Clinical Decision Support for Diabetes Care in the Hospital: A Time for Change Toward Improvement of Management and Outcomes

The increasing prevalence of diabetes permeates hospitals and dysglycemia is associated with poor clinical and economic outcomes. Despite endorsed guidelines, barriers to optimal management and gaps in care prevail. Providers’ limitations on knowledge, attitudes, and decision-making about hospital diabetes management are common. This adds to the complexity of dispersed glucose and insulin dosing data within medical records. This creates a dichotomy as safe and effective care are key objectives of healthcare organizations. This perspective highlights evidence of the benefits of clinical decision support (CDS) in hospital glycemic management. It elaborates on barriers CDS can help resolve, and factors driving its success. CDS represents a resource to individualize care and improve outcomes. It can help overcome a multifactorial problem impacting patients’ lives on a daily basis

Managing Hospitalized Patients Taking SGLT2 Inhibitors: Reducing the Risk of Euglycemic Diabetic Ketoacidosis

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are emerging as an important therapy not only for type 2 diabetes (T2DM), but also for heart disease and kidney disease. As these medicines gain acceptance, the number of hospitalized patients receiving them is likely to rise. During clinical trials, SGLT2 inhibitors were noted to have a potential risk for diabetic ketoacidosis (DKA), particularly DKA with relatively normal blood glucose levels, ‘euglycemic DKA’. Similar to DKA that is not associated with SGLT2 inhibitors, most of these events seem to be related to acute illnesses or other changes in a patient’s medications or self-management circumstances. This creates a need among hospital providers to create strategies to prevent DKA in their hospitalized patient and guidance on monitoring and treating euglycemic DKA. Our combined experience concerning this phenomenon has given a great deal of insight into this problem and the knowledge needed to improve patient care, by augmenting patient education, inpatient surveillance, and early treatment for euglycemic DKA

Managing Hospitalized Patients Taking SGLT2 Inhibitors: Reducing the Risk of Euglycemic Diabetic Ketoacidosis

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are emerging as an important therapy not only for type 2 diabetes (T2DM), but also for heart disease and kidney disease. As these medicines gain acceptance, the number of hospitalized patients receiving them is likely to rise. During clinical trials, SGLT2 inhibitors were noted to have a potential risk for diabetic ketoacidosis (DKA), particularly DKA with relatively normal blood glucose levels, ‘euglycemic DKA’. Similar to DKA that is not associated with SGLT2 inhibitors, most of these events seem to be related to acute illnesses or other changes in a patient’s medications or self-management circumstances. This creates a need among hospital providers to create strategies to prevent DKA in their hospitalized patient and guidance on monitoring and treating euglycemic DKA. Our combined experience concerning this phenomenon has given a great deal of insight into this problem and the knowledge needed to improve patient care, by augmenting patient education, inpatient surveillance, and early treatment for euglycemic DKA.</jats:p

SUN-507 Fueling the Fire: A Case of Hypokalemic Periodic Paralysis Associated with Type I Renal Tubular Acidosis and Thyrotoxicosis in Pregnancy

Abstract Background: Hypokalemic periodic paralysis (HPP) related to thyrotoxicosis, though rare, is more often seen in Asian males. Type 1 renal tubular acidosis (T1 RTA), which can also cause HPP, is typically managed with alkali therapy and potassium supplementation, though there are no well-established guidelines for management in pregnancy. Clinical Case: A 27-year-old Puerto Rican woman, at 32 weeks gestation, presented to the hospital with sudden onset muscle weakness, and was found to have 1/5 muscle strength in her lower extremities. She had no personal or family history of similar illness. Laboratory analysis revealed hypokalemia (potassium 2.0 mmol/L, range: 3.5 – 5); non-gap metabolic acidosis (sodium 137mmol/L, range 136 – 145; chloride 113 mmol/L, range 98- 107; and bicarbonate 8 mmol/L, range 22 – 29); and an arterial pH of 7.09. Urine studies demonstrated a urine pH of 6.5 and a urine sodium of 32 mmol/L which was diagnostic of T1 RTA in the context of her metabolic derangements. She was treated emergently with potassium and bicarbonate infusions, with improvement in her symptoms. Subsequent thyroid function testing revealed: a low TSH of 0.01 uIU/ml, normal free T4 of 1.66 (range: 0.9 - 1.7) ng/dl, normal free of T3 3.7 (range: 2.0 -4.4) pg/ml and elevated total T4 of 16.5 (range: 4.5 - 11.7) ug/dl. Renal ultrasound demonstrated medullary nephrocalcinosis. She was discharged on potassium and sodium citrate tablets. At 37 weeks, the patient was readmitted for induction of labor due to pre-eclampsia, and delivered a healthy male baby. Several months later, she presented to the Endocrinology clinic with symptoms of increased frequency bowel movements, palpitations and heat intolerance, which had been ongoing since pregnancy. On review, a metabolic panel prior to pregnancy had demonstrated non-gap acidosis and mild hypokalemia. Further testing demonstrated the following: TSH &amp;lt; 0.01 uIU/ml, Free T4 1.71 ng/dl, Free T3 4.8 pg/ml, TSI 280%, and a thyroid uptake scan with homogenous radiotracer uptake, with a 24-hour uptake of 40%. She was started on methimazole therapy, and continued on potassium and sodium citrate tablets with clinical and biochemical improvement. Conclusion: Thyrotoxicosis can augment hypokalemia in T1 RTA, and can increase the risk of HPP. Our patient had biochemical evidence of RTA prior to pregnancy, though without episodes of HPP, and we believe that her hyperthyroidism, triggered by pregnancy, may have been the additional insult that precipitated her paralysis. This is the first reported case of HPP related to co-existing thyrotoxicosis and T1 RTA in a pregnant individual. Reference:1. Tu ML, Fang YW, Leu JG, Tsai MH. An atypical presentation of high potassium renal secretion rate in a patient with thyrotoxic periodic paralysis: a case report. BMC Nephrol. 2018;19(1):160. Published 2018 Jul 4. doi:10.1186/s12882-018-0971-9</jats:p

MON-617 Improving Care Transitions: Optimizing Diabetes Medication Reconciliation

Abstract Introduction Medication reconciliation (MR) is essential in caring for hospitalized patients with diabetes (DM). Inaccuracies prevail, affecting transitions of care. Factors contributing to errors are driven by providers, patients, and systems of practice and increase in transitions out of hospital. A study showed that MR errors occurred in about 38 % of admissions. Common discrepancies among DM subjects were related to DM and cardiovascular drugs. An intervention aiming to reduce MR discrepancies at discharge achieved 70% less errors due to communication between inpatient providers, primary care and patients within 24 hours. Systems-based interventions and multidisciplinary approaches show promise to improve processes. However, a comprehensive assessment of the elements of practice to target and how interventions may be more effective is lacking. Our purpose was to examine aspects of practice among personnel responsible for the MR steps, and within the hospital workflow in order to identify gaps in the process. We intend to recognize factors to be targeted to optimize MR for DM, and to provide a multipronged approach to inform changes in hospital processes. Methods: We used quantitative and qualitative methods to investigate errors in the MR process as part of a hospital quality improvement program. We randomly included patients 18 years or older with type 1 or 2 DM evaluated by the endocrine team for 6 months. Chart reviews were conducted to assess type and frequency errors. Interviews of nurses, pharmacists, clinicians, and DM educators were sought to understand unique situations and the roles of health providers in the MR process. Results Twenty-two subjects were identified with one or more of the following gaps in their MR pertaining to DM medications: a) missing, b) redundancy, and c) dosing error. Scenarios included ≥2 discrepancies (4 of 22); ≥1 medication inappropriately changed from home regimen (18 of 22); redundantly adding a medication (4 of 22); wrong dose of medication (1 of 22); incomplete prescription for DM supplies (8 of 22). Conclusion: We identified deficits and their attribution to professionals and categorized errors in hospital workflows. Observations, providers’ insights and literature review enabled an assessment of MR failures. We developed a conceptual model where types of error, professionals’ roles, and solutions intersect Interface of prioritizing actions, hospital resources, use of checklists, interdisciplinary collaborations, and staff education is essential to advance adequate MR in the system of practice. Our future steps include a Plan-Do-Study-Act cycle to advance care.</jats:p