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Hyperglycemia <_____> in old patients is an
important correctable risk factor for inpatient morbidity and mortality.
Physician assistant filling the management void of inpatient diabetic and
hyperglycemic patient. Welcome to the Clinicians Round Table.
I am Lisa Dandrea, your host and with me today is Sue
Kling-Colson, a physical assistant with the Department of Internal Medicine at
the University of Michigan Health System. Today, we are discussing the
hospital intensive insulin program and the role of physician assistants for
management of diabetic and hyperglycemic patient.
Sue, you work with the team of internists and PAs and have
implemented an intensive insulin protocol for the management of the diabetic
and hyperglycemic inpatients, called HIIP. Why was this program initiated and
how does it work.
Is this program for the cardiothoracic surgery patients
It is expanded into cardiothoracic surgeries, transplant
surgeries, heart transplant, lung transplant, vascular surgery service, and a
couple of thoracic surgeries such as transhiatal esophagectomies and lung
And what about the other diabetic patients?
DR. LISA DANDREA:
And are the patients admitted to this program current
diabetics, or are all patients immediately in the program following surgery?
And how many providers are on your team?
And are the PAs hired with any specialized training or is
this on the job training?
It is all on the job training. A few of the PAs that are
working in this department are the nurse practitioners that have had a
certified diabetes education certificate, but it is not required.
So what are your protocols for treating the inpatient
The supervisor of my department, Dr. Roma Gyanchandani, she
developed an insulin infusion protocol. So when patients are in surgery and if
they have 2 consecutive blood sugars greater than 140 or one blood sugar
greater than 200, they are automatically started on the insulin infusion in the
OR and that continues they monitor the blood sugars based on the protocol
q.1h., q.2h., and the insulin infusion is continued as long as the patient is
needed or wean themselves off of it.
And how is that different from the management of the
diabetics in the other part of hospital?
So what’s your typical day?
We have usually a patient who probably about on average say
15 to 20 patients. We put the patient's up amongst the PAs will do sort of a
pre-round, will gather all their vitals and information and talk to the
patients, do our exam, and make any changes to their insulin regimen that we
see appropriate. Then we will round with one of our attending physicians
little later in the day, and at that time we will just go over the changes that
we have made. You know corroborating; just make some decisions ontougher
patients that kind of ensure about what we want to do with their insulin
What are the benefits of the patient participating in the
For both the stress-induced patients and the diabetic
patients, the studies have shown that this significantly reduces their risk of
infection, mortality from these surgeries, and their length of hospital stay.
A recent study from the hyperglycemia group at UCLA just documented a figure of
about 5 million dollars that they saved the hospital just from reducing length
of hospital stay for these patients. In the diabetic patients, I think there
is a big benefit for them if they were not under good control with their
diabetes preoperatively, this gives us an opportunity to figure out what their
insulin needs are or their, you know about a regimen for them to be and then
improve their A1c.
Do the PAs have any responsibility during the surgeries?
Not during the surgeries. No.
If you are just joining us, you are listening to The
Clinician's Round Table on ReachMD, The Channel for Medical Professionals. I
am Lisa Dandrea and I am speaking with Sue Kling-Colson, a physician assistant
with the department of internal medicine at the University of Michigan. We are
discussing the role of physician assistants for the management of diabetic and
hyperglycemic inpatients with their HIIP program.
Sue does the program offer any outpatient or followup care?
We do especially with the patients that we send home on a
different insulin regimen than what they came in on for a stress-induced
hyperglycemia, etc., requiring treatment after surgery and at the time of
discharge, we have an outpatient clinic and we try and see the patients that we
discharge home on a regimen at least once about 4 to 6 weeks after their
So you follow them there as well?
We do. And then we can bridge them to if it is
stress-induced hyperglycemic, we are seeing that they still need some insulin
to help control their blood sugars, we will transition them to a
endocrinologist or back to their primary care physician.
How about any other programs to help them manage their
diabetes? Do you guys do E-mail or place a website tools?
We don't do a lot of E-mail right now. We see patients from
all over the state and different areas of the country. So a lot of times we
will do phone followup with them. If they can't come back to our clinic, we
will talk to them a few times over the phone until they feel comfortable going
back to their primary care physician. We also have a diabetes center here at
the University of Michigan and we have diabetes educators and nutritionists and
they have type 1 and type 2 diabetes classes that we can set them up with if we
think they need more information about nutrition or the insulin or things like
Are there any other hospitals using this model?
There are quite a few other hospitals. We have a few others
in the area and a couple that we know of nationwide that we talk with often to
see if kind of different things that they are doing.
How is the patients benefited from the MDP 18 model that you
use in the hospital?
I think that we are able to be the complete diabetes
caregiver we can prescribe the insulin or the oral medications that they need
or we can also provide them with a lot of education. We are sort of a
physician and a certified diabetic educator combined. We can teach them about
their diet, their insulin regimen, the different types of insulin, and the
different meters and the different insulin products that are out there such as
the different pen devices.
And do you find that they are discharged quicker under your
That is what studies have shown. Yeah.
And what do you think the greatest value of a physician
assistant has brought to the endocrinology practice in terms of diabetes
With a new shift, I think in diabetes management in the
hospital, I think we provide diabetics with a great service. We can go into
detail with their insulin regimens and things that they have never been talked
to about in their past with their diabetes, what types of insulin they are on,
what type of different options there are out there for their insulin to improve
their control, and we can provide them with resources to set them up with an
endocrinologist. We have more time to spend with them in their inpatient
setting, they are kind of a captive audience at that point, so I think that a lot
of endocrinologists spend a lot of time in their outpatient setting and don't
have the opportunity to spend that time with the patient.
Can you tell us about any research projects that you are
currently involved in?
You know, we are trying to publish some data on our program
and we are trying to work with some companies on the continuous glucose sensors
to look at the efficacy of using those in our ICUs. There hasn't been any
studies done on the continuous glucose sensors. We don't know if certain
medications in the ICU might affect those sensors. If their efficacy and
accuracy is good in the ICU it would save a lot of workload for the techs and
nurses working with the insulin infusions in the ICUs if they won't have to be
checking the blood sugars you know q. hourly, with Chem <_____> and will
save the patient to finger pokes every hour, so we are working with some sensor
companies on that and then we are have a lot of other projects in the works.
So are you mostly just using insulin then when they are
We do try and use insulin most of the time we find with the
oral agents so many things can change. There are so many variables in the
inpatient setting that you can easily take away the oral agent once it has been
given to the patient. So we use insulin because it is a great healer, it
prevents inflammation, and it helps to get them under the tightest control,
give us the ability to change things as their picture changes in the hospital.
The future of this in the entire hospital is still in
question, but you guys are making some great changes in the postsurgical
patient and moving towards that goal it sounds like.
Yeah. Hoping to expand.
Can you tell us a little bit about how your supervising
physicians started the program and how it all came about?
When she first came to this University, she was asked by one
of the cardiothoracic surgeons after he had seen quite a few studies that
showed the benefits of having intense insulin therapy in cardiothoracic
patients. He came to Roma and asked her to start this program, and now when
she had worked on the insulin infusion protocol at previous facility and
brought that in and started working with a couple PAs initially to start the
Any nurse practitioners at all in your team?
We do have one nurse practitioner that works with us on the
DR. LISA DANDREA:
So where could people get more information about your
On the University Of Michigan website, there are different
clinics and we are under the Internal Medicine Department and then the
Endocrinology Department and then there is a link to our hyperglycemia program.