2019 Research Forum

Frantze Agtarap PharmD R1, Alice Peng PharmD, Jeff Jolliff PharmD Department of Clinical Pharmacy, Kern Medical, California Evaluation of Insulin Infusion Protocols After Staff Education

Discussion The effect of staff education on appropriate insulin infusion prescribing by physicians, timing of BG checks, and correct infusion rate adjustments significantly diminished over time, suggesting staff education should be provided on a recurring basis. Correct transition from DKA/HHS Protocol to STND Protocol, correct transition from an insulin infusion to SQ long-acting insulin, and safety and efficacy endpoints were not statistically significant, however this study was inadequately powered for these endpoints. The results of this study suggest staff education should be provided every 6 to 12 months. However, this study was not designed to assess factors that may have contributed to the diminished effect of the educational campaign. For example, these results may be confounded by the addition of new residents 6 months after the educational campaign was provided, high nursing turnover rate, or infrequent use of the insulin infusion protocols. Further data is required to assess these in the future. Conclusions • The effect of the educational campaign significantly diminished over time • Results highlight the need for staff education on a recurring basis Acknowledgements Special thanks to: • Brittany Andruszko, PharmD

Methods

Introduction

American Diabetes Association recommends the use of standardized insulin infusion protocols for the treatment of hyperglycemic crisis. Potential complications of insulin infusions: • Hypoglycemia, electrolyte disturbances, cerebral edema Kern Medical utilizes two protocols: • Hyperglycemic Crisis (DKA/HHS) Protocol • Standard Insulin Infusion (STND) Protocol Previous study: Peng, A, et al. Kern Medical. 2017 • Outcome: Evaluated the effect of staff education on compliance to the insulin infusion protocols before and 0-3 months after education intervention was provided • Education Intervention: Overview of hyperglycemic crisis treatment, goals and complications of each protocol, and how to use Kern Medical’s protocols • Conclusion: Staff education significantly improved the selection of the appropriate infusion protocol To determine the effect of staff education over time on: • Compliance • Appropriate insulin infusion protocol ordered • Correct transition from DKA/HHS Protocol to STND Protocol • Correct transition from an insulin infusion to subcutaneous (SQ) long- acting insulin

Data Collection • Retrospective chart review • Pre-education (Pre-Edu) cohort:

Exclusion Criteria • Lack of documentation • Used for trauma/surgery • Used for labor and delivery • Used for hyperglycemia treatment (not crisis) • Used for organ preservation after death • Duration of insulin infusion <3 hours

• July 1, 2016 to September 30, 2016

• Post-education (Post-Edu) cohort:

• January 1, 2017 to January 1, 2019 • 0 to 6 months • 6 to 12 months • 12 to 24 months

Results

Table 1. Compliance with Insulin Infusion Protocols

Post-Education

P-value

0-6 N=23

6-12 N=21

12-24 N=39 0-6 vs 6-12 0-12 vs 12-24

Time interval Post-Edu, months

BG checks, n

301

244

484

Appropriate protocols ordered, n (%) Correct transition from DKA/HHS to STND, n (%) Correct transition from insulin infusion to SQ long-acting insulin, n (%) Timing of BG checks Within ±15 minutes of scheduled BG check, n (%) >15 minutes late, n (%) >15 minutes early, n (%) Infusion rate adjustment, n Correctly adjusted, n (%) Incorrect rate despite correct sensitivity index, n (%) Did not follow STND protocol, n (%)

0.0187 0.5027

0.0049

23 (100) 9 (52.9)

16 (76.2) 24 (61.5)

7 (36.8)

13 (43.3)

1

17 (73.9) 12 (57.1) 22 (56.3)

0.3422

0.4983

0.0101 0.5359 0.0112 0.3133 0.0854 0.5918 0.7586 0.5083

252 (83.8) 182 (74.6) 364 (75.2)

0.0996 0.2853 0.3074

23 (7.6) 26 (8.6)

23 (9.4)

51 (10.5)

Objectives

39 (16.0) 69 (14.3)

301

244

484

0.0343

275 (91.2) 216 (88.6) 415 (85.7)

2 (0.7) 9 (3.0)

7 (2.9) 5 (2.0) 5 (2.0) 11 (4.5)

8 (1.7) 12 (2.5) 20 (4.1) 29 (6.0)

1 1

0.0396 0.001

Did not follow DKA/HHS protocol, n (%) 5 (1.7)

Other, n (%)

10 (3.4)

Figure 1. Effect of staff education over time

Effect of staff education over time

• Jessica Beck, PharmD • Jasmine Ho, PharmD • Janet Yoon, PharmD

100 120

• Timing of blood glucose (BG) checks • Correct adjustment of insulin infusion rate

0 20 40 60 80

References

• Peng, A, et al. Evaluation of education on insulin infusion use. Kern Medical. 2017. • AACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control. Endocr Pract . 2009;15(No. 4). • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009 Jul;32(7):1335-1343. (ADA Consensus statement). • Kelly, J. Continuous Insulin Infusion: When, where, and How? Diabetes Spectrum . 2014 Aug; 27(3): 218–223. • Finfer, S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med . 2009 Mar 26;360(13):1283-97.

• Safety

Appropriate protocol ordered Appropriate timing of BG check Correct rate adjustment

• Hypoglycemic events

Percent (%)

• Efficacy:

• Time to BG <250mg/dL • Time to anion gap (AG) <12mg/dL

Pre-Edu

0-3

3-6

6-12

12-24

Time Interval (months)

9