Diabetes: Emergency Department Workup v. 5 Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

Inclusion Criteria · Suspected DKA OR · Suspected new diabetes

Exclusion Criteria · None

Suspected DKA or Diabetes · Use ED DKA Suspected Plan to · Rule out DKA · Test for new diabetes

DKA confirmed?

Yes

Treat per DKA Pathway · Use ED DKA Suspected Plan

No Treat Diabetes (Non-DKA) Diabetes Diagnosis Confirmed?

Yes

· Use ED Diabetes (Non-DKA) Plan · If hyperglycemia with ketosis (BOHB ≥ 0.6 mmol/L or MODERATE to LARGE urine ketones), in consultation with endocrinologist consider ordering one-time “insulin for sick day -)” dose, following Sick Day Management Pathway

No Not Diabetes

For questions concerning this pathway, contact: [email protected] © 2017 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Last Updated: January 2017 Next Expected Revision: May 2018

Insulin Sick Day Management for Diabetes (Non-DKA) v. 5 Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

Inclusion Criteria · Type 1 Diabetes (or at Endocrine attending discretion for CF-related or steroid-induced hyperglycemia) AND · Moderate to large urine ketones OR Blood BOHB ≥ 0.6 mmol/L

! Reminder to initiate, BG > 250 mg/dL x 2 (or >500 mg/dL x 1) AND BOHB ≥ 0.6 mmol/L (or moderate to large urine ketones)

Exclusion Criteria

!

· Diabetic ketoacidosis (DKA) (use instead DKA Pathway) · Intravenous insulin

Watch for signs of DKA, evaluate if present

BOHB ≥ 0.6 mmol/L OR moderate to large urine ketones

Call Provider to evaluate for Diabetic Ketoacidosis (DKA) Has provider ordered Sick Day Management?

NO

Provider consider insulin dose adjustment

YES

Discharge Criteria

Sick Day Management

Treatment · Continue basal and rapid-acting insulin. Rapid-acting can be given for glucose correction every 2-3 hours. · Maintain good hydration · Give fluids, may require alternating carbohydrate-free and carb-containing fluids · Consider IV fluids if patient is unable to tolerate PO · Do not use glucagon for hypoglycemia while ketones present

· Sick day management RN teaching and education, in collaboration with Diabetes Nurse Educator

Monitoring · Ensure unused IV available for blood draws · Check serum BG and serum BOHB every 3 hours · If BOHB results unavailable after 30 minutes, check urine ketones · If serum glucose unavailable after 30 minutes or if concern for hypoglycemia, check fingerstick BG · Watch for signs of DKA (vomiting, persistent ketones not decreasing); evaluate for DKA (pH, electrolytes, BOHB) if signs are present BOHB 1.5 mmol/L* OR LARGE urine ketones within previous 1 hour

Insulin dose = insulin to cover carbs + insulin to correct glucose

Insulin dose = insulin to cover carbs + 1.5x(insulin to correct glucose)

Insulin dose = insulin to cover carbs + 2x(insulin to correct glucose)

Call inpatient provider to discontinue Sick Day Management (ED Sick Day calculator will discontinue after each one-time insulin dose is used) For questions concerning this pathway, contact: [email protected] © 2017 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

* If BOHB and urine ketone results differ, base correction dose on BOHB

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Hypoglycemia (Insulin-Related, Non-DKA) Management v. 5

Inclusion Criteria

Signs of hypoglycemia: pallor, sweating, shaking, irritability, confusion, or seizures

· Glucose LESS THAN 80 mg/dL · Patient receiving subcutaneous insulin (by pump or injection) or insulin in parenteral nutrition

! Notify Contact Provider for glucose < 60 mg/dL, OR cannot tolerate enteral intake with glucose < 80 mg/dL

Exclusion Criteria · Patient on IV continuous insulin infusions (including diabetic ketoacidosis (DKA))

Blood glucose less than 80 mg/dL identified

Patient safe to have simple carbohydrates administered orally or by feeding tube? NO

YES

Loss of consciousness ! or seizure with Call a glucose < 60 mg/dL? CODE BLUE

NO

YES

Treat hypoglycemia (oral)

Give simple carbohydrates

< 80 mg/dL

Check glucose 15 minutes post intervention

YES

Treat hypoglycemia (IV, IM) IV access

No IV access

Administer D10W bolus

Administer IM glucagon (may give up to 2 doses per episode)

Hold meal tray Age ≤ 5 years: 10 g (2.7 oz = 81 mL fruit juice) Glucose Age > 5 years: 15 g (4 oz fruit juice)

Continue glucose checks every 15 minutes Contact provider for plan. Provider decides to treat?

Glucose < 80 mg/dL

Check glucose 15 minutes post intervention

Glucose < 80 mg/dL, consider placing IV

Check glucose 15 minutes post intervention Check glucose every 30 minutes for 2 hours. Consider starting IV

Blood glucose 80 mg/dL or greater

Blood glucose 80 mg/dL or greater

Resume routine monitoring per physician order Cover carbohydrates in meal. Do not correct glucose value after hypoglycemia treatment.

Return to Home For questions concerning this pathway, contact: [email protected] © 2017 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Blood glucose 80 mg/dL or greater

If more than one hour until next meal give 10-15 carb snack without insulin coverage

Last Updated: January 2017 Next Expected Revision: May 2018

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Diabetes Emergency Department Workup Pathway Citation and Approval Approved August 2013 CSW Diabetes (Non DKA) Pathway Team: Endocrinology, Owner: Emergency Department (ED): Chief Resident: Chief Resident: Endocrinology Fellow: Endocrinology Fellow: Chief Medical Informatics Officer: Medical Unit Clinical Nurse Specialist: ED Clinical Nurse Specialist: Pharmacy:

Kate Ness, MD Anne Slater, MD Jeremiah Davis, MD Eric Johnson, MD Debika Nandi-Munshi, MD David Weary, MD Troy McGuire, MD Kristi Klee, DNP MSN RN CPN Elaine Beardsley, RN, MD Kara Niedner, PharmD

Clinical Effectiveness Team: Consultant: Project Manager: Data Analyst: Information System Analyst: Informatician: Librarian: Literature Reviewer: Program Coordinator:

Jen Hrachovec, PharmD MPH Jennifer Magin, MBA Suzanne Spencer, MBA MHA Heather Marshall Mike Leu, MD MH MHS Susan Klawansky, MLS Eileen Reichert, ARNP Ashlea Tade

Executive Approval: Sr. VP, Chief Medical Officer Sr. VP, Chief Nursing Officer

Mark Del Beccaro, MD Susan Heath, MN, RN, CNAA

Retrieval Website: http://www.seattlechildrens.org/pdf/ED-diabetes-non-DKA-pathway.pdf Please cite as: Seattle Children’s Hospital, Ness K, Slater A, Beardsley E, Klee K, Hrachovec JB, Leu MG, Magin J. 2013 August. Diabetes Emergency Department Workup Pathway. Available from: http://www.seattlechildrens.org/pdf/ED-diabetes-non-DKA-pathway.pdf

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Evidence Ratings This pathway was developed through local consensus based on published evidence and expert opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical Effectiveness, and other services as appropriate. When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.): Quality ratings are downgraded if studies: · Have serious limitations · Have inconsistent results · If evidence does not directly address clinical questions · If estimates are imprecise OR · If it is felt that there is substantial publication bias Quality ratings are upgraded if it is felt that: · The effect size is large · If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR · If a dose-response gradient is evident Guideline – Recommendation is from a published guideline that used methodology deemed acceptable by the team. Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE criteria (for example, case-control studies).

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Summary of Version Changes · · · · · · · · ·

Version 1 (5/21/2013): Go live Version 1.1 (8/20/2013): Sick Day Management added Version 1.2 (8/22/2013): ED wording changes, clarified sick day lab orders Version 2.0 (2/10/2014): Sick Day Management: added a yellow alert triangle to for a remind to initiate Version 3.0 (7/30/2014): Established Diagnosis: added guidance and recommendations for unreliable oral intake (Post-op, NPO) or vomiting Version 3.1 (10/9/2014): Established Diagnosis: added basal insulin to Unreliable Oral Intake or NPO for clarity Version 4.0 (3/30/2015): Perioperative Management added Version 4.1 (10/25/2016): Added warning triangle to hypoglycemia page Version 5 (1/6/2017): Rapid-acting insulin to be given at 0300 (removed instructions to give only if glucose >300mg/dL)

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Medical Disclaimer Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision.

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Bibliography Literature Search Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Susan Klawansky. Searches were performed in December 2012 in the following databases – on the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere: Embase, Clinical Evidence, National Guideline Clearinghouse and TRIP. Retrieval was limited to 2007 (date of then-current ISPAD guideline) to date, humans, and English language. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases as appropriate. Concepts searched were type 1 diabetes mellitus and ketones, ketone bodies, keto acids, hyperglycemia, hospitalization, inpatients. All retrieval was further limited to certain publication types representing high order evidence. Additional articles have been identified by project team members and added to the retrieval. Susan Klawansky, MLS, AHIP May 16, 2013 Identification 255 records identified through database searching

14 additional records identified through other sources

Screening 269 records after duplicates removed

268 records screened

160 records excluded

Eligibility 108 records assessed for eligibility

65 full-text articles excluded, 20 did not answer clinical question 29 did not meet quality threshold 16 outdated relative to other included study

Included 43 studies included in pathway Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

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Bibliography This pathway was developed primarily based on: American Diabetes A. Diagnosis and classification of diabetes mellitus. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S67-74. Accessed 20121224; 3/14/2013 6:01:49 PM. http:// dx.doi.org/10.2337/dc13-S067. American Diabetes A. Standards of medical care in diabetes--2013. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S11-66. Accessed 20121224; 3/14/2013 6:01:49 PM. http:// dx.doi.org/10.2337/dc13-S011. IDF/ISPAD 2011 Global Guideline for Diabetes in Childhood and Adolescence, available at http://www.ispad.org/resources/idfispad-2011-global-guideline-diabetes-childhood-andadolescence, last accessed 5/10/2013. ISPAD Clinical Practice Consensus Guidelines Compendium 2009 (Pediatr Diabetes 2009; 10 (Suppl 12): 1-210).

This supporting literature was also cited: Executive summary: Standards of medical care in diabetes--2013. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S4-10. Accessed 20121224; 3/14/2013 6:01:49 PM. http:// dx.doi.org/10.2337/dc13-S004. Summary of revisions for the 2013 clinical practice recommendations. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S3. Accessed 20121224; 3/14/2013 6:01:49 PM. http:// dx.doi.org/10.2337/dc13-S003. National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes for Children, Adolescents and Adults. . http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ ext004_type1_diabetes_children_adolescents_adults.pdf. Updated 2011. Exubera: Inhaled insulin for diabetes. Drug Ther Bull [Insulin Dosing]. 2007;45(1):5-8. Lexi-Comp pediatric and neonatal Lexidrugs: Glucagon. . http://www.crlonline.com/lco/action/ doc/retrieve/docid/pdh_f/130114. Accessed 3/14/13, 2013. American Diabetes A, Clarke W, Deeb LC, et al. Diabetes care in the school and day care setting. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S75-9. Accessed 20121224; 3/14/ 2013 6:01:49 PM. http://dx.doi.org/10.2337/dc13-S075. American Diabetes A, Lorber D, Anderson J, et al. Diabetes and driving. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S80-5. Accessed 20121224; 3/14/2013 6:01:49 PM. http:// dx.doi.org/10.2337/dc13-S080. Aschner P, Horton E, Leiter LA, Munro N, Skyler JS, Global Partnership for Effective Diabetes,Management. Practical steps to improving the management of type 1 diabetes: Recommendations from the global partnership for effective diabetes management. Int J Clin Pract [Insulin Dosing]. 2010;64(3):305-315. Accessed 12/7/2012 7:01:01 PM. Betts P, Brink S, Silink M, Swift PG, Wolfsdorf J, Hanas R. Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes. 2009;10(Suppl 12):169-174. Accessed 20090916. http://dx.doi.org/10.1111/j.1399-5448.2009.00579.x.

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Bibliography Brink S, Laffel L, Likitmaskul S, et al. Sick day management in children and adolescents with diabetes. Pediatr Diabetes [Insulin Dosing]. 2009;10(Suppl 12):146-153. Accessed 12/10/ 2012 4:06:58 PM. Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatric Diabetes [Insulin Dosing]. 2009;10:134-145. Davidson PC, Hebblewhite HR, Steed RD, Bode BW. Analysis of guidelines for basal-bolus insulin dosing: Basal insulin, correction factor, and carbohydrate-to-insulin ratio. Endocr Pract [Insulin Dosing]. 2008;14(9):1095-1101. Accessed 12/7/2012 7:01:01 PM. Edge J, Ackland FM, Payne S, et al. Inpatient care for children with diabetes: Are standards being met?. Arch Dis Child [Insulin Dosing]. 2012;97(7):599-603. Accessed 12/3/2012 5:01:19 PM. Elisaf MS, Rizos EC. Editorial: Current topics on the epidemiology, pathogenesis, and treatment of diabetes mellitus and its complications. Curr Vasc Pharmacol [Insulin Dosing]. 2012;10(2):138-139. Accessed 12/7/2012 7:01:01 PM. Fendler W, Hogendorf A, Szadkowska A, Mlynarski W. Non-coding glucometers among pediatric patients with diabetes: Looking for the target population and an accuracy evaluation of nocoding personal glucometer. Pediatr Endocrinol Diabetes Metab [Insulin Dosing]. 2011;17(2):57-63. Gosden C, Edge JA, Holt RI, et al. The fifth UK paediatric diabetes services survey: Meeting guidelines and recommendations?. Arch Dis Child [Insulin Dosing]. 2010;95(10):837-840. Accessed 12/7/2012 7:01:01 PM. Grajower MM. Management of diabetes mellitus on yom kippur and other jewish fast days. Endocr Pract [Insulin Dosing]. 2008;14(3):305-311. Accessed 12/7/2012 7:01:01 PM. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S100-8. Accessed 20121224; 3/14/2013 6:01:49 PM. http://dx.doi.org/10.2337/dc13-S100. Hanberger L, Samuelsson U, Bertero C, Ludvigsson J. The influence of structure, process, and policy on HbA(1c) levels in treatment of children and adolescents with type 1 diabetes. Diabetes Res Clin Pract [Insulin Dosing]. 2012;96(3):331-338. Accessed 12/7/2012 7:01:01 PM. http://dx.doi.org/10.1016/j.diabres.2012.01.016. Jonsson L, Hallstrom I, Lundqvist A. A multi-disciplinary education process related to the discharging of children from hospital when the child has been diagnosed with type 1 diabetes--a qualitative study. BMC Pediatr [Insulin Dosing]. 2010;10:36. Accessed 12/7/ 2012 7:01:01 PM. Kaufman FR, Devgan S, Roe TF, Costin G. Perioperative management with prolonged intravenous insulin infusion versus subcutaneous insulin in children with type I diabetes mellitus. J Diabetes Complications. 1996;10(1):6-11. King AB. Continuous glucose monitoring-guided insulin dosing in pump-treated patients with type 1 diabetes: A clinical guide. J Diabetes Sci Technol [Insulin Dosing]. 2012;6(1):191203. Accessed 12/7/2012 7:01:01 PM. King AB. Re: Analysis of guidelines for basal-bolus insulin dosing: Basal insulin, correction factor, and carbohydrate-to-insulin ratio. Endocr Pract [Insulin Dosing]. 2009;15(4):383. Accessed 12/7/2012 7:01:01 PM.

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Bibliography King AB. Re: Analysis of guidelines for basal-bolus insulin dosing: Basal insulin, correction factor, and carbohydrate-to-insulin ratio. Endocr Pract [Insulin Dosing]. 2009;15(4):383. Accessed 12/ 7/2012 7:01:01 PM. Lassmann-Vague V. Clavel S. Guerci B. Hanaire H. Leroy R. Loeuille GA. Mantovani I. Pinget M. Renard E. Tubiana-Rufi N. Societe francophone du diabete (ex ALFEDIAM). When to treat a diabetic patient using an external insulin pump. expert consensus. societe francophone du diabete (ex ALFEDIAM) 2009. Diabetes Metab [Insulin Dosing]. 2010;36(1):79-85. Accessed 12/7/2012 7:01:01 PM. Leelarathna L, Guzder R, Muralidhara K, Evans ML. Diabetes: Glycaemic control in type 1. Clin Evid (Online) [Insulin Dosing]. 2011;2011:0607. Lopes Souto D, Paes de Miranda M. Physical excercises on glycemic control in type 1 diabetes mellitus. Nutr Hosp [Insulin Dosing]. 2011;26(3):425-429. Accessed 12/3/2012 5:01:19 PM. Margeirsdottir HD, Larsen JR, Kummernes SJ, Brunborg C, Dahl-Jorgensen K. The establishment of a new national network leads to quality improvement in childhood diabetes: Implementation of the ISPAD guidelines. Pediatr Diabetes [Insulin Dosing]. 2010;11(2):88-95. Accessed 12/7/ 2012 7:01:01 PM. Matthews JB, Staeva TP, Bernstein PL, Peakman M, von Herrath M, ITN-JDRF Type 1 Diabetes Combination Therapy Assessment,Group. Developing combination immunotherapies for type 1 diabetes: Recommendations from the ITN-JDRF type 1 diabetes combination therapy assessment group. Clin Exp Immunol [Insulin Dosing]. 2010;160(2):176-184. Accessed 12/7/ 2012 7:01:01 PM. McIver FB, Mitchell CA, Finn CP, Kamp MC. Standardising practices through form design and education improves insulin management. Aust Health Rev [Insulin Dosing]. 2009;33(3):434441. Mooradian AD, Bernbaum M, Albert SG. Narrative review: A rational approach to starting insulin therapy. Ann Intern Med [Insulin Dosing]. 2006;145(2):125-134. Accessed 20060718; 3/13/ 2013 7:38:54 PM. National GC. Standards of medical care in diabetes. V. Diabetes care. . http://guideline.gov/ content.aspx?id=35248&search=diabetes+and+%22type+1%22+and+ketosis;. National GC. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. . http://guideline.gov/ content.aspx?id=35255&search=diabetes+and+%22type+1%22+and+hyperglycemia;. Pratoomsoot C, Smith HT, Kalsekar A, Boye KS, Arellano J, Valentine WJ. An estimation of the long-term clinical and economic benefits of insulin lispro in type 1 diabetes in the UK. Diabet Med [Insulin Dosing]. 2009;26(8):803-814. Accessed 12/7/2012 7:01:01 PM. Reiter J, Wexler ID, Shehadeh N, Tzur A, Zangen D. Type 1 diabetes and prolonged fasting. Diabet Med [Insulin Dosing]. 2007;24(4):436-439. Rhodes ET, Ferrari LR, Wolfsdorf JI. Perioperative management of pediatric surgical patients with diabetes mellitus. Anesth Analg. 2005;101(4):986-999. Russell-Minda E, Jutai J, Speechley M, Bradley K, Chudyk A, Petrella R. Health technologies for monitoring and managing diabetes: A systematic review. J Diabetes Sci Technol [Insulin Dosing]. 2009;3(6):1460-1471. Accessed 12/7/2012 7:01:01 PM. Sacks DB, Arnold M, Bakris GL, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem [Insulin Dosing]. 2011;57(6):e1-e47. Accessed 12/4/2012 1:32:58 PM. To Bibliography, Pg 3

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Bibliography Scheiner G, Sobel RJ, Smith DE, et al. Insulin pump therapy: Guidelines for successful outcomes. Diabetes Educ [Insulin Dosing]. 2009;35(Suppl 2):29S-41S. Shogbon AO, Levy SB. Intensive glucose control in the management of diabetes mellitus and inpatient hyperglycemia. Am J Health-Syst Pharm [Insulin Dosing]. 2010;67(10):798-805. Accessed 12/4/2012 1:32:58 PM. Tonella P, Fluck CE, Mullis PE. Metabolic control of type 1 diabetic patients followed at the university children's hospital in berne: Have we reached the goal?. Swiss Med Wkly [Insulin Dosing]. 2010;140:w13057. Accessed 12/7/2012 7:01:01 PM. http://dx.doi.org/10.4414/ smw.2010.13057. Vigeral C, Sola-Gazagnes A, Nejjar S, et al. Ambulatory 24-hour fast using flexible insulin therapy in patients with type 1 diabetes. Diabetes Metab [Insulin Dosing]. 2011;37(6):553-559. Accessed 12/7/2012 7:01:01 PM.

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