1
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Ang L, Lin YK, Schroeder LF, Huang Y, DeGeorge CA, Arnold P, Akanbi F, Knotts S, DuBois E, Desbrough N, Qu Y, Freeman R, Esfandiari NH, Pop-Busui R, Gianchandani R. Feasibility and Performance of Continuous Glucose Monitoring to Guide Computerized Insulin Infusion Therapy in Cardiovascular Intensive Care Unit. J Diabetes Sci Technol 2024; 18:562-569. [PMID: 38563491 PMCID: PMC11089859 DOI: 10.1177/19322968241241005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND We evaluated the feasibility of real-time continuous glucose monitoring (CGM) for titrating continuous intravenous insulin infusion (CII) to manage hyperglycemia in postoperative individuals in the cardiovascular intensive care unit and assessed their accuracy, nursing acceptance, and postoperative individual satisfaction. METHODS Dexcom G6 CGM devices were applied to 59 postsurgical patients with hyperglycemia receiving CII. A hybrid approach combining CGM with periodic point-of-care blood glucose (POC-BG) tests with two phases (initial-ongoing) of validation was used to determine CGM accuracy. Mean and median absolute relative differences and Clarke Error Grid were plotted to evaluate the CGM accuracy. Surveys of nurses and patients on the use of CGMs experience were conducted and results were analyzed. RESULTS In this cohort (mean age 64, 32% female, 32% with diabetes) with 864 paired POC-BG and CGM values analyzed, mean and median absolute relative difference between POC-BG and CGM values were 13.2% and 9.8%, respectively. 99.7% of paired CGM and POC-BG were in Zones A and B of the Clarke Error Grid. Responses from nurses reported CGMs being very or quite convenient (n = 28; 93%) and it was favored over POC-BG testing (n = 28; 93%). Majority of patients (n = 42; 93%) reported their care process using CGM as being good or very good. CONCLUSION This pilot study demonstrates the feasibility, accuracy, and nursing convenience of adopting CGM via a hybrid approach for insulin titration in postoperative settings. These findings provide robust rationale for larger confirmatory studies to evaluate the benefit of CGM in postoperative care to improve workflow, enhance health outcomes, and cost-effectiveness.
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Affiliation(s)
- Lynn Ang
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Lee F. Schroeder
- Department of Pathology, University of
Michigan, Ann Arbor, MI, USA
| | - Yiyuan Huang
- Department of Biostatistics, University
of Michigan, Ann Arbor, MI, USA
| | - Christina A. DeGeorge
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Patrick Arnold
- Department of Pharmacy, University of
Michigan, Ann Arbor, MI, USA
| | - Folake Akanbi
- Division of Endocrinology and
Metabolism, Department of Medicine, Michigan State University, East Lansing, MI,
USA
| | - Sharon Knotts
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Elizabeth DuBois
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Nicole Desbrough
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Yunyan Qu
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Regi Freeman
- Michigan Department of Nursing,
University of Michigan, Ann Arbor, MI, USA
| | - Nazanene H. Esfandiari
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
- Department of Medicine, Division of
Endocrinology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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2
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Engle K, Bacani G, Cook CB, Maynard GA, Messler J, Kulasa K. Glucometrics: Where Are We Now? Curr Diab Rep 2023:10.1007/s11892-023-01507-1. [PMID: 37052789 DOI: 10.1007/s11892-023-01507-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW Inpatient glucose data analysis, or glucometrics, has developed alongside the growing emphasis on glycemic control in the hospital. Shortcomings in the initial capabilities for glucometrics have pushed advancements in defining meaningful units of measurement and methods for capturing glucose data. This review addresses the growth in glucometrics and ends with its promising new state. RECENT FINDINGS Standardization, allowing for benchmarking and purposeful comparison, has been a goal of the field. The National Quality Foundation glycemic measures and recently enacted Center for Medicare and Medicaid Services (CMS) electronic quality measures for hypo- and hyperglycemia have allowed for improved integration and consistency. Prior systems have culminated in an upcoming measure from the Center for Disease Control and Prevention's National Healthcare Safety Network. It is poised to create a new gold standard for glucometrics by expanding and refining the CMS metrics, which should empower both local improvement and benchmarking as the program matures.
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Affiliation(s)
- Kelly Engle
- UCSD Division of Endocrinology, San Diego, CA, USA.
| | - Grace Bacani
- UCSD Nursing Development, Education and Research, San Diego, CA, USA
| | - Curtiss B Cook
- Mayo Clinic Arizona Division of Endocrinology, Phoenix, AZ, USA
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3
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Kyi M, Colman P, Gonzalez V, Hall C, Cheuk N, Fourlanos S. Early intervention model of inpatient diabetes care improves glycemia following hospitalization. J Hosp Med 2023; 18:337-341. [PMID: 36739111 DOI: 10.1002/jhm.13057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/20/2022] [Accepted: 01/19/2023] [Indexed: 02/06/2023]
Abstract
Admission to hospital provides an opportunity to optimize long-term diabetes management, but clinical inertia is common. We previously reported the randomized study of a proactive inpatient diabetes service (RAPIDS), investigating an early intervention model of care and demonstrated improved in-hospital glycemia and clinical outcomes. This follow-up study assessed whether proactive care in hospital improved postdischarge HbA1c. In a subgroup of 298 RAPIDS trial participants with type 2 diabetes, age <80 years, and admission HbA1c ≥ 7.0%, diabetes treatment intensification occurred more often in early intervention versus usual care groups (37% vs. 19% [p = .001]), adjusted odds ratio 3.2 (95% confidence interval [CI]: 1.7-6.0). There was a greater change in HbA1c in the early intervention group (mean -0.9% [95% CI -1.3 to -0.4]) versus the usual care group (-0.3% [-0.6 to -0.1]), p = .029. The value of acute care by dedicated inpatient diabetes teams can extend beyond improving inpatient clinical outcomes and can lead to sustained improvement in glycemia.
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Affiliation(s)
- Mervyn Kyi
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Northern Health Epping, Epping, Victoria, Australia
| | - Peter Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Vicky Gonzalez
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Candice Hall
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nathan Cheuk
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Parkville, Victoria, Australia
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4
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Idrees T, Castro-Revoredo IA, Migdal AL, Moreno EM, Umpierrez GE. Update on the management of diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2022; 10:10/4/e002705. [PMID: 35858714 PMCID: PMC9305812 DOI: 10.1136/bmjdrc-2021-002705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.
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Affiliation(s)
- Thaer Idrees
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Iris A Castro-Revoredo
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Alexandra L Migdal
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Emmelin Marie Moreno
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
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Abstract
PURPOSE OF REVIEW Persons with diabetes are more likely to require orthopedic surgery and are at an increased risk of developing postoperative complications. Recognizing the impact of diabetes on musculoskeletal health provides an opportunity to educate healthcare professionals in standardizing the perioperative approach of persons with diabetes. RECENT FINDINGS Elevated hemoglobin A1C, fructosamine, and blood glucose levels have been associated with increased risk for complications in the orthopedic population. These risks can be mitigated by the early identification and optimization of these patients in the perioperative period. Intraoperative and postoperative glycemic management should support efforts to maintain glucose at safe levels while avoiding hyperglycemia and hypoglycemia. This paper considers factors surrounding diabetes care in the orthopedic surgical patient. Perioperative care discussed includes optimization, hospitalization to discharge, and special considerations such as steroids and diabetes wearable technology. Hospitals should consider these strategies towards enhancing the care of persons with diabetes requiring musculoskeletal care.
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Affiliation(s)
- Ruben Diaz
- Hospital for Special Surgery, New York, NY, 10021, USA.
| | - Jenny DeJesus
- Hospital for Special Surgery, New York, NY, 10021, USA
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Pasquel FJ, Urrutia MA, Cardona S, Coronado KWZ, Albury B, Perez-Guzman MC, Galindo RJ, Chaudhuri A, Iacobellis G, Palacios J, Farias JM, Gomez P, Anzola I, Vellanki P, Fayfman M, Davis GM, Migdal AL, Peng L, Umpierrez GE. Liraglutide hospital discharge trial: A randomized controlled trial comparing the safety and efficacy of liraglutide versus insulin glargine for the management of patients with type 2 diabetes after hospital discharge. Diabetes Obes Metab 2021; 23:1351-1360. [PMID: 33591621 PMCID: PMC8571803 DOI: 10.1111/dom.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
AIM To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial. METHODS A total of 273 patients with glycated haemoglobin (HbA1c) 7%-10% (53-86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c <7% (53 mmol/mol) without hypoglycaemia or weight gain. RESULTS The between-group difference in HbA1c at 12 weeks and 26 weeks was -0.28% (95% CI -0.64, 0.09), and at 26 weeks it was -0.55%, (95% CI -1.01, -0.09) in favour of liraglutide. Liraglutide treatment resulted in a lower frequency of hypoglycaemia <3.9 mmol/L (13% vs 23%; P = 0.04), but there was no difference in the rate of clinically significant hypoglycaemia <3.0 mmol/L. Compared to insulin glargine, liraglutide treatment was associated with greater weight loss at 26 weeks (-4.7 ± 7.7 kg vs -0.6 ± 11.5 kg; P < 0.001), and the proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia was 48% versus 33% (P = 0.05) at 12 weeks and 45% versus 33% (P = 0.14) at 26 weeks in liraglutide versus insulin glargine. The proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia and no weight gain was higher with liraglutide at 12 (41% vs 24%, P = 0.005) and 26 weeks (39% vs 22%; P = 0.014). The incidence of gastrointestinal adverse events was higher with liraglutide than with insulin glargine (P < 0.001). CONCLUSION Compared to insulin glargine, treatment with liraglutide at hospital discharge resulted in better glycaemic control and greater weight loss, but increased gastrointestinal adverse events.
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Affiliation(s)
- Francisco J. Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maria A. Urrutia
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Saumeth Cardona
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Karla W. Z. Coronado
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bonnie Albury
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mireya C. Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ajay Chaudhuri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Gianluca Iacobellis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Juan Palacios
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Javier M. Farias
- Division of Endocrinology Sanatorio Guemes, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Gomez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Isabel Anzola
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maya Fayfman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Georgia M. Davis
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra L. Migdal
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Limin Peng
- Deartment of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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7
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The Association of Diabetes and Hyperglycemia on Inpatient Readmissions. Endocr Pract 2021; 27:413-418. [PMID: 33839023 DOI: 10.1016/j.eprac.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/09/2020] [Accepted: 01/10/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the association between inpatient glycemic control and readmission in individuals with diabetes and hyperglycemia (DM/HG). METHODS Two data sets were analyzed from fiscal years 2011 to 2013: hospital data using the International Classification of Diseases, Ninth Revision (ICD-9) codes for DM/HG and point of care (POC) glucose monitoring. The variables analyzed included gender, age, mean, minimum and maximum glucose, along with 4 measures of glycemic variability (GV), standard deviation, coefficient of variation, mean amplitude of glucose excursions, and average daily risk range. RESULTS Of 66 518 discharges in FY 2011-2013, 28.4% had DM/HG based on ICD-9 codes and 53% received POC monitoring. The overall readmission rate was 13.9%, although the rates for individuals with DM/HG were higher at 18.9% and 20.6% using ICD-9 codes and POC data, respectively. The readmitted group had higher mean glucose (169 ± 47 mg/dL vs 158 ± 46 mg/dL, P < .001). Individuals with severe hypoglycemia and hyperglycemia had the highest readmission rates. All 4 GV measures were consistent and higher in the readmitted group. CONCLUSION Individuals with DM/HG have higher 30-day readmission rates than those without. Those readmitted had higher mean glucose, more extreme glucose values, and higher GV. To our knowledge, this is the first report of multiple metrics of inpatient glycemic control, including GV, and their associations with readmission.
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8
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Korytkowski M, Antinori-Lent K, Drincic A, Hirsch IB, McDonnell ME, Rushakoff R, Muniyappa R. A Pragmatic Approach to Inpatient Diabetes Management during the COVID-19 Pandemic. J Clin Endocrinol Metab 2020; 105:5851514. [PMID: 32498085 PMCID: PMC7313952 DOI: 10.1210/clinem/dgaa342] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.
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Affiliation(s)
- Mary Korytkowski
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Address Reprint Requests to: Mary T. Korytkowski, MD, Professor of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, 3601 Fifth Avenue, Suite 3B, Pittsburgh PA 15213, Phone: 412 586 9714, Fax: 412 586 9726,
| | | | | | | | | | | | - Ranganath Muniyappa
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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9
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Seuradge C, Chen D, Hariharan S. Glycaemic Control in Critically Ill Adult Patients: Is intensive insulin therapy beneficial? CARIBBEAN MEDICAL JOURNAL 2020. [DOI: 10.48107/cmj.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES
Glycaemic control with intensive insulin therapy and its impact on patient outcomes have always been contentious in an intensive care setting. This study aims to assess the patterns of glycaemic control in critically ill patients at a tertiary care institution in Trinidad and its relationship to outcomes.
METHODS
All adult patients admitted to a multidisciplinary intensive care unit (ICU) for a period of two years were enrolled for a retrospective chart review. Data collected included demographics, admission blood glucose, mean morning blood glucose (MBG), the trend of glucose control, number of hypoglycaemic episodes, admission Simplified Acute Physiology Score (SAPS) II, ICU and hospital length of stay, duration of mechanical ventilation, anaemia, renal replacement therapy and hospital outcome.
RESULTS
A total of 104 patients were studied. Four different patterns of insulin therapy were practised at the ICU. The median age of patients was 55.5 years, the mean SAPS II was 49.3, the mean predicted mortality was 45.5% and the overall observed mortality was 38.5%. The majority of admissions had cardiovascular illnesses (25%), followed by sepsis (20.2%). Patients with multiple hypoglycaemic episodes had an increased mortality (p<0.01). Patients had a better outcome with a higher MBG (>100 mg/dL) (p<0.05). There was a significant difference in mortality among the four patterns of glycaemic control (p<0.001). Admission blood glucose, length of time of mechanical ventilation, ICU length of stay and renal replacement therapy were not found to be associated with adverse outcomes.
CONCLUSION
Intensive insulin therapy (IIT) may not benefit ICU patients but can be probably associated with higher mortality. Avoidance of hypoglycaemia as well as persistent hyperglycaemia may lead to a better outcome in critically ill patients.
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Affiliation(s)
- Crystal Seuradge
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
| | - Deryk Chen
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
| | - Seetharaman Hariharan
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
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10
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Cardona S, Tsegka K, Pasquel FJ, Fayfman M, Peng L, Jacobs S, Vellanki P, Halkos M, Guyton RA, Thourani VH, Galindo RJ, Umpierrez G. Sitagliptin for the prevention of stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery. BMJ Open Diabetes Res Care 2019; 7:e000703. [PMID: 31543976 PMCID: PMC6731905 DOI: 10.1136/bmjdrc-2019-000703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/18/2019] [Accepted: 08/17/2019] [Indexed: 02/07/2023] Open
Abstract
AIMS To determine if treatment with sitagliptin, a dipeptidyl peptidase-4 inhibitor, can prevent stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery. METHODS We conducted a pilot, double-blinded, placebo-controlled randomized trial in adults (18-80 years) without history of diabetes. Participants received sitagliptin or placebo once daily, starting the day prior to surgery and continued for up to 10 days. Primary outcome was differences in the frequency of stress hyperglycemia (blood glucose (BG) >180 mg/dL) after surgery among groups. RESULTS We randomized 32 participants to receive sitagliptin and 28 to placebo (mean age 64±10 years and HbA1c: 5.6%±0.5%). Treatment with sitagliptin resulted in lower BG levels prior to surgery (101±mg/dL vs 107±13 mg/dL, p=0.01); however, there were no differences in the mean BG concentration, proportion of patients who developed stress hyperglycemia (21% vs 22%, p>0.99), length of hospital stay, rate of perioperative complications and need for insulin therapy in the intensive care unit or during the hospital stay. CONCLUSION The use of sitagliptin during the perioperative period did not prevent the development of stress hyperglycemia or need for insulin therapy in patients without diabetes undergoing CABG surgery.
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Affiliation(s)
- Saumeth Cardona
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katerina Tsegka
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Maya Fayfman
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Biostatitics, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sol Jacobs
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Michael Halkos
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert A Guyton
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vinod H Thourani
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rodolfo J Galindo
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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11
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Helmle KE, Dechant AL, Edwards AL. Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes. Clin Diabetes 2019; 37:82-85. [PMID: 30705501 PMCID: PMC6336121 DOI: 10.2337/cd17-0078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc. (ACP), and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to increase the use of basal-bolus insulin therapy for hyperglycemia in an inpatient setting and to evaluate its effects on patient outcomes compared to sliding-scale insulin therapy.
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Affiliation(s)
- Karmon E Helmle
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anthony L Dechant
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alun L Edwards
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Corl D, Yin T, Ulibarri M, Lien H, Tylee T, Chao J, Wisse BE. What Can We Learn From Point-of-Care Blood Glucose Values Deleted and Repeated by Nurses? J Diabetes Sci Technol 2018; 12:985-991. [PMID: 29575924 PMCID: PMC6134629 DOI: 10.1177/1932296818763891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hospitals rely on point-of-care (POC) blood glucose (BG) values to guide important decisions related to insulin administration and glycemic control. Evaluation of POC BG in hospitalized patients is associated with measurement and operator errors. Based on a previous quality improvement (QI) project we introduced an option for operators to delete and repeat POC BG values suspected as erroneous. The current project evaluated our experience with deleted POC BG values over a 2-year period. METHOD A retrospective QI project included all patients hospitalized at two regional academic medical centers in the Pacific Northwest during 2014 and 2015. Laboratory Medicine POC BG data were reviewed to evaluate all inpatient episodes of deleted and repeated POC BG. RESULTS Inpatient operators choose to delete and repeat only 0.8% of all POC BG tests. Hypoglycemic and extreme hyperglycemic BG values are more likely to be deleted and repeated. Of initial values <40 mg/dL, 58% of deleted values (18% of all values) are errors. Of values >400 mg/dL, 40% of deleted values (5% of all values) are errors. Not all repeated POC BG values are first deleted. Optimal use of the option to delete and repeat POC BG values <40 mg/dL could decrease reported rates of severe hypoglycemia by as much as 40%. CONCLUSIONS This project demonstrates that operators are frequently able to identify POC BG values that are measurement/operator errors. Eliminating these errors significantly reduces documented rates of severe hypoglycemia and hyperglycemia, and has the potential to improve patient safety.
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Affiliation(s)
- Dawn Corl
- Department of Clinical Education, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Tom Yin
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - May Ulibarri
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Heather Lien
- Department of Clinical Education, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Tracy Tylee
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jing Chao
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brent E. Wisse
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
- Brent E. Wisse, MD, Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, University of Washington, 325 Ninth Ave, Box 359757, Seattle, WA 98104-2499, USA.
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Galindo RJ, Fayfman M, Umpierrez GE. Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients. Endocrinol Metab Clin North Am 2018; 47:203-222. [PMID: 29407052 PMCID: PMC5805476 DOI: 10.1016/j.ecl.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Maya Fayfman
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting. RECENT FINDINGS Strategies to reduce hypoglycemia rates should focus on the most common causes of iatrogenic hypoglycemia. Creating a standardized insulin order set with built-in clinical decision support can help reduce rates of hypoglycemia. Coordination of blood glucose monitoring, meal tray delivery, and insulin administration is an important and challenging task. Protocols and processes should be in place to deal with interruptions in nutrition to minimize risk of hypoglycemia. A glucose management page that has all the pertinent information summarized in one page allows for active surveillance and quick identification of patients who may be at risk of hypoglycemia. Finally, education of prescribers, nurses, food and nutrition services, and patients is important so that every member of the healthcare team can work together to prevent hypoglycemia. By implementing strategies to reduce hypoglycemia, we hope to lower rates of adverse events and improve quality of care while also reducing hospital costs. Future research should focus on the impact of an overall reduction in hypoglycemia to determine whether the expected benefits are achieved.
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Affiliation(s)
- Kristen Kulasa
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA.
| | - Patricia Juang
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA
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15
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Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, Peng L, Hodish I, Bodnar T, Wesorick D, Balakrishnan V, Osei K, Umpierrez GE. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diabetes Endocrinol 2017; 5:125-133. [PMID: 27964837 DOI: 10.1016/s2213-8587(16)30402-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 10/29/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of incretin-based drugs in the treatment of patients with type 2 diabetes admitted to hospital has not been extensively assessed. In this study, we compared the safety and efficacy of a dipeptidyl peptidase-4 inhibitor (sitagliptin) plus basal insulin with a basal-bolus insulin regimen for the management of patients with type 2 diabetes in general medicine and surgery in hospitals. METHODS We did a multicentre, prospective, open-label, non-inferiority randomised clinical trial (Sita-Hospital) in five hospitals in the USA, enrolling patients aged 18-80 years with type 2 diabetes and a random blood glucose concentration of 7·8-22·2 mmol/L who were being treated with diet or oral antidiabetic drugs or had a total daily insulin dose of 0·6 units per kg or less, admitted to general medicine and surgery services. We randomly assigned patients (1:1) to receive either sitagliptin plus basal glargine once daily (the sitagliptin-basal group) or a basal-bolus regimen with glargine once daily and rapid-acting insulin lispro or aspart before meals (the basal-bolus group) during the hospital stay. All other antidiabetic drugs were discontinued on admission. The randomisation was achieved by computer-generated tables with block stratification according to randomisation blood glucose concentrations (ie, higher or lower than 11·1 mmol/L). The primary endpoint of the trial was non-inferiority in mean differences between groups in their daily blood glucose concentrations during the first 10 days of therapy (point-of-care measurements; non-inferiority was deemed a difference <1 mmol/L). The safety endpoints included hypoglycaemia and uncontrolled hyperglycaemia leading to treatment failure. All participants who received at least one dose of study drug were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01845831. FINDINGS Between Aug 23, 2013, and July 27, 2015, we recruited 279 patients, and randomly assigned 277 to treatment; 138 to sitagliptin-basal and 139 to basal-bolus. The length of stay in hospital was similar for both groups (median 4 days [IQR 3-8] vs 4 [3-8] days, p=0·54). The mean daily blood glucose concentration in the sitagliptin-basal group (9·5 mmol/L [SD 2·7]) was not inferior to that in the basal-bolus group 9·4 mmol/L [2·7]) with a mean blood glucose difference of 0·1 mmol/L (95% CI -0·6 to 0·7). No deaths occurred in this trial. Treatment failure occurred in 22 patients (16%) in the sitagliptin-basal group versus 26 (19%) in the basal-bolus group (p=0·54). Hypoglycaemia occurred in 13 patients (9%) in the sitagliptin-basal group and in 17 (12%) in the basal-bolus group (p=0·45). No differences in hospital complications were noted between groups. Seven patients (5%) developed acute kidney injury in the sitagliptin-basal group and six (4%) in the basal-bolus group. One patient (0·7%) developed acute pancreatitis (in the basal-bolus group). INTERPRETATION The trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal-bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting. FUNDING Merck.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tim Bodnar
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Kwame Osei
- Ohio State University, Columbus, OH, USA
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16
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Ong KY, Kwan YH, Tay HC, Tan DSY, Chang JY. Prevalence of dysglycaemic events among inpatients with diabetes mellitus: a Singaporean perspective. Singapore Med J 2016; 56:393-400. [PMID: 26243976 DOI: 10.11622/smedj.2015110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION As the effectiveness of intensive glycaemic control is unclear and recommended glycaemic targets are inconsistent, this study aimed to ascertain the prevalence of dysglycaemia among hospitalised patients with diabetes mellitus in an Asian population and evaluate the current standards of inpatient glycaemic control. METHODS A retrospective observational study was conducted at a secondary hospital. Point-of-care blood glucose (BG) values, demographic data, medical history, glycaemic therapy and clinical characteristics were recorded. Dysglycaemia prevalence was calculated as proportions of BG-monitored days with at least one reading exceeding the cut points of 8, 10 and 15 mmol/L for hyperglycaemia, and below the cut point of 4 mmol/L for hypoglycaemia. RESULTS Among the 288 patients recruited, hyperglycaemia was highly prevalent (90.3%, 81.3% and 47.6% for the respective cut points), while hypoglycaemia was the least prevalent (18.8%). Dysglycaemic patients were more likely than normoglycaemic patients to have poorer glycated haemoglobin (HbA1c) levels (8.4% ± 2.6% vs. 7.3% ± 1.9%; p = 0.002 for BG > 10 mmol/L) and longer lengths of stay (10.1 ± 8.2 days vs. 6.8 ± 4.7 days; p = 0.007 for BG < 4 mmol/L). Hyperglycaemia was more prevalent in patients on more intensive treatment regimens, such as basal-bolus combination therapy and the use of both insulin and oral hypoglycaemic agents (100.0% and 96.0%, respectively; p < 0.001 for BG > 10 mmol/L). CONCLUSION Inpatient glycaemic control is suboptimal. Factors (e.g. type of treatment regimen, discipline and baseline HbA1c) associated with greater prevalence of dysglycaemia should be given due consideration in patient management.
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Affiliation(s)
- Kheng Yong Ong
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore ; Specialist Outpatient Clinics, Department of Pharmacy, Singapore General Hospital, Singapore
| | - Yu Heng Kwan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore ; Duke-NUS Graduate Medical School Singapore, Singapore
| | - Hooi Ching Tay
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
| | | | - Joanne Yeh Chang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Saulnier GE, Castro JC, Cook CB. Statistical transformation and the interpretation of inpatient glucose control data. Endocr Pract 2016; 20:207-12. [PMID: 24013995 DOI: 10.4158/ep13186.or] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To introduce a statistical method of assessing hospital-based non-intensive care unit (non-ICU) inpatient glucose control. METHODS Point-of-care blood glucose (POC-BG) data from hospital non-ICUs were extracted for January 1 through December 31, 2011. Glucose data distribution was examined before and after Box-Cox transformations and compared to normality. Different subsets of data were used to establish upper and lower control limits, and exponentially weighted moving average (EWMA) control charts were constructed from June, July, and October data as examples to determine if out-of-control events were identified differently in nontransformed versus transformed data. RESULTS A total of 36,381 POC-BG values were analyzed. In all 3 monthly test samples, glucose distributions in nontransformed data were skewed but approached a normal distribution once transformed. Interpretation of out-of-control events from EWMA control chart analyses also revealed differences. In the June test data, an out-of-control process was identified at sample 53 with nontransformed data, whereas the transformed data remained in control for the duration of the observed period. Analysis of July data demonstrated an out-of-control process sooner in the transformed (sample 55) than nontransformed (sample 111) data, whereas for October, transformed data remained in control longer than nontransformed data. CONCLUSION Statistical transformations increase the normal behavior of inpatient non-ICU glycemic data sets. The decision to transform glucose data could influence the interpretation and conclusions about the status of inpatient glycemic control. Further study is required to determine whether transformed versus nontransformed data influence clinical decisions or evaluation of interventions.
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Affiliation(s)
- George E Saulnier
- Department of Information Technology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Janna C Castro
- Department of Information Technology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona
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18
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Duggan EW, Klopman MA, Berry AJ, Umpierrez G. The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Curr Diab Rep 2016; 16:34. [PMID: 26971119 DOI: 10.1007/s11892-016-0720-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.
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Affiliation(s)
| | - Matthew A Klopman
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
| | - Arnold J Berry
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
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Ojeda MM. Carbohydrate Counting in the Acute Care Setting: Development of an Educational Program Based on Cognitive Load Theory. Creat Nurs 2016; 22:33-44. [PMID: 30188304 DOI: 10.1891/1078-4535.22.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The care of noncritically ill hospitalized patients with diabetes mellitus requiring insulin administration is multidisciplinary and complex. Evidence indicates that staff nurses may benefit from additional training in the nutritional management of patients with diabetes. In addition, unlicensed assistive personnel may be involved in the feeding and point-of-care testing of diabetic patients and thus play an important role in nursing care of such patients. Cognitive load theory assists educators in the identification of specific cognitive challenges that learners may face when presented with new material, but it also presents solutions to such challenges by way of specific instructional design methods to help overcome them. An educational program was piloted on a mixed audience of registered nurses and unlicensed assistive personnel at a community hospital; satisfaction with the program was found to be high.
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Affiliation(s)
- Maria M Ojeda
- Baptist Health South Florida, Inc., Miami, Florida, USA
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20
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Abstract
PURPOSE The purpose of this evidence-based practice improvement project was to improve patients' blood glucose control after cardiac surgery, specifically aiming to keep blood glucose levels less than 200 mg/dL. BACKGROUND/RATIONALE Glycemic control is essential for wound healing and infection prevention. Multiple factors including the use of corticosteroids and the stress of critical illness put cardiac surgery patients at greater risk for elevated blood glucose levels postoperatively. A Surgical Care Improvement Project measure related to infection prevention calls for the morning blood glucose level (closest to 6:00 AM) to be less than 200 mg/dL on postoperative days 0 to 2. Patients on our cardiothoracic surgery unit were experiencing blood glucose levels greater than benchmark goals. DESCRIPTION A practice improvement effort was designed to decrease the number of blood glucose results greater than 200 mg/dL after cardiac surgery. The clinical nurse specialists for diabetes and cardiac surgery worked with nursing staff and the interdisciplinary team to implement a 4-pronged approach to improve efficiency in care processes: (1) increase frequency of glucose monitoring, (2) improve accessibility of insulin orders, (3) develop delegation protocol to facilitate nurse-initiated insulin infusion, and (4) implement revised insulin infusion protocol. OUTCOMES Hyperglycemia was identified more quickly, and a nurse-initiated protocol prompted more timely use of revised insulin infusion orders and involvement of the diabetes specialty team. Clinically significant improvement in postoperative glycemic control was achieved. CONCLUSIONS Empowering nurses to initiate hyperglycemia treatment and consultation by diabetes specialists may greatly improve efficiency in care processes and clinical outcomes for cardiac surgery patients. IMPLICATIONS Clinical nurse specialists are well positioned to plan and implement interventions that facilitate an evidence-based approach to glycemic management after cardiac surgery.
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Bueno E, Benitez A, Rufinelli JV, Figueredo R, Alsina S, Ojeda A, Samudio S, Cáceres M, Argüello R, Romero F, Echagüe G, Pasquel F, Umpierrez GE. BASAL-BOLUS REGIMEN WITH INSULIN ANALOGUES VERSUS HUMAN INSULIN IN MEDICAL PATIENTS WITH TYPE 2 DIABETES: A RANDOMIZED CONTROLLED TRIAL IN LATIN AMERICA. Endocr Pract 2015; 21:807-13. [PMID: 26121460 DOI: 10.4158/ep15675.or] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Few randomized studies have focused on the optimal management of non-intensive care unit patients with type 2 diabetes in Latin America. We compared the safety and efficacy of a basal-bolus regimen with analogues and human insulins in general medicine patients admitted to a University Hospital in Asunción, Paraguay. METHODS In a prospective, open-label trial, we randomized 134 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dL to a basal-bolus regimen with glargine once daily and glulisine before meals (n = 66) or Neutral Protamine Hagedorn (NPH) twice daily and regular insulin before meals (n = 68). Major outcomes included differences in daily BG levels and frequency of hypoglycemic events between treatment groups. RESULTS There were no differences in the mean daily BG (157 ± 37 mg/dL versus 158 ± 44 mg/dL; P = .90) or in the number of BG readings within target <140 mg/dL before meals (76% versus 74%) between the glargine/glulisine and NPH/regular regimens. The mean insulin dose in the glargine/glulisine group was 0.76 ± 0.3 units/kg/day (glargine, 22 ± 9 units/day; glulisine, 31 ± 12 units/day) and was not different compared with NPH/regular group (0.75 ± 0.3 units/kg/day [NPH, 28 ± 12 units/day; regular, 23 ± 9 units/day]). The overall prevalence of hypoglycemia (<70 mg/dL) was similar between patients treated with NPH/regular and glargine/glulisine (38% versus 35%; P = .68), but more patients treated with human insulin had severe (<40 mg/dL) hypoglycemia (7.6% versus 25%; P = .08). There were no differences in length of hospital stay or mortality between groups. CONCLUSION The basal-bolus regimen with insulin analogues resulted in equivalent glycemic control and frequency of hypoglycemia compared to treatment with human insulin in hospitalized patients with diabetes.
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Efficacy of a hyperglycemia treatment program in a Vascular Surgery Department supervised by Endocrinology. Cir Esp 2015; 94:392-8. [PMID: 25882331 DOI: 10.1016/j.ciresp.2015.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 02/25/2015] [Accepted: 02/27/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the strategy and efficacy of a hyperglycemia treatment program supervised by Endocrinology. METHODS All patients with type 2 diabetes hospitalized at the vascular surgery department over a 12 month period were retrospectively reviewed. Clinical characteristics and hyperglycemia treatment during hospitalization, at discharge and 2-6 month after discharge were collected. Glycemic control was assessed using capillary blood glucose profiles and HbA1c at admission and 2-6 months post-discharge. RESULTS A total of 140 hospitalizations of 123 patients were included. The protocol to choose the insulin regimen was applied in 96.4% of patients (22.8% correction dose, 23.6% basal-correction dose and 50% basal-bolus-correction dose [BBC]). Patients with BBC had higher HbA1c (7.7±1.5% vs. 6.7 ±0.8%; P<.001) and mean glycemia on the first day of hospitalization (184.4±59.2 vs. 140.5±31.4mg/dl; P<.001). Mean blood glucose was reduced to 162.1±41.8mg/dl in the middle and 160.8±43.3mg/dl in the last 24h of hospitalization in patients with BBC (P=.007), but did not change in the remaining patients. In 22.1% patients with treatment changes performed at discharge, HbA1c decreased from 8.2±1.6 to 6.8±1.6% at 2-6 months post-discharge (P=.019). CONCLUSIONS The hyperglycemia treatment protocol applied by an endocrinologist in the hospital, allows the identification of the appropriate therapy and the improvement of the glycemic control during hospitalization and discharge, supporting its efficacy in clinical practice.
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Koziol J, Johnson K, Brenner K, Fortmann A, Morrisey R, Philis-Tsimikas A. Novel approach to inpatient glucometric monitoring and variability in a community hospital setting. J Diabetes Sci Technol 2015; 9:246-56. [PMID: 25539653 PMCID: PMC4604585 DOI: 10.1177/1932296814564992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hyperglycemia and glucose variability in the hospital environment are associated with higher rates of complications, longer lengths of stay, and mortality. Standardized metrics are needed to assess the efficacy and safety of glucose management interventions. Glucometric data were collected from 2024 inpatients in a San Diego hospital between 2009 and 2011. As a complementary measure of glucose control, individual patient excursion rates were calculated using counts of distinct excursions from normal to critical glucose ranges >180 or <70 mg/dL. Prediction models for excursion rates were devised, based on patient demographic and clinical characteristics. Patients were predominantly male (51.2%), Caucasian (86.0%), and elderly (median age 72 years). Obesity was prevalent: 32% were overweight and 33% were obese. Median length of hospitalization was 5.0 days (range, 0.8-139.4 days). Unadjusted rate of excursions >180 mg/dL was 0.456 per 24 hours. The proportion of zero excursions decreased as severity of illness decreased, but was unrelated to age. Excursion rates were slightly smaller for major and extreme severity of illness compared to mild or moderate illness severity. Excursion rates did not vary in a monotone fashion with age, although the general pattern reflected a reduction in excursion rates from the first age quartile (19 to 59) through the last age quartile (83 to 100). Using the Akaike information criterion, zero-inflated negative binomial models were identified as appropriate for analyzing glucose excursion rates. Systematic approaches to glucose reporting and management in the hospital environment offer "windows of opportunity" to improve diabetes care.
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Nya-Ngatchou JJ, Corl D, Onstad S, Yin T, Tylee T, Suhr L, Thompson RE, Wisse BE. Point-of-care blood glucose measurement errors overestimate hypoglycaemia rates in critically ill patients. Diabetes Metab Res Rev 2015; 31:147-54. [PMID: 25044666 DOI: 10.1002/dmrr.2575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/23/2014] [Accepted: 06/23/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hypoglycaemia is associated with morbidity and mortality in critically ill patients, and many hospitals have programmes to minimize hypoglycaemia rates. Recent studies have established the hypoglycaemic patient-day as a key metric and have published benchmark inpatient hypoglycaemia rates on the basis of point-of-care blood glucose data even though these values are prone to measurement errors. METHODS A retrospective, cohort study including all patients admitted to Harborview Medical Center Intensive Care Units (ICUs) during 2010 and 2011 was conducted to evaluate a quality improvement programme to reduce inappropriate documentation of point-of-care blood glucose measurement errors. Laboratory Medicine point-of-care blood glucose data and patient charts were reviewed to evaluate all episodes of hypoglycaemia. RESULTS A quality improvement intervention decreased measurement errors from 31% of hypoglycaemic (<70 mg/dL) patient-days in 2010 to 14% in 2011 (p < 0.001) and decreased the observed hypoglycaemia rate from 4.3% of ICU patient-days to 3.4% (p < 0.001). Hypoglycaemic events were frequently recurrent or prolonged (~40%), and these events are not identified by the hypoglycaemic patient-day metric, which also may be confounded by a large number of very low risk or minimally monitored patient-days. CONCLUSIONS Documentation of point-of-care blood glucose measurement errors likely overestimates ICU hypoglycaemia rates and can be reduced by a quality improvement effort. The currently used hypoglycaemic patient-day metric does not evaluate recurrent or prolonged events that may be more likely to cause patient harm. The monitored patient-day as currently defined may not be the optimal denominator to determine inpatient hypoglycaemic risk.
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Affiliation(s)
- Jean-Jacques Nya-Ngatchou
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Diabetes and Obesity Center of Excellence, University of Washington, Seattle, WA, USA
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Maynard G, Kulasa K, Ramos P, Childers D, Clay B, Sebasky M, Fink E, Field A, Renvall M, Juang PS, Choe C, Pearson D, Serences B, Lohnes S. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract 2014; 21:355-67. [PMID: 25536971 DOI: 10.4158/ep14367.or] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. METHODS POPULATION all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.
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Pérez A, Reales P, Barahona MJ, Romero MG, Miñambres I. Efficacy and feasibility of basal-bolus insulin regimens and a discharge-strategy in hospitalised patients with type 2 diabetes--the HOSMIDIA study. Int J Clin Pract 2014; 68:1264-71. [PMID: 25269951 DOI: 10.1111/ijcp.12498] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIMS Guidelines recommend use of basal-bolus insulin in hospitalised patients with hyperglycaemia, but information about implementation and medication reconciliation at discharge is scarce. The HOSMIDIA study evaluated a management program involving basal-bolus insulin and an algorithm for medication reconciliation at discharge in non-critically ill hospitalised patients with type 2 diabetes in clinical practice. METHODS HOSMIDIA was a prospective, observational study performed during routine clinical practice at 15 Spanish hospitals during hospitalisation, with follow-up 3 months postdischarge. Study patients (n = 134) received a basal-bolus regimen with insulin glargine during hospitalisation and treatment at discharge was adjusted according to a simple algorithm. The control group (n = 62) included patients with similar characteristics hospitalised during the month before study initiation and had no follow-up after discharge. RESULTS Compared with control subjects, patients in the prospective study achieved lower mean total (167.7 ± 41.1 vs. 190.5 ± 53.3 mg/dl) preprandial (164.2 ± 42.4 vs. 189.6 ± 52.6 mg/dl; p < 0.001) and fasting (137.0 ± 42.2 vs. 165.8 ± 56.5 mg/dl) blood glucose levels while hospitalised, without increased hypoglycaemic episodes (17.7% vs. 19.3% patients). In the prospective study, glycaemic control improved from admission to discharge, with control maintained 3 months after discharge. The main treatment modification at discharge compared with admission was addition of basal insulin, and treatment at discharge was maintained at 3 months in 89% of patients. CONCLUSION The HOSMIDIA study confirmed that management of hyperglycaemia with basal-bolus insulin is feasible and effective in routine clinical practice, and that a simple strategy facilitating the reconciliation of medication on discharge can improve glycaemic control postdischarge.
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Affiliation(s)
- A Pérez
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Maynard G, Ramos P, Kulasa K, Rogers KM, Messler J, Schnipper JL. How Sweet Is It? The Use of Benchmarking to Optimize Inpatient Glycemic Control. Diabetes Spectr 2014; 27:212-7. [PMID: 26246782 PMCID: PMC4523730 DOI: 10.2337/diaspect.27.3.212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
In Brief Hyperglycemia in the hospital setting affects 38-46% of noncritically ill hospitalized patients. Evidence from observational studies indicates that inpatient hyperglycemia, in patients with and without diabetes, is associated with increased risks of complications and mortality. Substantial evidence indicates that correction of hyperglycemia through insulin administration reduces hospital complications and mortality in critically ill patients, as well as in general medicine and surgery patients. This article provides a review of the evidence on the different therapies available for hyperglycemia management in noncritically ill hospitalized patients.
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Rodriguez A, Magee M, Ramos P, Seley JJ, Nolan A, Kulasa K, Caudell KA, Lamb A, MacIndoe J, Maynard G. Best Practices for Interdisciplinary Care Management by Hospital Glycemic Teams: Results of a Society of Hospital Medicine Survey Among 19 U.S. Hospitals. Diabetes Spectr 2014; 27:197-206. [PMID: 26246780 PMCID: PMC4523728 DOI: 10.2337/diaspect.27.3.197] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective. The Society for Hospital Medicine (SHM) conducted a survey of U.S. hospital systems to determine how nonphysician providers (NPPs) are utilized in interdisciplinary glucose management teams. Methods. An online survey grouped 50 questions into broad categories related to team functions. Queries addressed strategies that had proven successful, as well as challenges encountered. Fifty surveys were electronically distributed with an invitation to respond. A subset of seven respondents identified as having active glycemic committees that met at least every other month also participated in an in-depth telephone interview conducted by an SHM Glycemic Advisory Panel physician and NPP to obtain further details. The survey and interviews were conducted from May to July 2012. Results. Nineteen hospital/hospital system teams completed the survey (38% response rate). Most of the teams (52%) had existed for 1-5 years and served 90-100% of noncritical care, medical critical care, and surgical units. All of the glycemic control teams were supported by the use of protocols for insulin infusion, basal-bolus subcutaneous insulin orders, and hypoglycemia management. However, > 20% did not have protocols for discontinuation of oral hypoglycemic agents on admission or for transition from intravenous to subcutaneous insulin infusion. About 30% lacked protocols assessing A1C during the admission or providing guidance for insulin pump management. One-third reported that glycemic triggers led to preauthorized consultation or assumption of care for hyperglycemia. Institutional knowledge assessment programs were common for nurses (85%); intermediate for pharmacists, nutritionists, residents, and students (40-45%); and uncommon for fellows (25%) and attending physicians (20%). Many institutions were not monitoring appropriate use of insulin, oral agents, or insulin protocol utilization. Although the majority of teams had a process in place for post-discharge referrals and specific written instructions were provided, only one-fourth were supported with written protocols to standardize medication, education, equipment, and follow-up instructions. Conclusion. Inpatient glycemic control teams with NPPs often function in environments without a full set of measurement, education, standardization, transition, and order tools. Executive hospital leaders, community partners, and the glycemic control teams themselves need to address these deficiencies to optimize team effectiveness.
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Bansal B, Mithal A, Carvalho P, Mehta Y, Trehan N. Medanta insulin protocols in patients undergoing cardiac surgery. Indian J Endocrinol Metab 2014; 18:455-467. [PMID: 25143899 PMCID: PMC4138898 DOI: 10.4103/2230-8210.137486] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Hyperglycemia is common in patients undergoing cardiac surgery and is associated with poor outcomes. This is a review of the perioperative insulin protocol being used at Medanta, the Medicity, which has a large volume cardiac surgery setup. Preoperatively, patients are usually continued on their preoperative outpatient medications. Intravenous insulin infusion is intiated postoperatively and titrated using a column method with a choice of 7 scales. Insulin dose is calculated as a factor of blood glucose and patient's estimated insulin sensitivity. A comparison of this protocol is presented with other commonly used protocols. Since arterial blood gas analysis is done every 4 hours for first two days after cardiac surgery, automatic data collection from blood gas analyzer to a central database enables collection of glucose data and generating glucometrics. Data auditing has helped in improving performance through protocol modification.
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Affiliation(s)
- Beena Bansal
- Senior Consultant, Division of Endocrinology and Diabetes, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Ambrish Mithal
- Chairman, Division of Endocrinology and Diabetes, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Pravin Carvalho
- Scientist, Gida Technology Services, Bangalore, Karnataka, India
| | - Yatin Mehta
- Chairman, Institute of Critical Care and Anaesthesiology, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Naresh Trehan
- Chairman, Heart Institute-Division of Cardiothoracic and Vascular Surgery, Medanta, The Medicity, Gurgaon, Haryana, India
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Maynard G, Schnipper JL, Messler J, Ramos P, Kulasa K, Nolan A, Rogers K. Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics. J Diabetes Sci Technol 2014; 8:630-40. [PMID: 24876426 PMCID: PMC4764218 DOI: 10.1177/1932296814532237] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Insulin is a top source of adverse drug events in the hospital, and glycemic control is a focus of improvement efforts across the country. Yet, the majority of hospitals have no data to gauge their performance on glycemic control, hypoglycemia rates, or hypoglycemic management. Current tools to outsource glucometrics reports are limited in availability or function. Society of Hospital Medicine (SHM) faculty designed and implemented a web-based data and reporting center that calculates glucometrics on blood glucose data files securely uploaded by users. Unit labels, care type (critical care, non-critical care), and unit type (eg, medical, surgical, mixed, pediatrics) are defined on upload allowing for robust, flexible reporting. Reports for any date range, care type, unit type, or any combination of units are available on demand for review or downloading into a variety of file formats. Four reports with supporting graphics depict glycemic control, hypoglycemia, and hypoglycemia management by patient day or patient stay. Benchmarking and performance ranking reports are generated periodically for all hospitals in the database. In all, 76 hospitals have uploaded at least 12 months of data for non-critical care areas and 67 sites have uploaded critical care data. Critical care benchmarking reveals wide variability in performance. Some hospitals achieve top quartile performance in both glycemic control and hypoglycemia parameters. This new web-based glucometrics data and reporting tool allows hospitals to track their performance with a flexible reporting system, and provides them with external benchmarking. Tools like this help to establish standardized glucometrics and performance standards.
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Affiliation(s)
- Greg Maynard
- Department of Medicine, Division of Hospital Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
| | | | - Jordan Messler
- Morton Plant Hospital, Incompass Health, Clearwater, FL, USA
| | - Pedro Ramos
- University of California, San Diego, San Diego, CA, USA
| | - Kristen Kulasa
- Department of Endocrinology, Diabetes and Metabolism, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - Ann Nolan
- Society of Hospital Medicine, Philadelphia, PA, USA
| | - Kendall Rogers
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Saulnier GE, Castro JC, Cook CB. Statistical transformation and the interpretation of inpatient glucose control data from the intensive care unit. J Diabetes Sci Technol 2014; 8:560-7. [PMID: 24876620 PMCID: PMC4455452 DOI: 10.1177/1932296814524873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Glucose control can be problematic in critically ill patients. We evaluated the impact of statistical transformation on interpretation of intensive care unit inpatient glucose control data. Point-of-care blood glucose (POC-BG) data derived from patients in the intensive care unit for 2011 was obtained. Box-Cox transformation of POC-BG measurements was performed, and distribution of data was determined before and after transformation. Different data subsets were used to establish statistical upper and lower control limits. Exponentially weighted moving average (EWMA) control charts constructed from April, October, and November data determined whether out-of-control events could be identified differently in transformed versus nontransformed data. A total of 8679 POC-BG values were analyzed. POC-BG distributions in nontransformed data were skewed but approached normality after transformation. EWMA control charts revealed differences in projected detection of out-of-control events. In April, an out-of-control process resulting in the lower control limit being exceeded was identified at sample 116 in nontransformed data but not in transformed data. October transformed data detected an out-of-control process exceeding the upper control limit at sample 27 that was not detected in nontransformed data. Nontransformed November results remained in control, but transformation identified an out-of-control event less than 10 samples into the observation period. Using statistical methods to assess population-based glucose control in the intensive care unit could alter conclusions about the effectiveness of care processes for managing hyperglycemia. Further study is required to determine whether transformed versus nontransformed data change clinical decisions about the interpretation of care or intervention results.
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Affiliation(s)
- George E Saulnier
- Department of Information Technology, Mayo Clinic, Scottsdale, AZ, USA
| | - Janna C Castro
- Department of Information Technology, Mayo Clinic, Scottsdale, AZ, USA
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, AZ, USA
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Restuccia JD, Mohr D, Meterko M, Stolzmann K, Kaboli P. The association of hospital characteristics and quality improvement activities in inpatient medical services. J Gen Intern Med 2014; 29:715-22. [PMID: 24424776 PMCID: PMC4000331 DOI: 10.1007/s11606-013-2759-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/06/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Quality of U.S. health care has been the focus of increasing attention, with deficiencies in patient care well recognized and documented. However, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs. OBJECTIVE To identify 1) the extent of QIAs in Veterans Administration (VA) inpatient medical services; and 2) factors associated with widespread adoption of QIAs, in particular use of hospitalists, non-physician providers, and extent of goal alignment between the inpatient service and senior managers on commitment to quality. DESIGN Cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COM) at all 124 VA acute care hospitals. We conducted hierarchical regression, regressing QIA use on facility contextual variables, followed by use of hospitalists, non-physician providers, and goal alignment/quality commitment. MAIN MEASURES Outcome measures pertained to use of a set of 27 QIAs and to three dimensions--infrastructure, prevention, and information gathering--that were identified by factor analysis among the 27 QIAs overall. KEY RESULTS Survey response rate was 90 % (111/124). Goal alignment/quality commitment was associated with more widespread use of all four QIA categories [infrastructure (b = 0.42; p < 0.001); prevention (b = 0.24; p < 0.001); information gathering (b = 0.28; p = <0.001); and overall QIA (b = 0.31; p < 0.001)], as was greater use of hospitalists [infrastructure (b = 0.55; p = 0.03); prevention (b = 0.61; p < 0.001); information gathering (b = 0.75; p = 0.01); and overall QIAs (b = 0.61; p < 0.001)]; higher occupancy rate was associated with greater infrastructure QIAs (b = 1.05, p = 0.02). Non-physician provider use, hospital size, university affiliation, and geographic region were not associated with QIAs. CONCLUSION As hospitals respond to changes in healthcare (e.g., pay for performance, accountable care organizations), this study suggests that practices such as use of hospitalists and leadership focus on goal alignment/quality commitment may lead to greater implementation of QIAs.
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Affiliation(s)
- Joseph D Restuccia
- Center for Organizational Leadership and Management Research (COLMR), Boston VA Healthcare System, Boston, MA, USA,
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Glycemic Control Mentored Implementation: Creating a National Network of Shared Information. Jt Comm J Qual Patient Saf 2014; 40:111-8. [DOI: 10.1016/s1553-7250(14)40014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Vindedzis SA, Sherriff JL, Stanton KG. Hypoglycemia in Insulin-Treated Adults on Established Nasogastric Feeding in the General Ward: A Systematic Review. DIABETES EDUCATOR 2014; 40:290-298. [PMID: 24525570 DOI: 10.1177/0145721714523510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE This study aimed to address 2 questions: First, what are the existing summary statistics of frequency of hypoglycemia in insulin-treated adults on established nasogastric feeding in the general ward? Second, to what extent does lack of homogeneity in defining, identifying, and reporting hypoglycemia affect these statistics? METHODS A systematic review of the literature documenting hypoglycemia in insulin-treated adults on nasogastric feeding for ≥ 3 days in the general ward was carried out. Data sources were PubMed, Embase, ProQuest, Cochrane, Directory of Open Access Journals, and PLoS. Search period was 1999 onward, postdating introduction of analog insulin. RESULTS Initially, 231 studies were identified, with 9 judged suitable for inclusion, according to inclusion/exclusion criteria. All included studies had as their primary objective the assessment of efficacy of insulin/feed regimens in the target population. Studies exhibited major heterogeneity. Definitions of hypoglycemia varied from < 60 mg/dL (3.3 mmol/L) to < 80 mg/dL (4.4 mmol/L), and 5 methods of reporting frequency of hypoglycemia were utilized, precluding pooled analysis. A descriptive synthesis of results was generated with some comparable results presented on a modified forest plot, showing 2.1% to 10.2% of patients with a hypoglycemic event and 1.1% to 5.4% blood glucose level < 70 mg/dL (3.9 mmol/L). CONCLUSIONS Hypoglycemia is not uncommon in this population, but further research is needed for quantification. Standardized documentation and reporting methods incorporating sample size and study duration, such as hypoglycemic events per patient-days, would facilitate interstudy comparisons, as would documentation of hypoglycemia at the 2 most commonly defined levels: < 63 mg/dL (3.5 mmol/L) and < 70 mg/dL (3.9 mmol/L).
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Affiliation(s)
- Sally A Vindedzis
- Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Australia (Ms Vindedzis, Dr Stanton)
| | - Jill L Sherriff
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Bentley, Australia (Dr Sherriff)
| | - Kim G Stanton
- Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Australia (Ms Vindedzis, Dr Stanton)
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Abstract
Hypoglycemia in the inpatient setting is a common occurrence with potentially harmful outcomes. Large trials in both the inpatient and outpatient settings have found a correlation between hypoglycemia and morbidity and mortality. The incidence of hypoglycemia is difficult to assess, due to a lack of standardized definitions and different methods of data collection between hospital systems. Risk factors that predispose to hypoglycemia involve the changing clinical statuses of patients, nutrition issues, and hospital processes. Mechanisms contributing to morbidity due to hypoglycemia may include an increase in sympathoadrenal responses, as well as indirect changes affecting cytokine production, coagulation, fibrinolysis, and endothelial function. Prevention of hypoglycemia requires implementation of several strategies that include patient safety, quality control, multidisciplinary communication, and transitions of care. In this article, we discuss all of these issues and provide suggestions to help predict and prevent hypoglycemic episodes during an inpatient stay. We address the issues that occur upon admission, during the hospital stay, and around the time of discharge. We believe that decreasing the incidence of inpatient hypoglycemia will both decrease costs and improve patient outcomes.
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Affiliation(s)
- Leslie Eiland
- VA Nebraska - Western Iowa Health Care System, Omaha, NE, USA
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Umpierrez GE, Gianchandani R, Smiley D, Jacobs S, Wesorick DH, Newton C, Farrokhi F, Peng L, Reyes D, Lathkar-Pradhan S, Pasquel F. Safety and efficacy of sitagliptin therapy for the inpatient management of general medicine and surgery patients with type 2 diabetes: a pilot, randomized, controlled study. Diabetes Care 2013; 36:3430-5. [PMID: 23877988 PMCID: PMC3816910 DOI: 10.2337/dc13-0277] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study investigated the safety and efficacy of sitagliptin (Januvia) for the inpatient management of type 2 diabetes (T2D) in general medicine and surgery patients. RESEARCH DESIGN AND METHODS In this pilot, multicenter, open-label, randomized study, patients (n = 90) with a known history of T2D treated with diet, oral antidiabetic agents, or low total daily dose of insulin (≤0.4 units/kg/day) were randomized to receive sitagliptin alone or in combination with glargine insulin (glargine) or to a basal bolus insulin regimen (glargine and lispro) plus supplemental (correction) doses of lispro. Major study outcomes included differences in daily blood glucose (BG), frequency of treatment failures (defined as three or more consecutive BG >240 mg/dL or a mean daily BG >240 mg/dL), and hypoglycemia between groups. RESULTS Glycemic control improved similarly in all treatment groups. There were no differences in the mean daily BG after the 1st day of treatment (P = 0.23), number of readings within a BG target of 70 and 140 mg/dL (P = 0.53), number of BG readings >200 mg/dL (P = 0.23), and number of treatment failures (P > 0.99). The total daily insulin dose and number of insulin injections were significantly less in the sitagliptin groups compared with the basal bolus group (both P < 0.001). There were no differences in length of hospital stay (P = 0.78) or in the number of hypoglycemic events between groups (P = 0.86). CONCLUSIONS Results of this pilot indicate that treatment with sitagliptin alone or in combination with basal insulin is safe and effective for the management of hyperglycemia in general medicine and surgery patients with T2D.
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Umpierrez GE, Korytkowski M. Is incretin-based therapy ready for the care of hospitalized patients with type 2 diabetes?: Insulin therapy has proven itself and is considered the mainstay of treatment. Diabetes Care 2013; 36:2112-7. [PMID: 23801801 PMCID: PMC3687276 DOI: 10.2337/dc12-2233] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Significant data suggest that overt hyperglycemia, either observed with or without a prior diagnosis of diabetes, contributes to an increase in mortality and morbidity in hospitalized patients. In this regard, goal-directed insulin therapy has remained as the standard of care for achieving and maintaining glycemic control in hospitalized patients with critical and noncritical illness. As such, protocols to assist in management of hyperglycemia in the inpatient setting have become commonplace in hospital settings. Clearly, insulin is a known entity, has been in clinical use for almost a century, and is effective. However, there are limitations to its use. Based on the observed mechanisms of action and efficacy, there has been a great interest in using incretin-based therapy with glucagon-like peptide-1 (GLP-1) receptor agonists instead of, or complementary to, an insulin-based approach to improve glycemic control in hospitalized, severely ill diabetic patients. To provide an understanding of both sides of the argument, we provide a discussion of this topic as part of this two-part point-counterpoint narrative. In the point narrative preceding the counterpoint narrative below, Drs. Schwartz and DeFronzo provide an opinion that now is the time to consider GLP-1 receptor agonists as a logical consideration for inpatient glycemic control. In the counterpoint narrative provided below, Drs. Umpierrez and Korytkowski provide a defense of insulin in the inpatient setting as the unquestioned gold standard for glycemic management in hospitalized settings.
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Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA.
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Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, Boord JB, Braithwaite SS, Cagliero E, Dungan KM, Falciglia M, Figaro MK, Hirsch IB, Klonoff D, Korytkowski MT, Kosiborod M, Lien LF, Magee MF, Masharani U, Maynard G, McDonnell ME, Moghissi ES, Rasouli N, Rubin DJ, Rushakoff RJ, Sadhu AR, Schwartz S, Seley JJ, Umpierrez GE, Vigersky RA, Low CC, Wexler DJ. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013; 36:1807-14. [PMID: 23801791 PMCID: PMC3687296 DOI: 10.2337/dc12-2508] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.
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Affiliation(s)
- Boris Draznin
- Division of Endocrinology, Diabetes and Metabolism, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Bersoux S, Cook CB, Kongable GL, Shu J. Trends in glycemic control over a 2-year period in 126 US hospitals. J Hosp Med 2013; 8:121-5. [PMID: 23255411 DOI: 10.1002/jhm.1997] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/30/2012] [Accepted: 11/01/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cross-sectional data on inpatient glucose control in a large sample of US hospitals are now available, but little is known about changes in glycemic control over time in these institutions. OBJECTIVE To evaluate trends in glycemic control in US hospitals over 2 years. DESIGN Retrospective analysis. METHODS Point-of-care blood glucose (POC-BG) test results at 126 hospitals during January to December 2007 and January to December 2009 were extracted using the Remote Automated Laboratory System-Plus (Medical Automation Systems, Charlottesville, VA), and patient-day-weighted mean glucose levels were compared. SETTING/PATIENTS Hospitalized patients. RESULTS A total of 12,541,929 POC-BG measurements from 1,010,705 patients were analyzed for 2007, and 10,659,418 POC-BG measurements from 656,206 patients were analyzed for 2009. Patient-day-weighted mean POC-BG in 2009 decreased by 5 mg/dL in the non-intensive care unit (non-ICU) data compared with that in 2007 (154 mg/dL vs 159 mg/dL, respectively; P < 0.001). However, POC-BG values were clinically unchanged in intensive care unit (ICU) data from 2009 vs 2007 (167 mg/dL vs 166 mg/dL; P < 0.001). From 2007 to 2009, the proportion of patient-day-weighted mean POC-BGs that were >180 mg/dL declined from 28% to 25% in non-ICU patients (P < 0.001), but not in ICU. Decreases in patient-day-weighted mean POC-BG values in non-ICU patients were significant regardless of hospital size, type, and geographic region (all P < 0.001), but similar decreases were not found in ICU data. CONCLUSIONS In this first analysis of glucose changes in US hospitals, improvements over 2 years occurred in non-ICU patients. Ongoing analysis will determine whether this trend continues.
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Affiliation(s)
- Sophie Bersoux
- Division of Community Internal Medicine Mayo Clinic, Scottsdale, AZ 85259, USA.
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Maynard GA, Budnitz TL, Nickel WK, Greenwald JL, Kerr KM, Miller JA, Resnic JN, Rogers KM, Schnipper JL, Stein JM, Whitcomb WF, Williams MV. 2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level. Jt Comm J Qual Patient Saf 2012; 38:301-10. [PMID: 22852190 DOI: 10.1016/s1553-7250(12)38040-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions). METHODS More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center. RESULTS Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams. CONCLUSIONS Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.
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Affiliation(s)
- Gregory A Maynard
- Division of Hospital Medicine, University of California, San Diego, USA.
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Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract 2012; 17:853-61. [PMID: 21550947 DOI: 10.4158/ep11042.or] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To provide data on glucose control in hospitals in the United States, analyzing measurements from the largest number of facilities to date. METHODS Point-of-care bedside glucose (POC-BG) test results were extracted from 575 hospitals from January 2009 to December 2009 by using a laboratory information management system. Glycemic control for patients in the intensive care unit (ICU) and non-ICU areas was assessed by calculating patient-day-weighted mean POC-BG values and rates of hypoglycemia and hyperglycemia. The relationship between POC-BG levels and hospital characteristics was determined. RESULTS A total of 49,191,313 POC-BG measurements (12,176,299 ICU and 37,015,014 non-ICU values) were obtained from 3,484,795 inpatients (653,359 in the ICU and 2,831,436 in non-ICU areas). The mean POC-BG was 167 mg/dL for ICU patients and 166 mg/dL for non-ICU patients. The prevalence of hyperglycemia (>180 mg/dL) was 32.2% of patient-days for ICU patients and 32.0% of patient-days for non-ICU patients. The prevalence of hypoglycemia (<70 mg/dL) was 6.3% of patient-days for ICU patients and 5.7% of patient-days for non-ICU patients. Patient-day-weighted mean POC-BG levels varied on the basis of hospital size (P<.01), type (P<.01), and geographic location (P<.01) for ICU and non-ICU patients, with larger hospitals (≥400 beds), academic hospitals, and US hospitals in the West having the lowest mean POC-BG values. The percentage of patient-days in the ICU characterized by hypoglycemia was highest among larger and academic hospitals (P<.05) and least among hospitals in the Northeast (P<.001). CONCLUSION Hyperglycemia is common in hospitals in the United States, and glycemic control may vary on the basis of hospital characteristics. Increased hospital participation in data collection may support a national benchmarking process for the development of optimal practices to manage inpatient hyperglycemia.
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Affiliation(s)
- Christine M Swanson
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona 85259, USA
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Hsia E, Seggelke SA, Gibbs J, Rasouli N, Draznin B. Comparison of 70/30 biphasic insulin with glargine/lispro regimen in non-critically ill diabetic patients on continuous enteral nutrition therapy. Nutr Clin Pract 2012; 26:714-7. [PMID: 22205560 DOI: 10.1177/0884533611420727] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite significant advances in inpatient diabetes management, it is still a challenge to choose the safest and most efficacious subcutaneous insulin regimen for diabetic patients on continuous enteral nutrition (EN) therapy. The authors conducted a retrospective analysis of glycemic control in 22 non-critically ill diabetic patients, receiving at least 3 days of continuous EN. Patients received different insulin regimens while on continuous EN, including a basal/bolus glargine/lispro regimen (group 1, n = 8), 70/30 biphasic insulin twice daily (group 2, n = 8), and 70/30 biphasic insulin 3 times a day (group 3, n = 6). The glucose data from 72 hours from the initiation of EN were analyzed (12 point-of-contact glucose measurements per patient). Overall, the degree of control was comparable in all groups, with target range maintained more consistently in group 3 (70/30 insulin administered 3 times daily). In this group, 69% of values were in the target range (140-180 mg/dL) as compared with 24% in glargine/lispro group and 22% in the 70/30 insulin bid group. Eight hypoglycemic episodes occurred among the 3 groups: 5 episodes in group 1 (5.4%), 2 episodes in group 2 (2.1%), and 1 episode in group 3 (1.4%) (P = .05, groups 2 and 3 vs group 1). Administration of 70/30 biphasic insulin 3 times daily is a safe therapeutic regimen in diabetic patients on continuous EN as it maintains glycemia in the target range and might produce fewer episodes of hypoglycemia.
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Affiliation(s)
- Elisa Hsia
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Denver, 12801 E 17th Ave, Aurora, CO 80045, USA
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Abstract
Inpatient glucose control today is complex and challenging for the clinician. The importance of avoiding wide swings in the BG levels and hypoglycemic events cannot be underestimated. Nurses must be at the table as insulin protocols or physician order sets are being developed to address issues with readability and understanding. Education of all staff is extremely important with follow-up education at intervals for both nurses and physician providers. While there are no official guidelines for quality of inpatient glycemic control, a multidisciplinary team consisting of key physicians (endocrinology and others), clinical nurse specialists, and diabetes educator and clinical pharmacist can develop quality improvement projects for monitoring and process improvement. Continuous monitoring of practices will reduce the risk for errors and support safe practices.
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Qureshi A, Deakins DA, Reynolds LR. Obstacles to optimal management of inpatient hyperglycemia in noncritically ill patients. Hosp Pract (1995) 2012; 40:36-43. [PMID: 22615077 DOI: 10.3810/hp.2012.04.968] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Compelling evidence continues to evolve linking hyperglycemia in hospitalized patients with adverse clinical outcomes. In 2012, The Endocrine Society's clinical practice guidelines for management of hyperglycemia in non-critical care settings were published, and explicit blood glucose targets for noncritically ill patients were recommended. These matched those set by the American Diabetes Association (ADA) in the Standards of Medical Care in Diabetes--2012. Although there are more specific targets for achieving optimal glycemic control in critically ill and noncritically ill inpatients, implementing standardized processes to achieve these goals continues to remain a challenge. This article summarizes these obstacles and emphasizes the quality of care and safety issues (eg, hypoglycemia and insulin errors) that are associated with the management of hyperglycemia in hospitalized patients. The use of intravenous insulin via computerized or manual standardized protocols in critically ill patients has been shown to be effective in achieving glucose control; we focus on the barriers to the appropriate use of subcutaneous insulin in hospitalized patients with noncritical illness. We also elaborate on how to overcome most of these obstacles and the clinical inertia to treat hyperglycemia through focused education and surveillance, and then "re-education," using a multidisciplinary, collaborative approach. Transition from intravenous insulin to subcutaneous insulin, and transition from an inpatient to an outpatient glycemic regimen at the time of discharge, are identified as aspects of management that require extra attention. We also emphasize the need for a multidisciplinary task force responsible for monitoring and enhancing glycemic control practices in the hospital on an ongoing basis.
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Affiliation(s)
- Ambreen Qureshi
- Department of Internal Medicine, Division of Endocrinology and Molecular Medicine, University of Kentucky College of Medicine, Lexington, KY; University of Kentucky Chandler Medical Center, Lexington, KY.
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Abstract
Despite the emergence of glucometrics (i.e., systematic analysis of data on blood glucose levels of inpatients) as a subject of high interest, there remains a lack of standardization on how glucose parameters are measured and reported. This dilemma must be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines and that can also be supported by quality care organizations. In this article, we review some of the questions that need to be resolved through consensus and review of the evidence, and discuss some of the limitations in analyzing and reporting inpatient glucose data that must be addressed (or at least accepted as limitations) before hospitals can commit resources to gathering, compiling, and presenting inpatient glucose statistics as a health care quality measure. Standards must include consensus on which measures to report, the unit of analysis, definitions of targets for hyperglycemia treatment, a definition of hypoglycemia, determination of how data should be gathered (from chart review or from laboratory information systems), and which type of sample (blood or point of care) should be used for analysis of glycemic control. Hospitals and/or their representatives should be included in the discussion. For inpatient glucose control to remain a focus of interest, further dialogue and consensus on the topic are needed.
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Affiliation(s)
- Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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Wesorick DH, Grunawalt J, Kuhn L, Rogers MAM, Gianchandani R. Effects of an educational program and a standardized insulin order form on glycemic outcomes in non-critically ill hospitalized patients. J Hosp Med 2010; 5:438-45. [PMID: 20690189 DOI: 10.1002/jhm.780] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The optimal approach to managing hyperglycemia in noncritically ill hospital patients is unclear. OBJECTIVE To investigate the effects of targeted quality improvement interventions on insulin prescribing and glycemic control. DESIGN A cohort study comparing an intervention group (IG) to a concurrent control group (CCG) and an historic control group (HCG). SETTING University of Michigan Hospital. PATIENTS Hyperglycemic, noncritically ill hospital patients treated with insulin. INTERVENTION Physician and nurse education and a standardized insulin order form based on the principles of physiologic insulin use. MEASUREMENTS Glycemic control and insulin prescribing patterns. RESULTS Patients in the IG were more likely to be treated with a combination of scheduled basal and nutritional insulin than in the other groups. In the final adjusted regression model, patients in the IG were more likely to be in the target glucose range (odds ratio [OR], 1.72; P = 0.01) and less likely to be severely hyperglycemic (OR, 0.65; P < 0.01) when compared to those in the CCG. Patients in the IG were also less likely to experience hypoglycemia than those in the CCG (P = 0.06) or the HCG (P = 0.01). Over 80% of all patient-days for all groups contained glucose readings outside of the target range. CONCLUSIONS Standardized interventions encouraging the physiologic use of subcutaneous insulin can lead to significant improvements in glycemic control and patient safety in hospitalized patients. However, the observed improvements are modest, and poor metabolic control remains common, despite these interventions. Additional research is needed to determine the best strategy for safely achieving metabolic control in these patients.
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Affiliation(s)
- David H Wesorick
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Whelan CT. The role of the hospitalist in quality improvement: systems for improving the care of patients with acute coronary syndrome. J Hosp Med 2010; 5 Suppl 4:S1-7. [PMID: 20842745 DOI: 10.1002/jhm.828] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Quality improvement (QI) initiatives for systems of care are vital to deliver quality care for patients with acute coronary syndrome (ACS) and hospitalists are instrumental to the QI process. Core hospitalist competencies include the development of protocols and outcomes measures that support quality of care measures established for ACS. The hospitalist may lead, coordinate, or participate in a multidisciplinary team that designs, implements, and assesses an institutional system of care to address rapid identification of patients with ACS, medication safety, safe discharge, and meeting core measures that are quality benchmarks for ACS. The use of metrics and tools such as process flow mapping and run charts can identify quality gaps and show progress toward goals. These tools may be used to assess whether critical timeframes are met, such as the time to fibrinolysis or percutaneous coronary intervention (PCI), or whether patients receive guideline-recommended medications and counseling. At the institutional level, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is an initiative designed to improve outcomes in elderly patients who are at higher risk for adverse events during the transition from inpatient to outpatient care. BOOST offers resources related to project management and data collection, and tools for patients and physicians. Collection and analysis of objective data are essential for documenting quality gaps or achievement of quality benchmarks. Through QI initiatives, the hospitalist has an opportunity to contribute to an institution's success beyond direct patient care, particularly as required for public disclosure of institutional performance and financial incentives promoted by regulatory agencies.
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Affiliation(s)
- Chad T Whelan
- Division of Hospital Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
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Miller AD, Phillips LM, Schulz RM, Bookstaver PB, Rudisill CN. Differences in hospital glycemic control and insulin requirements in patients recovering from critical illness and those without prior critical illness. Clin Pharmacol 2010; 2:143-8. [PMID: 22291498 PMCID: PMC3262364 DOI: 10.2147/cpaa.s11259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Hospital patients recovering from critical illness on general floors often receive insulin therapy based on protocols designed for patients admitted directly to general floors. The objective of this study is to compare glycemic control and insulin dosing in patients recovering from critical illness and those without prior critical illness. Methods Medical record review of blood glucose measurements and insulin dosing in 25 patients under general ward care while transitioning from the intensive care unit (transition group) and 25 patients admitted directly to the floor (direct floor group). Results Average blood glucose did not differ significantly between groups (transition group 9.49 mmol/L, direct floor group 9.6 mmol/L; P = 0.83). Significant differences in insulin requirements were observed between groups with average daily doses of 55.9 units in patients transitioning from the intensive care unit (ICU) versus 25.6 units in the direct floor group (P = 0.004). Conclusions Patients recovering from critical illness required significantly larger doses of insulin than those patients admitted directly to the floor. Managing insulin therapy in patients transitioning from the ICU may require greater insulin doses.
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Affiliation(s)
- April D Miller
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy - University of South Carolina Campus, Columbia, SC, USA.
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Schnipper JL, Liang CL, Ndumele CD, Pendergrass ML. Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial. Endocr Pract 2010; 16:209-18. [PMID: 20061280 DOI: 10.4158/ep09262.or] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia. METHODS We conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital's computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL. RESULTS Between April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose <40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58). CONCLUSION The use of an order set built into a hospital's CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program.
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613, USA.
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