HgbA1c 18.2 - Insulin Initiation - Avg LOS?

core0 · Jun 9, 2007

[Originally I posted this in the case mgmt forum, but got no response. I know I can count on you guys! :) ]
I am working on a paper and trying to evoke the idea that it is not appropriate to start a patient on insulin and discharge them home the same day from the hospital.
Here's the situation:
I am with a hospitalist group right now (as an ACNP student) and we were consulted on a surgical patient (bilateral orchiectomies r/t CA) with poorly controlled DMII. His HgbA1c came back 18.2, so obviously, his current regimen is not working. We initiated 70/30 and the MD was planning on discharging him home later that same day. As I'm still a student, I don't have much say, yet, but we ended up being able to keep him an additional day because the surgeon agreed (he was the primary).
Research doesnt really give me any comparison on avg LOS for insulin teaching in the hospital, and I have failed to successfully manipulate the CMS website to find the information. I have found, however, that there are certain tasks/knowledge a patient with DMII must comprehend prior to discharge from the hospital, including the "7 Survival Skills." If I can't get any numbers, I'll just base the paper on the idea that you cannot properly assess effectiveness of insulin and ensure competency of the patient within the same date of initiation.
FYI: This particular patient is a 75 yr old Spanish-speaking only patient, that had "never" been taught proper nutrition or DM management, per his report. Case mgmt was getting his Medicare set up because he had never applied for it (or however you go about getting it). We were also working to set him up with outpatient diabetes education and home health. I was thinking those of you with your extensive Medicare expertise would know the avg LOS covered for a 75 yo patient admitted with a secondary diagnosis of Uncontrolled DMII, and initiation of insulin that he is to continue using at home. He lives alone, but has a positive support system and I believe a family member would be able to learn how to help manage his DMII.
Thanks!!

Insulin teaching doesn't usually affect the length of stay. You can do everything past the admission as an outpatient. What really matters for the patient to go home is are they stable enough. While a A1c of 18 is fairly shocking it is not unknown. This converts to a blood sugar of over 500. Sadly there are diabetics that function at that level. As long as he is not ketotic you could probably go either way. The key would be good follow up with both the diabetes educators and his PCP. The other key is that his admission wasn't for DMII it was for surgery so he really doesn't fall into this category unless he was symptomatic.

David Carpenter, PA-C

DaisyRN, ACNP · Jun 9, 2007

hey david,

i guess what bothers me (now i'm still a student, coming from an outpatient setting last semester that focused a great deal on diabetic education, so that may be part of my inner conflict), is the idea of this guy going home on insulin without the education he needs to ensure at least minimal competency. i could just imagine him saying, oh i need 30 units and perhaps reading the little numbers wrong, see's "80" as a "30" and ods on insulin, or gives it without eating, or whatever. i'm probably just being too cautious... i guess it'd be different if he weren't spanish-speaking only, 75 years old, only checking his bss 3x a month, and lived alone.

core0 · Jun 9, 2007

hey david,
i guess what bothers me (now i'm still a student, coming from an outpatient setting last semester that focused a great deal on diabetic education, so that may be part of my inner conflict), is the idea of this guy going home on insulin without the education he needs to ensure at least minimal competency. i could just imagine him saying, oh i need 30 units and perhaps reading the little numbers wrong, see's "80" as a "30" and ods on insulin, or gives it without eating, or whatever. i'm probably just being too cautious... i guess it'd be different if he weren't spanish-speaking only, 75 years old, only checking his bss 3x a month, and lived alone.

i didn't say any education. if he gets an hour or two in the appropriate language that will probably do. in our hospitals the dm educators see them the same day and do the inpatient teaching. they go over dosing with the family and get them comfortable with injections. in this guys case i would definitely have the family work with him. you have to look at what the gain is. if you keep him in the hospital for two weeks with daily teaching he will probably have a better understanding. however, is it really any safer. if he gets initial teaching in the hospital and then good close follow up with his pcp and dm educator there is no reason he can't go out same day as long as he is not symptomatic. while it would feel better to keep someone in the hospital for the necessary education, thats not the environment that we live in. i would think that home nursing once per day. f/u with dm in 2-3 days and pcp that week would be the ticket. you hopefully would be able to get home visits covered. also, i don't do hospitalist but i would think that he would be better served with long acting plus short acting insulin. if hes not on metformin also he should be. with the current debate over actos/avandia i would like to know his cardiac status before doing those meds (ie i would be cautious in a 75yo).

just my thoughts

david carpenter, pa-c

Trauma Columnist · Jun 9, 2007

It seems to me that you should be doing the education regarding the oral agents and diet first prior to starting insulin. I work in the outpatient setting and had a Spanish-only speaking gentleman who I was almost ready to put on insulin. However, when I got him rudimentary Spanish language teaching for diet, exercise and medication, his hgb A1C went from 13 to 6.5 in less than three months.

My point is that since he is noncompliant with oral agents and diet, what makes the ordering provider think insulin will help? Its only going to be something else that he won't be compliant about.

As to length of stay, I start insulin in the outpatient setting if I can provide the education. Otherwise, I set them up with our Diabetic Resource Center. Medicare will pay for a couple of visits for teaching. Another avenue is home health for teaching.

Good luck - you are looking in the right direction - to provide your patient with the best care possible.

DaisyRN, ACNP · Jun 9, 2007

hey, yea, i'm sorry... i didnt mean to imply you said no education. i wasnt meaning that we should keep him for 2 wks, i was thinking more like 24 additional hours, just to monitor the insulin response and allow for diabetic teaching the first day with nutritionist as well, and then f/u from the diabetic educator the next day to make sure the patient was able to appropriately return demo the insulin inj. and important info. other than that, i think your plan was right on target with what i was thinking... we set this guy up with home health (which actually i think medicare will cover hh indefinitely if patients are unable to self medicate or have family to do it competently). and outpatient ed.

as for oral/diet therapy... yes, this guy had been a diabetic for 10 yrs? i think... and was on glucovance. my preceptor told me, "if the oral hypoglycemics aren't working, then just stop them all together and use insulin instead." um. i don't know about ya'll, but i know this is not current evidence based care nor standard of care, but i'm just a student. hopefully his pcp will get it figured out. also, the day before discharge, the fnp for the group saw the patient and ordered glucovance, the same day he started the insulin, and the next day... his fasting bs was 102 vs. the 300s it had been. so, i think this shows that together, the oral/insulin combo worked. and yet, when it came time to send him home, my precept dc'd his glucovance. :nono:

also, his cardio status was great... he was otherwise healthy.

i didn't say any education. if he gets an hour or two in the appropriate language that will probably do. in our hospitals the dm educators see them the same day and do the inpatient teaching. they go over dosing with the family and get them comfortable with injections. in this guys case i would definitely have the family work with him. you have to look at what the gain is. if you keep him in the hospital for two weeks with daily teaching he will probably have a better understanding. however, is it really any safer. if he gets initial teaching in the hospital and then good close follow up with his pcp and dm educator there is no reason he can't go out same day as long as he is not symptomatic. while it would feel better to keep someone in the hospital for the necessary education, thats not the environment that we live in. i would think that home nursing once per day. f/u with dm in 2-3 days and pcp that week would be the ticket. you hopefully would be able to get home visits covered. also, i don't do hospitalist but i would think that he would be better served with long acting plus short acting insulin. if hes not on metformin also he should be. with the current debate over actos/avandia i would like to know his cardiac status before doing those meds (ie i would be cautious in a 75yo).

just my thoughts

david carpenter, pa-c

DaisyRN, ACNP · Jun 9, 2007

wow, that's great he responded so well. i think that education is the key here. i dont think anyone had ever taken the time to appropriately teach him about diet/exercise/medication. i guess my take on the whole thing is its partly a role transition for me... i did outpatient last semester and now that i've started inpatient, i want to make sure they're taken care of at home... and its like you have more time to focus on education and how they're going to make those lifestyle adjustments in the outpatient settings. i know that the dm educators focus on these topics... but after that we refer them to their pcps and just hope it works out in the long run.

i'm learning how to change my thinking... and its not always easy. :)

it seems to me that you should be doing the education regarding the oral agents and diet first prior to starting insulin. i work in the outpatient setting and had a spanish-only speaking gentleman who i was almost ready to put on insulin. however, when i got him rudimentary spanish language teaching for diet, exercise and medication, his hgb a1c went from 13 to 6.5 in less than three months.

my point is that since he is noncompliant with oral agents and diet, what makes the ordering provider think insulin will help? its only going to be something else that he won't be compliant about.

as to length of stay, i start insulin in the outpatient setting if i can provide the education. otherwise, i set them up with our diabetic resource center. medicare will pay for a couple of visits for teaching. another avenue is home health for teaching.

good luck - you are looking in the right direction - to provide your patient with the best care possible.