Primary Care Clinicians and Insulin
With Type 2 diabetes emerging as an epidemic, primary care clinicians need to become savvy at initiating and adjusting insulin. Given the nationwide shortage of endocrinologists, referring all patients on insulin for endocrine appointments is not realistic in most areas of the country.
Although the 2009 ADA guidelines recommend insulin as an early therapy to improve glycemic control, insulin continues to be started later than needed. It is often used as a "threat" to motivate patients to follow their meal plan and exercise. Unfortunately, years of such tactics have created a negative image for insulin, preventing its use by many patients who really need it. As diabetes professionals, we need to help the primary care community utilize insulin therapy appropriately.
At Sutter Medical Foundation, we recently implemented a multi-faceted program to support and educate primary care providers in initiating and managing insulin therapy. We think of our new system as "one stop shopping" for clinicians. Our Medical Director for Diabetes Education, Kimberly Buss, MD, MPH, along with our diabetes education team, has developed and implemented clear and concise outpatient insulin guidelines for typical patients with type 2 diabetes. These guidelines, which are evidence-based and referenced in the current literature, are available as a resource within our electronic medical record. They have also been published as "pocket guides" for provider easy reference.
Furthermore, these guidelines have been translated into order sets within our electronic medical record, so that insulin orders are generated based upon the guideline recommendations. This is a key component of the success of our new system. Even if the provider is not an expert on insulin, the guidelines and order sets make insulin orders easy.
The orders direct the clinician to the typical starting dose. For new basal insulin starts, for example, the guidelines recommend 10 units (or 0.1 u/kg for thin patients) of basal insulin, with instructions to titrate up one unit every night until fasting blood sugars are less than 130 or hypoglycemia develops. All new prandial insulin starts recommend either initiating an insulin-to-carbohydrate ratio of 1:15 or beginning a fixed dose of four units of rapid acting insulin with each meal, instructing the patient to eat a consistent carbohydrate diet. Both options include the addition of a correction factor that starts at 1:50. Twelve coordinating patient handouts have been written especially for Sutter Medical Foundation and are available within the electronic medical record for printing and distribution to patients.
In addition, automatic referral for diabetes education by a Certified Diabetes Educator is included in the electronic medical record standard orders. The CDEs in the patient education department assist the clinicians with insulin starts, insulin adjustment, and patient follow-up. We have also provided continuing education opportunities for our staff and our Diabetes Nurse champions (nurses in our care centers with diabetes-specific training in insulin administration and meter instruction). Utilizing the electronic medical record helps to improve this process, with standardized documentation immediately routed to the provider.
We hope that this new tool will do the following:
- Increase the comfort level of primary care physicians in the use of insulin
- Allow earlier initiation of insulin
- Provide up-to-date education on contemporary insulin strategies
About 100 providers have been educated to date, and the electronic medical record tools are set are to "go live" this summer. I encourage other diabetes professionals to reach out to primary care providers and partner with them to improve the quality of care for our patients with diabetes.
This project would not have been possible without the passion and dedication of Dr. Buss. Enthusiasm has spread throughout our system and is creating a wave of new possibilities in the treatment of diabetes. We have been privileged to collaborate with many wonderful individuals throughout this process and are thankful to the people who shared their time, knowledge, and energy with us. We hope that our experience will encourage others to work collaboratively and share knowledge and tools.
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