by Tim Gieseke, MD, CMD

In 2013, each of our facilities will be challenged to adopt performance improvement projects (QAPI) that involve all of the departments within our facilities with the goal of sustainable implementation of significant best practices. This new process will be a mandatory part of our clinical practice in 2014.
 
One obvious QAPI is the inappropriate use of Sliding Scale Insulin (SSI) in our facilities. This year, the AGS updated the Beers Criteria for Potentially Inappropriate Medication use in the Elderly. SSI is included in this list for the first time as a strategy to avoid because of the higher risk of hypoglycemia without improvement in management of hyperglycemia regardless of the setting of care. They rate the quality of the evidence as Moderate and the strength of the recommendation as Strong.

For our patients with diabetes who require insulin and are medically stable, best practice recommendations include the use of long acting basal insulin (Glargine - Lanus, Levemir -Detemir, or NPH) to cover basal metabolic needs. For meal coverage a short acting insulin (Regular) or rapid acting insulin (Lispro - Humalog, Aspart - Novalog, or Glulisine -Apidra) is recommended. The rapid acting insulin can be given immediately ac, with meals, or p.c. with hold orders if the patient won’t be eating or hold and call for new orders if the glucose is < 70. These hold and call orders minimize the risk of hypoglycemia.

In this scheme, SSI is only used to correct for pre-meal unacceptable hyperglycemia. In essence, SSI has become what endocrinologist call “Corrective Scale Insulin (CSI)” where the meal insulin may have added CSI according to the ordered corrective scale. If this is done, particularly in the LTC setting where carbohydrates offered are similar in each meal, corrective insulin is seldom required in the medically stable patient.

In addition, geriatric experts discourage the use of CSI at bedtime, since this insulin will have its peak effect in 3-5 hrs when our patients are asleep and least likely to be observed. This is when the literature suggests our patients are at their greatest risk for unrecognized serious hypoglycemia.

The goal for glycemic control in the elderly with Type 2 IDDM is recommended according to A1C. The ADA recommends a less stringent standard than < 7.0 in those with long standing DM or established CV complications. AGS recommends < 8.0 for most of our patients. However, in patients with shorter RBC survival (t1/2), the A1C may be too low. This may occur in patients with ESRD, in those receiving erythropoietin stimulators, and not uncommonly in older women. This should be suspected when the A1C is low, but the a.c. finger stick glucose (FSG) are high (150-300). Most labs provide the estimated average glucose (eAG) with the reported A1C. This can be used to infer whether pre-meal FSG are in a range to achieve the desired glycemic goal. An A1C of 6.0, 7.0, 8.0, & 9.0 produce an eAG of 126, 154, 183, & 212 respectively. This means that a range of pre-meal FSG in the 120-180 range will usually provide an A1C in the 7.0-7.5 range.

How does QAPI fit into these recommendations? The literature suggests many of our medically stable patients are on SSI:

1. Without basal or meal insulin use or
2. With basal, but no scheduled meal insulin or
3. Have SSI ordered at h.s. (without occasional 2 or 3 am FSG checks).

How is your facility doing?

This is something that can easily be measured and tracked on a weekly basis. If you do have a problem, the principles of QAPI can be brought to bear looking at a root cause analysis with involvement of your Medical Director, Medical Staff, referring Hospitalist Medical Director, and others on your team.

Look to future WAVE articles on QAPI, and visit AMDA’s web site (www.amda.com) for Webinar on QAPI by Dr. Karyn Leible (9/25/12).

Comment from Anonymous

I like the idea that members are challenged to start QAPI. While I have read some useful information here about the genral best practice i have seen any guidance as to how the QA or PI have been implemented.