Patient Safety - Ask the Experts - Discussion Forum

Patient Safety - Ask the Experts - Physician's Corner Q&A



Question from Maria Gomes MD :

I use insulin-glucose infusions extensively in the care of diabetic patients in hospital settings. I notice that when moving patients from the intensive care unit to the telemetry unit in our hospital, it is not uncommon that the nurses make mistakes in handling the infusion, which works so well in the ICU setting. I think the problem is the poor training of the nurses, and I am sometimes frustrated because it is hard to teach them how to best handle the infusions.


Answer from Richard Hellman, MD, FACP, FACE:

You have correctly focused on what is an all too common problem in hospitals today. In a study by Peter Pronovost, a study that collected data from more than 100 hospitals in 3 different countries, it was reported that only 58% of the supervisors felt that their trainees had adequate knowledge and had adequate education and supervision. In order to promote safety in all clinical settings, it is key that we closely examine the education program of those who care for our patients. The solution, in this case, would be to provide more robust educational formats to both initially train the nurses, evaluate their knowledge in this area, and provide refresher courses in order to help them use these algorithms correctly.


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Wrong Direction

Question from Howard Rosen MD, FACE:

I have often seen hypoglycemia develop in the hospital setting because patients receive insulin and then are transported by the transportation department to another part of the hospital and become hypoglycemic in another part of the hospital. What is the best way to deal with this problem?


Answer from Richard Hellman, MD, FACP, FACE:

Unfortunately the problem you have brought up is extremely common. Dr. David Bates, a leading patient-safety expert in Boston, has stated that the example you gave represents one of the most common causes of hypoglycemia in hospital settings. Another related problem is when, after insulin is given, a meal is either delayed or sent by mistake to some other room. In both cases there is an imbalance between insulin and the meal, and hypoglycemia results. In order to promote a culture of safety within the clinical unit, it is necessary that people discuss how to best coordinate their responsibilities. Everyone needs to communication better with each other if these common problems are to be eliminated. In dedicated diabetes units, these problems can and have been completely eliminated merely by better communication and education of all of the people involved in patient care.


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Information on new drugs

Question from Kent Ishihara, MD (AACE Member):

As a practicing endocrinologist, I find that I often need information on new drugs, about which we have little joint experience because they were just approved by the FDA, but the FDA does not provide that initially. How can we improve this?


Answer from Richard Hellman, MD, FACP, FACE:

This is a very important problem which highlights the shortcomings of the present method of drug approval in the United States. There is good evidence to show that the risk-benefit ratio of drugs varies widely with different comorbid or demographic groups. Often, because of changes in drug metabolism because of age or comorbid conditions, the drug dosage, usefulness, and safety may be different. One option, used in some countries, is to have a “limited roll-out”, that is, a drug is approved conditionally but is identified as a new drug so people understand that there is limited data, and it may have different recommendations attached to it just because of the newness. Other suggestions that have been made include developing a robust drug registry so that professional medical societies can rapidly evaluate the drug’s performance regarding quality and safety among different subgroups. This approach is being developed by the American College of Cardiology and might well be something our society may consider, either alone or in conjunction with other organizations.


Patient Safety - Ask the Experts - Allied Health Professional's Corner Q&A


Which 'Type' is it?

Question from Janice Monachino, BSN, CDE:

A good deal of my work is done in hospital settings, teaching diabetes care. I am troubled by the fact that often the nurses caring for the patients are far from clear as to what the difference is between Type 1 and Type 2 diabetes. They particularly have a problem with elderly patients with Type 1 diabetes, in which they seem to think the age of the patient precludes that the person is totally insulin-dependent. Is this a widespread problem?


Answer from Richard Hellman, MD, FACP, FACE:

Yes it is. But there seems to be considerable evidence that patients are becoming more generally educated about diabetes, in large part because of the increased interest in the media, and also in part because of the internet and the wealth of information immediately available, much of which is inaccurate, but some is excellent. Unfortunately, there is currently less attention paid to diabetes education in the basic curriculum of both nurses and medical students. Diabetes is a disease which costs consume more than 1/6 of the entire health care budget, but the amount of attention paid to it in both education and health policy seems inadequate. We need to do a better job of building the knowledge base of those who come in contact with patients with diabetes and who care for them. The American Association of Clinical Endocrinologists is happy to work with other organizations and other providers of health care to provide a more comprehensive approach to the care of diabetes. It is always worthwhile to remind ourselves that complex subjects, such as diabetes care, are best handled by people who have both knowledge, interest, and experience in these matters, and the development of a team approach to diabetes care has proven to be most effective.




Carbohydrate counting skills

Question from Melissa White, MS, RD, CDE:

So often, when I meet with patients on insulin pumps, their carbohydrate counting skills prove to be very deficient. As a result, they often have very high and variable blood glucose levels. Is this a common problem nationwide?


Answer from Richard Hellman, MD, FACP, FACE:

Indeed it is. Carbohydrate counting is not easy, since it depends in part of the proper analysis of portion size, as well as knowledge of the composition of various foodstuffs. Even the most expert can sometimes make mistakes. An alternate strategy, which is outlined in the 2007 AACE Guidelines for Diabetes on the section of Medical Nutrition Therapy, is having consistent carbohydrate amounts at a given meal. If a patient is willing to do this, this can be just as effective, if not more so, because it is easier to teach and easier to remember. Both techniques can be highly effective, but often the choice of technique has to be matched with the skills, interests, and knowledge of the particular patient.



Information on new drugs

Question from Debra McConville, APRN, BC, CDE:

So often, I see patients referred from other physicians who have widely fluctuating blood glucose levels, despite large doses of insulin and multiple oral agents. Yet, it seems as if their basic knowledge is often minimal, particularly regarding dietary issues. Is there a more systematic approach to such patients?


Answer from Richard Hellman, MD, FACP, FACE:

Unfortunately, though diet and exercise is always the base from which we should start planning the care of people with diabetes, both patients and doctors often forget this. It is easier to prescribe a pill than change one’s lifestyle. A patient can out-eat any therapy for diabetes. On the other hand, for an obese Type 2 patient, quite often a weight loss of 15 pounds may greatly reduce hyperglycemia and may eliminate the need for a good deal of the glucose-lowering therapy the patient is on. A stepwise approach to medical therapy is often best, and both the American Association of Clinical Endocrinologists and the American Diabetes Association have rational approaches to how to select the initial agent, the proper interval to wait before beginning another, and the alternatives that are available so that the scenario you have described is avoided.


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Patient Safety - Ask the Experts - Patient's Corner Q&A


Some assembly required

Question from "M.L.":

Yesterday I was in my doctor’s office. I am on an insulin pump. My blood sugars had been too high and my doctor wanted to change the basal rates of insulin, but I could not remember how to do this and the doctor also did not know how to do this. We finally found a nurse in the office who did know, and I also called a help number from the company and together they helped me find the doses so they could be changed. Is this a common problem?


Answer from Richard Hellman, MD, FACP, FACE:

Unfortunately, it is becoming an increasingly common problem. As the insulin pumps become more sophisticated, we are seeing, nationwide, more problems resulting from pumps that are not understood by either the patient or the doctor. Many patients are being put on insulin pumps after only a few hours of initial education, and they do not realize the potential risks to them if they make a serious mistake in the use of their pump.


The American Association of Clinical Endocrinologists holds an annual hands-on teaching session for our endocrinologists just finishing their training. But we need to provide even more educational and re-education opportunities for our doctors. Unfortunately, many non-specialist physicians have neither the time nor the support staff to provide this service for the patients.


Likewise education needs to be tailored to the needs of the patient and their family. Re-education is essential, but since only some patients will benefit from the on-line tutorials, which are generally available, I recommend that much of it be face-to-face. Coordination of care for the patient with diabetes on an insulin pump in many countries, such as in France, is done primarily by expert multidisciplinary teams of diabetes specialists. There are examples of such programs available in the United States, and they do an outstanding job of educating both the team and the patient and their family. There needs to be more of these multidisciplinary diabetes groups in order to provide better protection for our patients. Unfortunately, policy planners and payors have not yet understood that it is not enough to provide an insulin pump, they also need to pay for both your education and re-education; It is essential that your pump use can be completely integrated into your care so the pump can be used both safely and effectively to keep your glucose levels in the optimal range.




Short-acting and long-acting insulin

Question from "L.G.":

Sometimes I accidentally give short-acting insulin instead of long-acting insulin and my blood sugar gets too low? What should I do?


Answer from Richard Hellman, MD, FACP, FACE:

The first thing to do is to check your glucose level to see whether it is too high, in the normal range, or too low. If it is already low, I would give glucose tablets or another rapidly absorbed carbohydrate dose immediately and call your doctor for advice. Your doctor will decide, based on how sensitive you are to the effect of insulin, how much insulin you gave, the time of the day, your calorie intake and activity, as to how much replacement carbohydrate to take, how many hours to continue checking, and when it is safe to take your long-acting dose. If your glucose is elevated, you can call your doctor first. But is your glucose is in the normal range, taking some carbohydrate and then calling is also prudent.


After the episode is successfully treated, we then need to examine why this happened, so as to prevent it from happening again. Sometimes the mistake happens when people are in a hurry and don’t look closely at the bottle of insulin. It is always good to make a habit of rechecking the label of bottle and the dosage of insulin at least once. Sometimes the mistake may be due to the lighting being poor, or it may indicate your vision may not be as good as it has been. Please discuss this with your doctor or other health professional. It is very important to make it very unlikely that this mistake ever occurs again. Insulin is a very powerful drug, and safety matters.



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Patient Safety - Ask the Experts - Discussion Forum


Byetta and Patient Safety

Question from J.A. MOORE:

I have been taking Byette and have a nightly pain which the Dr says is my stomach. I am overweight and have high triglycerides. The Drs ran all kinds of tests on my gall bladder xrays plus other tests....including nuclear meds test. Gall bladder tests turned up negative. Then the Gastro Drs said it must be the valve on the stomach that's weak on diabetics and they gave me some medicine that kept me going to the toliet. I quit the medicine after almost a week of torture. But I took 3-Omega Oils capsules 3 times a day and Liptor and Tricore. My lipids were tested two weeks ago and the pain is gone and my Lipids very low in normal range with one type being under the allowable rate but my Endo Dr said that was OK. SHOULD I WORRY THAT I may have or had pancreatitis? I am still taking the Byette plus Metformin and Lantus..


Answer from Richard Hellman, MD, FACP, FACE:

Dear J.A. Moore,


Your question about Byetta and your nightly pain, which your doctor says is from your stomach, is a very important one, and thank you for asking it. It is not clear as to whether you are free of abdominal pain at this time. If you are pain free at this time, it may be difficult to be sure as to why you had pain in the past. If you are still having nightly pain, then my comments may be more relevant. Since I am not your doctor, I do not know enough about you to make a diagnosis or offer therapy, but I hope I can be helpful in some general suggestions. As we get older, the risk that a pain in the abdomen is a serious medical condition increases. But resistant pain in the abdomen can be from many causes: infections, such as a H.Pylori infection of the stomach, inflammation, such as pancreatitis, or a disease of the intestine called Crohn's disease, motility problems, such as gastroparesis, and other possibilities, vascular problems such as abdominal aneurysms, and also tumors, such as cancers of the stomach and of the pancreas. But there are other, much more common and simple problems, such as irritability of the gastrointestinal tract either due to drugs, such as metformin, or conditions as irritable bowel syndrome. I certainly could not tell from what you have said whether your problem is any of the above, or whether it is or was related to byetta.


But I think your questions are right-on and you should find out why you have had pain and whether it has anything to do with either byetta or to metformin. Your doctor should be able to do some screening tests for pancreatitis, and gastroenterologists can answer other of your questions, but I would encourage you to proceed to ask your health providers to answer your excellent questions.


You should also note that in the editorial I wrote on byetta, I discussed the responsibility of doctors to answer questions of this type. Thank you again for your excellent question. I hope I have been helpful.


Read the Original Article - Byetta and Patient Safety



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Inpatient insulin infusion pumps

Question from Siobhain McHale:

There is a need for policy and procedure to be written if one is to allow an inpatient to keep their insulin infusion pump while in the hospital.


Are there any hospitals that have policies and procedures in place that would allow inpatient's to keep their insulin infusion pumps and use them during their hospital stay? Is there any precedent or research that either supports this practice or is there literature that this would be too risky?


Answer from Irl B. Hirsch, MD:

As insulin pump use continues to grow, not only in the US but around the world, this topic is receiving much more attention. Currently, there is no standard on how to best deal with CSII in the hospital setting. Importantly, there are no randomized trials (to my knowledge anyway) using CSII in patients receiving outpatient pump therapy and assessing subsequent outcomes when continued on their pump.


The situation is complicated by the degree of illness (and cognition) by the patient and therefore level of potential for self-care and the level of comfort of insulin therapy in general and CSII in particular by the treating physician. Often the treating physician in the hospital has little to no experience with CSII further complicating what the best practice may be. On top of the typical patient on a medical floor, there are futher issues to consider for the patient in surgery if the anesthesiologist is not familiar with CSII.


With this background, each hospital needs to have a written policy on how to best handle patients using CSII. There are many potential options. In my hospital for example if the patient is able to self-mange his or her diabetes we simply allow the patient to handle the insulin with the nurse recording all insulin bolus insulin for the medical record. Other hospitals require automatic referral to an endocrinologist or endocrine team (which often includes a nurse or nurse practitioner with expertise in CSII). I have also seen hospital policy demand the patient remove the pump and instead move to multiple injections (often a "sliding scale" mentality with no scheduled insulin). Obviously, this is doomed to failure. If a decision is made to stop the pump and instead use multiple injections, at the very least basal insulin (glargine or detemir) and prandial insulin (rapid acting analogue) should be the approximate doses used with the pump.


This deserves more study but due to such variability in the understanding of insulin and CSII, any study may be difficult to interpret in the "real world".


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