In-hospital management of type 2 diabetes mellitus

Implementation of a New Intravenous Insulin Method on Intermediate-Care Units in Hospitalized Patients

Good blood glucose control in hospitalized adults leads to reduced mortality. Intravenous (IV) insulin has been shown to be an effective way to achieve tight control of blood glucose. Managing IV insulin is a labor-intensive task for nurses and is generally done in intensive care units with high nurse-to-patient ratios. In this 3-month study, intermediate-care general medicine units with a nurse-to-patient ratio of 1 to 5 or 6 were evaluated for effectiveness of monitoring IV insulin. The project, which relied on intensive in-service education, an audit tool, and continuous positive feedback for nurses, yielded positive results.

Transitioning safely from intravenous to subcutaneous insulin

The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease.

[Consensus document on the management after hospital discharge of patient with hyperglycaemia]

The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge.

Planejamento da alta hospitalar do paciente diabético: construção de uma proposta

As complicações agudas e crônicas enfrentadas pelo paciente diabético e sua família após a alta hospitalar podem ser consequência de deficiências no processo educativo ao longo da hospitalização e do preparo formal para alta. O objetivo deste estudo é apresentar uma proposta de planejamento da alta hospitalar do paciente diabético adulto. Foi realizada revisão de literatura sobre alta hospitalar da clientela em questão, selecionando-se artigos publicados de 2004 a fevereiro de 2009. Considerando a literatura, foi desenvolvido um impresso para nortear o planejamento da alta. Este abrange informações a serem colhidas e trabalhadas junto ao cliente, ao longo dos primeiros quatro dias de internação, considerando as necessidades individuais e o Autocontrole ineficaz da saúde. A alta precisa estar inserida no Processo de Enfermagem, uma vez que o enfermeiro tem papel fundamental na identificação das necessidades do paciente e família. O impresso auxilia a identificação das necessidades do cliente e das ações realizadas pela equipe.

Pharmacists' role in ensuring safe and effective hospital use of insulin

PURPOSE

To highlight the potential errors that may occur with insulin use in the inpatient setting and to describe how pharmacists can be part of the solution by implementing practices that reduce the likelihood of insulin-related medication errors.

SUMMARY

Insulin is a drug with a low therapeutic index, and it bears a heightened risk of causing significant patient harm when used in error, making it a high-alert medication. Both underdosing and overdosing of insulin may be associated with adverse outcomes. The use of standard insulin order sets for scheduled subcutaneous insulin administration and standard concentrations for i.v. insulin are recommended to ensure the safe use of this medication. Any ambiguous insulin therapy orders should be clarified in writing prior to administration. Preparation of all insulin infusions should occur within the pharmacy. Pharmacists should be aware of possible medication errors related to inappropriate use of abbreviations such as U for units. Safe insulin storage practices are recommended to reduce the risk for insulin error. Insulin pen delivery devices may be used in hospitals, but safe use depends on ongoing oversight by a multidisciplinary committee, introduction of one device at a time, and initial and regular follow-up education of nurses, including agency nurses and those who work part-time. In addition, ongoing monitoring is needed to assure ongoing safety. The use of sliding-scale insulin can lead to hyperglycemia and hypoglycemia and is confusing and prone to error; it is not recommended.

CONCLUSION

Pharmacists can contribute to the safe use of insulin in the inpatient setting by minimizing the likelihood of medication errors related to prescribing, transcription, dispensing, administration, storage, and communication.

Psychometric validation and use of a novel diabetes in-patient treatment satisfaction questionnaire

AIMS

To develop the first psychometrically validated Diabetes Treatment Satisfaction Questionnaire for in-patients (DTSQ-IP) and examine determinants of in-patient diabetes treatment satisfaction.

METHODS

We studied 366 in-patients with insulin-treated diabetes at a single UK centre. We developed a 19-item DTSQ-IP to assess in-patient diabetes treatment satisfaction, and collected data on in-patient length of stay (LOS) and in-patient care at the same time.

RESULTS

Psychometric analyses including Principal Components Analysis and Cronbach's alpha reliability coefficient showed that a single satisfaction score (excluding two items scored individually) can be computed for the entire DTSQ-IP, indicating very good internal consistency reliability (0.92). The DTSQ-IP detected considerable dissatisfaction with meal choice and timing (13.7% of in-patients would never have chosen similar meals at home), and with in-patient hypoglycaemia (35.3% felt that their blood glucose was too low most of the time). In-patients on surgical wards, women, and those long established on insulin were significantly more dissatisfied, particularly with competence of hospital staff. Patients who administered their own insulin were not significantly less dissatisfied overall, but were so with the choice of meals (P = 0.005). Multiple regression analysis produced a model accounting for 8.2% of variability in DTSQ-IP (r = 0.29; P = 0.0058) and 21.7% of variability in LOS (r = 0.46; P = 0.0001).

CONCLUSIONS

The DTSQ-IP is a novel, psychometrically validated and sensitive tool that adds to the DTSQ portfolio. The DTSQ-IP facilitates efforts to assess and improve treatment satisfaction in in-patients with diabetes.

Metabolic syndrome

Hirsutism is a finding that can lead to subsequent metabolic diagnoses such as the metabolic syndrome. Metabolic syndrome describes a cluster of cardiometabolic risk factors associated with overweight and obesity. Although it has been the subject of some controversy, perhaps due to the many definitions proposed by different health organizations, metabolic syndrome is clinically relevant in that it is a predictor of vascular risk, even independent of any associated type 2 diabetes. While various definitions may differ in precise cut-off points, they uniformly emphasize key pathophysiologic processes: visceral obesity, dyslipidemia, insulin resistance, and hypertension. Management of metabolic syndrome focuses on methods of reducing the component risk factors, and therapies thus target the above processes as well as controlling inflammation and the prothrombotic state. Treatments can include not only pharmacologic approaches but behavior modification as well.

Total and excess bed occupancy by age, specialty and insulin use for nearly one million diabetes patients discharged from all English Acute Hospitals

To investigate total diabetes bed occupancy and prolonged inpatient length of stay (LOS) in all English Acute Hospitals, we analysed hospital episode statistics (HES) discharge data for all English Acute Hospitals over 4 years for ICD10 discharge codes of E10 ('insulin-dependent diabetes') or E11 ('non-insulin dependent diabetes') by age-band (18-60, 61-75 and >75 years) and specialties. We matched these data to control discharges without these codes. There were 943,613 diabetes discharges (6,508,668 bed days) and 10,724,414 matched controls. Mean diabetes LOS increased with age for each specialty and both E10 and E11 codes, but excess diabetes LOS decreased with age. Excess diabetes LOS was <1.0 days in most groups and highest (1.2 days) in insulin-dependent surgical patients under 60 years old, where 19.7% of bed days were excess. A similar pattern was seen for 76,570 diabetes inpatients with key cardiac or surgical conditions. Excess bed occupancy due to prolonged mean LOS accounted for 325,033 bed days under general medical and surgical codes. There were 25,525 discharges with diabetic ketoacidosis (126,495 bed days) in these 4 years. Excess diabetes LOS is concentrated in younger age groups. Excess bed occupancy due to prolonged LOS in medical and surgical inpatients is three times greater than bed occupancy due to diabetic ketoacidosis. Strategies to reduce excess diabetes bed occupancy should emphasize reducing inpatient LOS in younger inpatients.

"Glucometrics"--assessing the quality of inpatient glucose management

BACKGROUND

For patients with diabetes, the quality of outpatient glycemic control is readily assessed by hemoglobin A1c. In contrast, standardized measures for assessing the quality of blood glucose (BG) management in hospitalized patients are lacking. Because of recent studies demonstrating the benefits of strict glycemic control in critically ill patients, hospitals nationwide are dedicating resources to address this important issue. To facilitate advances in this nascent field, standardized metrics for inpatient glycemic control should be developed and validated.

METHODS

We used 1 month of fingerstick BG levels from a general hospital ward to develop and test three analytic models, based on three units of inpatient BG analysis: population (i.e., ward), patient-day, and patient. To assess the effect of the source of blood samples, we repeated these analyses after adding venous plasma glucose levels. Finally, we employed an idealized intensive care unit data set to establish "gold standard" metrics for inpatient glycemic control.

RESULTS

Mean and median BG levels and the proportion of BG levels within an "optimal" range (80-139 mg/dL) were similar among the three models, whereas hypoglycemic and hyperglycemic event rates varied considerably. Inclusion of venous glucose levels did not substantially affect the results. Of the three models tested, the patient-day model appears to most faithfully reflect the quality of inpatient glycemic control. Achieving 85% of BG levels within optimal range may be considered gold standard.

CONCLUSIONS

If validated elsewhere, these "glucometrics" would permit objective comparisons of inpatient glycemic control among hospitals and patient care units, and would allow institutions to gauge the success of their quality improvement initiatives.