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Lamanna DL, McDonnell ME, Chen AF, Gallagher JM. Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery. J Bone Joint Surg Am 2022; 104:2117-2126. [PMID: 36005390 DOI: 10.2106/jbjs.22.00149] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs). ➤ Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal. ➤ There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery. ➤ There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered. ➤ The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered. ➤ The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.
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Affiliation(s)
- Daniel L Lamanna
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Demidowich AP, Batty K, Zilbermint M. Instituting a Successful Discharge Plan for Patients With Type 2 Diabetes: Challenges and Solutions. Diabetes Spectr 2022; 35:440-451. [PMID: 36561646 PMCID: PMC9668725 DOI: 10.2337/dsi22-0013] [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] [Indexed: 11/16/2022]
Abstract
Achieving target inpatient glycemic management outcomes has been shown to influence important clinical outcomes such as hospital length of stay and readmission rates. However, arguably the most profound, lasting impact of inpatient diabetes management is achieved at the time of discharge-namely reconciling and prescribing the right medications and making referrals for follow-up. Discharge planning offers a unique opportunity to break through therapeutic inertia, offer diabetes self-management education, and institute an individualized treatment plan that prepares the patient for discharge and promotes self-care and engagement. However, the path to a successful discharge plan can be fraught with potential pitfalls for clinicians, including lack of knowledge and experience with newer diabetes medications, costs, concerns over insurance coverage, and lack of time and resources. This article presents an algorithm to assist clinicians in selecting discharge regimens that maximize benefits and reduce barriers to self-care for patients and a framework for creating an interdisciplinary hospital diabetes discharge program.
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Affiliation(s)
- Andrew P. Demidowich
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Kristine Batty
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Bethesda, MD
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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.
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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]
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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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Najmi U, Haque WZ, Ansari U, Yemane E, Alexander LA, Lee C, Demidowich AP, Motevalli M, Mackay P, Tucker C, Notobartolo C, Sartippour P, Raynor J, Zilbermint M. Inpatient Insulin Pen Implementation, Waste, and Potential Cost Savings: A Community Hospital Experience. J Diabetes Sci Technol 2021; 15:741-747. [PMID: 33843291 PMCID: PMC8258519 DOI: 10.1177/19322968211002514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Insulin pen injectors ("pens") are intended to facilitate a patient's self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs. METHODS Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions. RESULTS 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year. CONCLUSIONS In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.
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Affiliation(s)
- Urooj Najmi
- American International School of Medicine, Atlanta, GA, USA
| | - Waqas Zia Haque
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Umair Ansari
- Pharmacy Department, Suburban Hospital, Bethesda, MD, USA
| | | | | | - Christina Lee
- Pharmacy Department, Suburban Hospital, Bethesda, MD, USA
| | - Andrew P. Demidowich
- Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahsa Motevalli
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Periwinkle Mackay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cindy Notobartolo
- Department of Safety, Security and Employee Health Services, Suburban Hospital, Bethesda, MD, USA
| | - Poroshat Sartippour
- Department of Management Information System, Suburban Hospital, Bethesda, MD, USA
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, Bethesda, MD 20814, USA. ; Twitter: @Zilbermint; LinkedIn: https://www.linkedin.com/in/mishazilbermint/
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Rajpal A, Sayyed Kassem L, Aron DC. Management of diabetes in elderly patients during the COVID-19 pandemic: current and future perspectives. Expert Rev Endocrinol Metab 2021; 16:181-189. [PMID: 34096441 DOI: 10.1080/17446651.2021.1927708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/06/2021] [Indexed: 02/09/2023]
Abstract
Introduction: The COVID-19 pandemic has affected the entire population with the most deleterious effects in elders. Elders, especially those with diabetes, are at the highest risk of COVID-19 related adverse outcomes and mortality. This is usually linked to the comorbidities that accumulate with age, diabetes-related chronic inflammation, and the pandemic's psychosocial effects.Areas covered: We present some approaches to manage these complicated elderly patients with diabetes during the COVID-19 pandemic. In the inpatient setting, we suggest similar (pre-pandemic) glycemic targets and emphasize the importance of using IV insulin and possible use of continuous glucose monitoring to reduce exposure and PPE utilization. Outside the hospital, we recommend optimal glycemic control within the limits imposed by considerations of safety. We also describe the advantages and challenges of using various technological platforms in clinical care.Expert opinion: The COVID-19 pandemic has lifted the veil off serious deficiencies in the infrastructures for care at both the individual level and the population level and also highlighted some of the strengths, all of which affect individuals with diabetes and COVID-19. We anticipate that things will not return to 'normal' after the COVID-19 pandemic has run its course, but rather they will be superseded by 'New Normal.'
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Affiliation(s)
- Aman Rajpal
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Laure Sayyed Kassem
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - David C Aron
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
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Abstract
The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, FACE, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, 6th Floor Endocrinology Office, Bethesda, MD 20814, USA.
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Demidowich AP, Batty K, Love T, Sokolinsky S, Grubb L, Miller C, Raymond L, Nazarian J, Ahmed MS, Rotello L, Zilbermint M. Effects of a Dedicated Inpatient Diabetes Management Service on Glycemic Control in a Community Hospital Setting. J Diabetes Sci Technol 2021; 15:546-552. [PMID: 33615858 PMCID: PMC8120056 DOI: 10.1177/1932296821993198] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community hospitals account for over 84% of all hospitals and over 94% of hospital admissions in the United States. In academic settings, implementation of an Inpatient Diabetes Management Service (IDMS) model of care has been shown to reduce rates of hyper- and hypoglycemia, hospital length of stay (LOS), and associated hospital costs. However, few studies to date have evaluated the implementation of a dedicated IDMS in a community hospital setting. METHODS This retrospective study examined the effects of changing the model of inpatient diabetes consultations from a local, private endocrine practice to a full-time endocrine hospitalist on glycemic control, LOS, and 30-day readmission rates in a 267-bed community hospital. RESULTS Overall diabetes patient days for the hospital were similar pre- and post-intervention (20,191 vs 20,262); however, the volume of patients seen by IDMS increased significantly after changing models. Rates of hyperglycemia decreased both among patients seen by IDMS (53.8% to 42.5%, P < .0001) and those not consulted on by IDMS (33.2% to 29.9%; P < .0001). When examined over time, rates of hypoglycemia steadily decreased in the 24 months after dedicated IDMS initiation (P = .02); no such time effect was seen prior to IDMS (P = .34). LOS and 30DRR were not significantly different between IDMS models. CONCLUSIONS Implementation of an endocrine hospitalist-based IDMS at a community hospital was associated with significantly decreased hyperglycemia, while avoiding concurrent increases in hypoglycemia. Further studies are needed to investigate whether these effects are associated with improvements in clinical outcomes, patient or staff satisfaction scores, or total cost of care.
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Affiliation(s)
- Andrew P. Demidowich
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
- Division of Endocrinology,
Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, USA
- Andrew P. Demidowich, MD, Assistant
Professor of Medicine, Johns Hopkins Medicine, Howard County General
Hospital, 5755 Cedar Ln, Columbia, MD 21044, USA.
| | - Kristine Batty
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
| | - Teresa Love
- Rehab Services, Diabetes
Management & The Center for Wound Healing, HCGH, Johns Hopkins Medicine,
Columbia, MD, USA
| | - Sam Sokolinsky
- JHHS Quality and Clinical
Analytics, Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD,
USA
| | - Lisa Grubb
- Johns Hopkins Armstrong Institute
at HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Catherine Miller
- Division of Nursing – Critical
Care, HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Larry Raymond
- Rehab Services, Diabetes
Management & The Center for Wound Healing, HCGH, Johns Hopkins Medicine,
Columbia, MD, USA
| | - Jeanette Nazarian
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
| | - M. Shafeeq Ahmed
- Johns Hopkins Armstrong Institute
at HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Leo Rotello
- Johns Hopkins Community Physicians
at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine,
Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology,
Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians
at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine,
Bethesda, MD, USA
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