1
|
Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2022; 69:500-508. [PMID: 36038498 DOI: 10.1016/j.endien.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/28/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Hyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes. AIMS We implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA1c > 8%, to improve their metabolic control after hospital admission. METHODS Non-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge. RESULTS During the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ± 1,5 vs. 7,3 ± 1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program. CONCLUSIONS The program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.
Collapse
|
2
|
Control de la glucemia durante la hospitalización: Enfermera de práctica avanzada y herramientas semiautomáticas de prescripción de insulina. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
3
|
Goyal N, Rose R, Johnson SA, Babbel D, Plugge T, Hodgkin J, Simmons D, Yarbrough P. Insulin for Hospitalized Patients With Well-Controlled Type 2 Diabetes Mellitus: A Quality Improvement Initiative. J Healthc Qual 2022; 44:210-217. [PMID: 35302962 DOI: 10.1097/jhq.0000000000000342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Inpatient management of diabetes mellitus (DM) often involves substituting oral medications with insulin which can result in unnecessary insulin use. Attempting to address unnecessary insulin use, a quality improvement initiative implemented a newly developed evidence-based care pathway for inpatient diabetes management focused on patients with recent hemoglobin A1c values < 8% and no prescription of outpatient insulin. This retrospective observational preintervention and postintervention and interrupted time series analysis evaluates this intervention. Over a 21-month time period, there was a significant decrease in mean units of insulin administered per day of hospitalization from 2.7 (2.2-3.3) in the preintervention group to 1.7 (1.2-2.3) in the postintervention group ( p = .017). During the initial 72 hours after admission, a significant downward trend in mean glucose values and mean insulin units per day was seen after the intervention. There was no significant change in hypoglycemic or hyperglycemic events between the two groups. The proportion of patients who received zero units of insulin during their admission increased from 27.7% to 52.5% after the intervention ( p < .001). An evidence-based pathway for inpatient management of DM was associated with decreased insulin use without significant changes in hypoglycemic or hyperglycemic events.
Collapse
|
4
|
Leighton ME, Thompson BM, Castro JC, Cook CB. Nurse adherence to post–hypoglycemic event monitoring for hospitalized patients with diabetes mellitus. Appl Nurs Res 2020; 56:151338. [DOI: 10.1016/j.apnr.2020.151338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
|
5
|
Horton WB, Law S, Darji M, Conaway MR, Akbashev MY, Kubiak NT, Kirby JL, Thigpen SC. A MULTICENTER STUDY EVALUATING PERCEPTIONS AND KNOWLEDGE OF INPATIENT GLYCEMIC CONTROL AMONG RESIDENT PHYSICIANS: ANALYZING THEMES TO INFORM AND IMPROVE CARE. Endocr Pract 2019; 25:1295-1303. [PMID: 31412227 DOI: 10.4158/ep-2019-0299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control. Abbreviations: DM = diabetes mellitus; Emory = Emory University Healthcare; IGC = inpatient glycemic control; IGCQ = Inpatient Glycemic Control Questionnaire; IRB = Institutional Review Board; PGY = postgraduate year; UMMC = University of Mississippi Medical Center; UVA = University of Virginia Health System; UL = University of Louisville Health Sciences Center.
Collapse
|
6
|
Bain A, Hasan SS, Babar ZUD. Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review. Diabet Med 2019; 36:948-960. [PMID: 31050037 DOI: 10.1111/dme.13982] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/12/2022]
Abstract
AIM To conduct a systematic review of literature to identify interventions that are effective in improving insulin prescribing for people with diabetes in the hospital setting. METHODS Computerized bibliographic databases were searched for studies published in English that described the effectiveness of interventions to improve insulin prescribing within the hospital setting. Studies were eligible for inclusion if they reported data that compared insulin prescribing practice after an intervention or compared with a control group. Studies were not excluded on the basis of publication date, geographical location or risk of bias assessment. RESULTS We identified 35 studies for inclusion in the review, including two cluster randomized controlled trials, two cohort studies, and 31 uncontrolled before-after studies. Studies reported a variety of interventions that aimed to increase insulin prescribing accuracy or completeness or decrease the use of discouraged subcutaneous sliding scale insulin regimens. Differences in definition of insulin prescribing error, terminology and common practice based on geographical location was evident, and quality issues with respect to study design and reporting somewhat limited the interpretation of conclusions. CONCLUSIONS Implementing strategies that are sensitive to local context and designed to increase adherence to insulin prescribing guidelines are associated with a reduction in prescribing errors. Future implementation should build on effective approaches including multifaceted interventions involving multiple stakeholders at various institutional levels. Future studies in insulin prescribing errors would benefit from the use of standardized approaches, terminology and outcome measures to enable greater comparison.
Collapse
Affiliation(s)
- A Bain
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S S Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | | |
Collapse
|
7
|
Horton WB, Law S, Darji M, Conaway MR, Kubiak NT, Kirby JL, Thigpen SC. Construction and preliminary evaluation of the inpatient glycemic control questionnaire (IGCQ): a survey tool assessing perceptions and knowledge of resident physicians. BMC MEDICAL EDUCATION 2019; 19:228. [PMID: 31234836 PMCID: PMC6591905 DOI: 10.1186/s12909-019-1657-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 06/06/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Uncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool. METHODS We developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items. RESULTS Two hundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development. CONCLUSIONS We constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.
Collapse
Affiliation(s)
- William B. Horton
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - Sidney Law
- Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Monika Darji
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Mark R. Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA USA
| | - Nancy T. Kubiak
- Division of General Internal Medicine, Palliative Medicine, and Medical Education, Department of Medicine, University of Louisville, Louisville, KY USA
| | - Jennifer L. Kirby
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - S. Calvin Thigpen
- Division of General Internal Medicine and Hypertension, Department of Medicine, University of Mississippi Medical Center, Jackson, MS USA
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Apsey HA, Coan KE, Castro JC, Jameson KA, Schlinkert RT, Cook CB. Overcoming clinical inertia in the management of postoperative patients with diabetes. Endocr Pract 2016; 20:320-8. [PMID: 24246354 DOI: 10.4158/ep13366.or] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the impact of an intervention designed to increase basal-bolus insulin therapy administration in postoperative patients with diabetes mellitus. METHODS Educational sessions and direct support for surgical services were provided by a nurse practitioner (NP). Outcome data from the intervention were compared to data from a historical (control) period. Changes in basal-bolus insulin use were assessed according to hyperglycemia severity as defined by the percentage of glucose measurements >180 mg/dL. RESULTS Patient characteristics were comparable for the control and intervention periods (all P≥.15). Overall, administration of basal-bolus insulin occurred in 9% (8/93) of control and in 32% (94/293) of intervention cases (P<.01). During the control period, administration of basal-bolus insulin did not increase with more frequent hyperglycemia (P = .22). During the intervention period, administration increased from 8% (8/96) in patients with the fewest number of hyperglycemic measurements to 60% (57/95) in those with the highest frequency of hyperglycemia (P<.01). The mean glucose level was lower during the intervention period compared to the control period (149 mg/dL vs. 163 mg/dL, P<.01). The proportion of glucose values >180 mg/dL was lower during the intervention period than in the control period (21% vs. 31% of measurements, respectively, P<.01), whereas the hypoglycemia (glucose >70 mg/dL) frequencies were comparable (P = .21). CONCLUSION An intervention to overcome clinical inertia in the management of postoperative patients with diabetes led to greater utilization of basal-bolus insulin therapy and improved glucose control without increasing hypoglycemia. These efforts are ongoing to ensure the delivery of effective inpatient diabetes care by all surgical services.
Collapse
Affiliation(s)
- Heidi A Apsey
- Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Kathryn E Coan
- Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Janna C Castro
- Department of Information Technology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Kimberly A Jameson
- Division of Planning Services and Practice Analysis, Mayo Clinic, Scottsdale, Arizona
| | | | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona
| |
Collapse
|
10
|
Gianchandani R, Umpierrez GE. Inpatient Use of Computer-Guided Insulin Devices Moving into the Non-Intensive Care Unit Setting. Diabetes Technol Ther 2015; 17:673-5. [PMID: 26355754 PMCID: PMC4575546 DOI: 10.1089/dia.2015.0213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Roma Gianchandani
- Department of Internal Medicine, Division of Metabolism and Endocrinology, Inpatient Hyperglycemia Service, University of Michigan, Ann Arbor, Michigan
| | | |
Collapse
|
11
|
Yost J, Ganann R, Thompson D, Aloweni F, Newman K, Hazzan A, McKibbon A, Dobbins M, Ciliska D. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: a systematic review and meta-analysis. Implement Sci 2015; 10:98. [PMID: 26169063 PMCID: PMC4499897 DOI: 10.1186/s13012-015-0286-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 06/30/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nurses are increasingly expected to engage in evidence-informed decision-making (EIDM) to improve client and system outcomes. Despite an improved awareness about EIDM, there is a lack of use of research evidence and understanding about the effectiveness of interventions to promote EIDM. This project aimed to discover if knowledge translation (KT) interventions directed to nurses in tertiary care are effective for improving EIDM knowledge, skills, behaviours, and, as a result, client outcomes. It also sought to understand contextual factors that affect the impact of such interventions. METHODS A systematic review funded by the Canadian Institutes of Health Research (PROSPERO registration: CRD42013003319) was conducted. Included studies examined the implementation of any KT intervention involving nurses in tertiary care to promote EIDM knowledge, skills, behaviours, and client outcomes or studies that examined contextual factors. Study designs included systematic reviews, quantitative, qualitative, and mixed method studies. The search included electronic databases and manual searching of published and unpublished literature to November 2012; key databases included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica (EMBASE). Two reviewers independently performed study selection, risk of bias assessment, and data extraction. Studies with quantitative data determined to be clinically homogeneous were synthesized using meta-analytic methods. Studies with quantitative data not appropriate for meta-analysis were synthesized narratively by outcome. Studies with qualitative data were synthesized by theme. RESULTS Of the 44,648 citations screened, 30 citations met the inclusion criteria (18 quantitative, 10 qualitative, and 2 mixed methods studies). The quality of studies with quantitative data ranged from very low to high, and quality criteria was generally met for studies with qualitative data. No studies evaluated the impact on knowledge and skills; they primarily investigated the effectiveness of multifaceted KT strategies for promoting EIDM behaviours and improving client outcomes. Almost all studies included an educational component. A meta-analysis of two studies determined that a multifaceted intervention (educational meetings and use of a mentor) did not increase engagement in a range of EIDM behaviours [mean difference 2.7, 95 % CI (-1.7 to 7.1), I (2) = 0 %]. Among the remaining studies, no definitive conclusions could be made about the relative effectiveness of the KT interventions due to variation of interventions and outcomes, as well as study limitations. Findings from studies with qualitative data identified the organizational, individual, and interpersonal factors, as well as characteristics of the innovation, that influence the success of implementation. CONCLUSIONS KT interventions are being implemented and evaluated on nurses' behaviour and client outcomes. This systematic review may inform the selection of KT interventions and outcomes among nurses in tertiary care and decisions about further research.
Collapse
Affiliation(s)
- Jennifer Yost
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Rebecca Ganann
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - David Thompson
- School of Nursing, Faculty of Health and Behavioural Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, Canada.
| | - Fazila Aloweni
- Singapore General Hospital, 31 Third Hospital Avenue, Singapore, Singapore.
| | - Kristine Newman
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, 350 Victoria Street, Toronto, ON, Canada.
| | - Afeez Hazzan
- Department of Medicine, McMaster University, St. Peter's Hospital-Hamilton Health Sciences, 88 Maplewood Avenue, Hamilton, ON, Canada.
| | - Ann McKibbon
- Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Maureen Dobbins
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| | - Donna Ciliska
- School of Nursing, Faculty of Health Sciences, McMaster University, Main Street West, Hamilton, ON, Canada.
| |
Collapse
|
12
|
Tamler R, Dunn AS, Green DE, Skamagas M, Breen TL, Looker HC, LeRoith D. Effect of online diabetes training for hospitalists on inpatient glycaemia. Diabet Med 2013; 30:994-8. [PMID: 23398488 DOI: 10.1111/dme.12151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 10/15/2012] [Accepted: 02/05/2013] [Indexed: 01/07/2023]
Abstract
AIM An online diabetes course for medical residents led to lower patient blood glucose, but also increased hypoglycaemia despite improved trainee confidence and knowledge. Based on these findings, we determined whether an optimized educational intervention delivered to hospitalists (corresponding to an Acute Physician or Specialist in Acute Hospital Medicine in the UK) improved inpatient glycaemia without concomitant hypoglycaemia. METHODS All 22 hospitalists at an academic medical centre were asked to participate in an online curriculum on the management of inpatient dysglycaemia in autumn 2009 and a refresher course in spring 2010. RESULTS All hospitalists completed the initial intervention. Median event blood glucose decreased from 9.3 mmol/l (168 mg/dl) pre-intervention to 7.8 mmol/l (141 mg/dl) post-intervention and 8.5 mmol/l (153 mg/dl) post-refresher (P < 0.001 for both). Hospitalizations categorized as hyperglycaemia decreased from 83.3 to 55.6% (P = 0.014), with a trend towards euglycaemia (10-28.9%, P = 0.08) and no change in hypoglycaemia. Hyperglycaemic patient-days decreased from 72.0 to 57.3% (P = 0.004), with greater target glycaemia (27.3-39.4%, P = 0.016) and no change in hypoglycaemia. CONCLUSIONS An optimized online educational intervention delivered to hospitalists yielded significant improvements in inpatient glycaemia without increased hypoglycaemia.
Collapse
Affiliation(s)
- R Tamler
- Hilda & J. Lester Gabrilove Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | | | | | | | | | | |
Collapse
|
13
|
Coan KE, Schlinkert AB, Beck BR, Haakinson DJ, Castro JC, Apsey HA, Schlinkert, RT, Cook CB. Clinical inertia during postoperative management of diabetes mellitus: relationship between hyperglycemia and insulin therapy intensification. J Diabetes Sci Technol 2013; 7:880-7. [PMID: 23911169 PMCID: PMC3879752 DOI: 10.1177/193229681300700410] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our objective was to assess the application of insulin regimens in surgical postoperative patients with diabetes. METHODS A chart review was conducted of patients with diabetes who were hospitalized postoperatively between January 1 and April 30, 2011. Analysis was restricted to patients hospitalized for ≥3 days and excluded cases with an endocrinology consult. Insulin regimens were categorized as "basal plus short acting," "short acting only," or "none," and the pattern of use was evaluated by hyperglycemia severity according to tertiles of both mean glucose and the number of glucose measurements >180 mg/dl. RESULTS Among cases selected for analysis (n = 119), examination of changes in insulin use based on tertiles of mean glucose showed that use of basal plus short-acting insulin increased from 10% in the lowest tertile (mean glucose, 120 mg/dl) to 18% in the highest tertile (mean glucose, 198 mg/dl; p < .01); however, 70% of patients in the highest tertile continued to receive short-acting insulin only, with 12% receiving no insulin. Intensification of insulin to a basal plus short-acting regimen was also seen when changes were evaluated by the number of measurements >180 mg/dl (p < .01), but 70% and 12% of patients in the highest tertile still remained only on short-acting insulin or received no insulin, respectively. CONCLUSIONS Use of basal plus short-acting insulin therapy increased with worsening hyperglycemia, but many cases did not have therapy intensified to the recommended insulin regimen--evidence of clinical inertia. Strategies should be devised to overcome inpatient clinical inertia in the treatment of postoperative patients with diabetes.
Collapse
|
14
|
|