INITIATE a patient on INSULIN DRIP
(whether using the INITIATE phase of the GLUCOSE
OPTIMIZER, or your own UNIT based Indications),
all subsequent Insulin adjustments MUST BE MADE
USING THE TITRATE PHASE of the GLUCOSE OPTIMIZER
until patient is ready to come off Insulin drip
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Lets now look at the -TRANSITION Phase of the
program
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TRANSITIONING OFF from continuous IV Insulin drip
to subcut Intermittent insulin is recommended
WHEN TO TRANSITION OFF INSULIN DRIP?

• When transfer out of ICU is expected in next 12
  to 24 hours OR
• When patient has recovered from critical illness
  is stable (e.g. extubated, off inotropes, off
  CVVH etc)

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Answering 5 questions in this section will help
generate recommendations orders for
TRANSITIONING off from Continuous Insulin
Infusion to Intermittent Subcut Insulin
IMPORTANT ! Your Unit may use a different method
to TRANSITION OFF Insulin Drip. The TRASITION
PHASE of the GLUCOSE OPTIMIZER serves as general
guidelines that may be modified as needed
Enter current insulin rate Current BG level
(Question 1 2)
Enter TOTAL Insulin recd in last 4 hours e.g. If
the Insulin drip rate for each of the LAST 4
hours was 2 units/hr, 1 unit/hr, 2 units/hr,
and 2 units/hr, then the TOTAL FOR 4 HOURS
2122 7 units. Hence click on the 7 -9 units
box
Select one of the 3 Sliding scales (low, mid or
high) in consultation with MD/NP.
Press here for recommendation
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TRANSITION Recommendations are displayed in this
box
Recommendations for Lantus Insulin (Basal,
Long-acting) are shown here
Recommendations for Prandial Insulin are shown
here
IMPORTANT ! Transition Orders MUST be entered by
MD/NP, in power chart
Sliding scale (Supplemental Insulin) is shown
here
Transition orders needs to be entered in Power
chart.
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Follow diabetes Management Power plan as
applicable
IMPORTANT ! 1) Orders need to be entered by
MD/NP, in power chart
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If the program fails to load, you will just see a
blank grey screen (as shown here)
Troubleshooting
simply CLOSE ALL open Browser Windows (you can
keep PowerChart open) then reopen the Glucose
Optimizer from a new UMMS home page
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Remember, Help is only a Click Away !
For IMMEDIATE questions, Call or Page
SUGGESTIONS Your Feedback is VALUABLE
You can always access this ONLINE Tutorial from
the Help page
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TIPS TRICKS

• Have the patients flowsheet with you when you
  access the Glucose Optimizer on the computer
• You can then easily refer to the flowsheet, to
  enter the current BG, the previous BG the
  current insulin dose in the Glucose Optimizer
• Next, as the Glucose Optimizer recommends a new
  Insulin drip rate, chart it directly in the
  flowsheet (so that you dont have to remember
  it).
• Next change the settings on the infusion pump to
  the new rate

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Where to draw blood for BG checks?

• Finger stick is the preferred method
• Arterial line may be used
• DO NOT USE CENTRAL LINE OR PERIPHERAL LINE that
  is infusing Dextrose containing IV fluids.
• This will give a FALSELY HIGH BG reading
• Prompting you to erroneously increase Insulin
• Thus causing hypoglycemia

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Screen patients for Hyperglycemia!!

• Hyperglycemia cannot to treated UNLESS it is
  first IDENTIFIED!
• To detect hyperglycemia all CRITICALLY ILL
  patients MUST be screened with q 6h BG at
• (6am, 12 noon, 6pm 12 midnight)
• Remind RESIDENTS (MD/NP) to order q6h BG in
  PowerChart!

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What is the rationale for Tight Glycemic Control?
gt220
lt 40
40-60
60-80
80-120
120-180
180-220
HYPERglycemia
HYPOglycemia
Normal
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Because evidence shows that HYPERGLYCEMIA is bad!
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Hyperglycemia INCREASES Mortality!
in Myocardial Infarction patients
Even modest increase in BG to 160 doubles the
mortality rate!
in Cardiac Surgery patients
and in other ICU patients
in stroke patients
If BG lt 100 Mortality 10
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evidence also shows that NORMOGLYCEMIA is good!
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2001
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Morbidity is reduced too!

• 30 to 50 reductions in
• Bacteremia
• Transfusion needs
• Need for CVVH
• Duration of mechanical ventilation
• Length of stay
• Polyneuropathy
• Ref NEJM 2001, van den Berghe et al

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Your role is crucial!Your efforts are
appreciated!

• Each time you check a BG level and adjust Insulin
  drip, you are making a SIGNIFICANT CONTRIBUTION
  to improving mortality morbidity
• Remember, the aim is to normalize BG in ALL
  CRITICALLY ILL PATIENTS DIABETICS AS WELL AS
  NON-DIABETICS

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Explanation of EXPO formula for Glucose Optimizer

• The EXPO formula is mathematically designed to
  aggressively prescribe insulin at high BG, adjust
  the infusion to achieve a 20 decrease per hour
  in BG until BG falls below 150 mg/dL, rapidly
  taper insulin as BG falls, and maintain a BG in
  the 80-150 mg/dL range.
• There are built in safety features including
  curtailing insulin if the BG falls below 80
  mg/dL, limiting hourly increases in the insulin
  infusion rate to no more than 5 units, and
  setting a cap on the insulin resistance
  coefficient at ten times the starting IRC.

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EXPO Insulin Dosing Formula

• The insulin resistance coefficient (IRC) is
  adjusted using a correction factor that is based
  upon the previous IRC (calculated from the
  previous BG and insulin infusion rate), and the
  difference between current BG and the fraction
  (Fx) of previous BG expected from the current
  insulin infusion rate. This Fx has a sigmoidal
  relationship where the insulin infusion rate is
  expected to achieve a BG after one hour that is
  80 of previous BG when previous BG is gt 150
  mg/dL, and 100 of previous BG when previous BG
  is lt 120 mg/dL, the upper limit of our desired BG
  range. In other words, the IRC is adjusted to
  achieve a 20 decrease per hour in BG until BG
  falls below 150 mg/dL, and to keep BG stable when
  below 120 mg/dL.

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Your Suggestions are Valuable

• Please to access a short survey to let your
  MANAGER know that you have completed this online
  tutorial. Go to
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  4loBJqP_2bpA_3d_3d
• (Note It will take a few seconds for the survey
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