The Endocrine Hospitalist: Enhancing the Quality of Diabetes Care

Increasing Frequency of Hemoglobin A1c Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma

BACKGROUND

The American Diabetes Association (ADA) recommends measuring A1c in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1c measurements in hospitalized patients.

METHODS

We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1c in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1c, (2) more rapid turnaround of A1c results, and (3) an EHR glucose-management tab and insulin order set that included A1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1c measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis.

RESULTS

Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1c measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention.

CONCLUSIONS

We demonstrate a novel approach in improving A1c in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.

Centers for Medicare & Medicaid Services' Hospital Harm Measures for Severe Hypoglycemia and Hyperglycemia: Is Your Hospital Ready?

Poor inpatient glycemic management is associated with increased lengths of stay and in-hospital morbidity and mortality. Improving inpatient glycemic outcomes can be difficult because there are no standardized benchmarks, and many hospitals lack the capacity to electronically extract and analyze glucose data. The Centers for Medicare & Medicaid Services recently proposed new electronic clinical quality measures to be incorporated into its mandatory Hospital Inpatient Quality Reporting Program. Among these measures is an assessment of hospital harm from severe hypoglycemia and severe hyperglycemia. Hospitals must be ready to collect the necessary data for these new measures by January 2023. The new measures could bring welcome attention to the need to implement guideline-based inpatient glycemic management. However, some hospitals that serve high-risk populations may be at risk for losing funding if they are unable to comply.

Instituting a Successful Discharge Plan for Patients With Type 2 Diabetes: Challenges and Solutions

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.

Hospital Diabetes Meeting 2022

The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood glucose targets, (3) software for inpatient diabetes, (4) surgery, (5) transitions, (6) coronavirus disease and diabetes in the hospital, (7) drugs for diabetes, (8) continuous glucose monitoring, (9) quality improvement, (10) diabetes care and educatinon, and (11) uniting people, process, and technology to achieve optimal glycemic management. This meeting covered new technology that will enable better care of people with diabetes if they are hospitalized.