Real-world community hospital hyperglycemia management in noncritically ill, type 2 diabetic patients: a comparison between basal-bolus insulin and correctional insulin

Purpose

This study evaluated the safety and efficacy of two insulin regimens for inpatient hyperglycemia management: combination short-plus long-acting insulin (basal-bolus insulin regimen, BBIR) vs. short-acting insulin only (correctional insulin only regimen, CIOR).

Methods

Chart reviews identified noncritically ill patients with pre-existing type 2 diabetes mellitus receiving insulin injections. Study participants (N = 138) were divided into BBIR (N = 104) and CIOR (N = 34) groups. Data for the entire duration of each patient's stay were analyzed.

Results

The primary outcome of percent hyperglycemic days was higher in BBIR vs. CIOR (3.97 ± 0.33% vs. 1.22 ± 0.38%). The safety outcome of percent hypoglycemic events was not different between BBIR and CIOR (0.78 ± 0.22% vs. 0.53 ± 0.37%). Regarding secondary outcomes, the percentage of euglycemic days was lower in BBIR vs. CIOR (26.74 ± 2.97% vs. 40.98 ± 5.91%). Overall blood glucose (BG) and daily insulin dose were higher in BBIR vs. CIOR (231.43 ± 5.37 vs. 195.55 ± 6.25 mg/dL and 41.36 ± 3.07 vs. 5.02 ± 0.68 units, respectively). Insulin regimen-associated differences in hyperglycemia and daily insulin dose persisted after adjusting for covariates.

Conclusion

Our observations linking BBIR to worse glycemic outcomes differ from those reported in the randomized controlled Rabbit 2 and Rabbit 2 Surgery trials. This discrepancy can be partly explained by the fact that BBIR patients displayed worse glycemic baselines. Also, there was no diabetes stewardship team to monitor BG and modify insulin therapy, which is relevant since achieving euglycemia in BBIR patients requires more dose adjustments. This study highlights challenges with standard inpatient glycemic management and calls for further research assessing the benefits of pharmacist-led diabetes stewardship.

Improved postoperative blood glucose control through implementation of clinical pharmacist driven glycemic management model after colorectal surgery

BACKGROUND

Poor postoperative glycemic control has been linked with higher mortality, cardiovascular complications, stroke, infection, impaired wound healing, and increased length of stay.

METHODS

This multicenter, retrospective study of colorectal surgery patients with Type 2 Diabetes Mellitus evaluated the difference in mean blood glucose levels postoperatively in a pharmacist driven glycemic management model vs standard of care. Secondary objectives assessed hyperglycemic events, severe hyperglycemia, hypoglycemia, postoperative infection, and rates of endocrinology consults.

RESULTS

186 patients were included, 120 in the pharmacist driven cohort and 66 in the standard of care. The pharmacist managed cohort demonstrated significantly lower mean blood glucose (133.9 vs 148.3 mg/dL, 95% CI [-17 to -11] p < 0.001), significantly fewer hyperglycemic events (9.6% vs 20.5%, p < 0.0001), and non-significant reduction of hypoglycemic events (0.7% vs 1.2%, p = 0.1443).

CONCLUSIONS

Expansion of the postoperative care team by utilizing pharmacists to manage postoperative blood glucose resulted in improved glycemic control.

Pharmacist Role in Providing Inpatient Diabetes Management

PURPOSE OF REVIEW

Glycemic management of hospitalized patients remains a growing burden in organizations across the country. Attainment of well-established glycemic targets has shown improved clinical outcomes. Empowered glucose management interdisciplinary teams are critical in organizations attaining improved outcomes. Pharmacists possess diverse knowledge and skills that uniquely position them to take a leadership role in healthcare organizations' efforts to achieve safe and effective glycemic outcomes in hospitalized patients.

RECENT FINDINGS

Various models of pharmacy care have demonstrated success in improving patient outcomes related to acute care glycemic management. The authors of this manuscript will summarize published data related to improved outcomes when pharmacists are utilized in a patient-directed intervention model. In addition, we will describe the implementation of pharmacy stewardship, delineating the role of the pharmacist in providing oversight and shaping institutions to promote optimal glycemic management on a macrolevel. Pharmacists have demonstrated the ability to aid institutions looking to improve acute glycemic management while serving effectively in various models of care across their respective organization.

Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic

INTRODUCTION

The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy specialists (CPS) in patient-aligned care teams (PACT) to improve patient care outcomes and create access for veterans. With the unfortunate arrival of Coronavirus disease 2019 (COVID19), PACT CPS were duty-bound to expand telehealth services at an accelerated rate. The purpose of this quality improvement analysis is to compare CPS efficiency as well as some objective patient metrics to assess for a change in the quality of care. This is the first study to compare the efficiency and quality of care by CPS in the VA pre-COVID19 and during the COVID19 pandemic.

METHODS

This is a retrospective review of PACT CPS comprehensive medication management from 3/10/19 to 11/30/19 and 3/10/20 to 11/30/20. Data points focused on clinic encounters, patient accountability to appointments, disease state expansion, and markers of disease-state management. Given diabetes and hypertension are the main disease states managed by most PACT CPS', the study evaluated changes in hemoglobin A1c (HbA1c) and blood pressure (BP) between the two cohorts as well. Data were analyzed using GraphPad Software or Microsoft Excel. A student T-test was used for continuous data and Chi-squared or Fishers Exact for nominal data.

RESULTS

The total number of PACT CPS encounters increased 32% in 2020, and the number of unique patients increased by 12%. There were a statistically significant increase in telephone and direct-to-consumer (DCT) video visits. The rates of no shows and cancellations significantly decreased between 2019 and 2020. There was no difference in the average change in HbA1c or average blood pressure between the two study groups.

CONCLUSIONS

When PACT CPS services transitioned from primarily face-to-face visits to all virtual care, the consistency of care improved, and the quality of care was not compromised.

Effects of a Dedicated Inpatient Diabetes Management Service on Glycemic Control in a Community Hospital Setting

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.

The Financial Impact of an Inpatient Diabetes Management Service

CONTEXT

Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management.

OBJECTIVE

To review recent literature on the financial and clinical impact of IDMS in hospital settings.

METHODS

We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine.

FINDINGS

In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management.

CONCLUSION

IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

Diabetic Control Agents and Their Impact on Cardiac Surgery Patients: A Clinical Overview

Chronic hyperglycemia is associated with poor cardiovascular surgical outcomes due to microvascular and macrovascular complications. This is a major concern as over one third of cardiovascular surgical patients have diabetes mellitus which greatly increases their risk of experiencing adverse cardiovascular events. A literature review was performed to identify articles discussing the effects of anti-diabetic medications (ADMs) on cardiovascular outcomes and surgical mortality and morbidity rates. Optimizing perioperative glucose levels remains a key factor in producing good surgical outcomes. In addition, recognizing gender differences, increasing patient satisfaction, and implementing dedicated diabetic teams all improve surgical mortality and morbidity rates in the diabetic population.

Blood Glucose Control and Opportunities for Clinical Pharmacists in Infectious Diseases Ward

Objective

Increased risk of infection following hyperglycemia has been reported in hospitalized patients. Sliding-scale insulin protocol is an out-of-date method; therefore, it is necessary to examine new approaches in this regard. This study aimed to evaluate the efficacy of sliding-scale protocol versus basal-bolus insulin protocol, which supervised by clinical pharmacists in an infectious disease ward.

Methods

In this prospective randomized clinical trial, 90 hyperglycemic patients who hospitalized in Loghman Hakim Hospital Infectious Disease Ward (Tehran, Iran) were randomized into two groups: sliding-scale insulin protocol (the control group) and the basal-bolus protocol groups that were under supervision clinical pharmacists. Some demographic, laboratory, and clinical variables, as well as patient's blood glucose were measured four times daily.

Findings

The results indicated significant improvement among the patients in the intervention group. General indicators including fever, blood glucose level, the duration of hospitalization, incidence of hypoglycemia, days to achieve normal blood glucose, and leukocyte count improved in intervention group.

Conclusion

According to this study, basal-bolus insulin protocol, which supervised by clinical pharmacy service, showed better blood glucose control and infection remission compared to the sliding-scale protocol.

Physicians as Advisors Not Leaders of Multidisciplinary Teams: A Qualitative Study of an Innovative Practice

Background and Aims

As various models of team-based chronic disease management have proliferated, physicians have assumed the leadership role in most of them. However, physician time is costly, and regular attendance of team meetings adds another task to a long list of responsibilities. This is the first study to explore the role of physicians as advisors rather than leaders of a multidisciplinary team.

Methods

We conducted an exploratory qualitative research study of a subspecialty medical home located within a tertiary academic medical center that cares for highly complex pediatric and adult patients with inflammatory bowel diseases. The medical home team consists of a psychologist, dieticians, social workers, a clinical pharmacist, and nurses. No physicians regularly attend team meetings. We conducted semi-structured interviews with nonphysician team members (N = 11) and gastroenterologists (N = 6). Two authors coded interview transcripts in NVivo 11 for themes related to “physician role” using an inductive qualitative analysis approach.

Results

Nonphysician participant believed gastroenterologists did not need to attend weekly meetings. Having only nonphysician personnel in the room made them feel more empowered to openly express their views. Gastroenterologists expressed interest in attending one or more, but not all meetings, in order to better understand the process of the team and desired a more formal feedback loop for staying informed about their patients’ progress.

Conclusions

Our findings suggest that gastroenterologist participation may not require regular attendance of team meetings. Team meeting consisting of nonphysician providers would result in cost savings and may empower nonphysician providers.

Perceptions of Integration of the Clinical Pharmacist into the Patient Care Medical Home Model

INTRODUCTION

The patient-centered medical home (PCMH) model is a multidisciplinary, team-based approach to healthcare that focuses on actively involving the patient in clinical decision making. The Veterans Health Administration (VA), while desiring to be a national leader in the delivery of primary care services, used the principles of the PCMH model to design the patient-aligned care team (PACT). The purpose of this study, was to explore the perception of the PACT members after integration of a clinical pharmacist to the PACT.

METHODS

This was a single-center cross-sectional study conducted at an integrated Veterans Health Administration system. We electronically surveyed PACT staff practicing within VA-Tennessee Valley Health Care System as of October 1, 2016 using a modified version of the Medicine Medication Use Processes Matrix (MUPM) containing 19 items on five theoretical grouping of processes (evaluation and management, monitoring, medication review, documentation, and education) and two groupings(clinician satisfaction and access).

RESULTS

Ninety-one complete responses were received. Perceptions were positive, with 79% rated as either 4 ("moderate contribution") or 5 ("major contribution"). Individual responses based on discipline, with the exception of the medical support assistant were rated positive, specifically job satisfaction.

CONCLUSIONS

This study evaluated the perceptions of clinical pharmacist integration into the PACT model. Respondents perceived clinical pharmacist beneficial.

Survey evaluation of in-hospital diabetes seminars provided by medical professionals, for medical professionals

Purpose: Diabetes is a multifactorial disease, and interprofessional teamwork is essential for its treatment. For successful interprofessional teamwork, individual medical professionals need to have certain skills, experience, and mutual understanding of the role of different professions. However, there are few opportunities to educate medical professionals to meet these demands. To resolve this problem, educational seminars about diabetes were conducted by and for medical professionals, and their effects were assessed using a questionnaire survey. Participants and methods: Medical professionals, including a dietician, a physiotherapist, a pharmacist, a clinical laboratory technician, and a doctor, provided 10 lectures, approximately 50 mins each, for medical professionals about their specialized skills in diabetes care. Nurses who were certified diabetes educators in Japan planned and organized the seminars. In every seminar, participants were asked to complete a questionnaire regarding their profession, motivation to attend the seminar, general comments about the seminar, expectations regarding future seminars, and effects of the seminar on their daily work or attitude toward patients. Results: Among the 367 participants, 332 completed the questionnaire (respondents). The results revealed that by attending the seminars, some respondents strongly realized their lack of knowledge, some were inspired and encouraged to study more about diabetes, and some could understand other professions' work in diabetes care better than before. Over 70% of respondents reported that attending the seminar had changed their daily work or attitude toward patients; the remainder, however, felt unchanged for reasons such as their own lack of experience and ability, and the few chances to aid patients with diabetes. Conclusion: Educational diabetes seminars by and for medical professionals were implemented. The survey of the effects of the seminar has provided further insights into the needs and current situation of education for medical professionals.

Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., 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 effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.

Common Models Used for Inpatient Diabetes Management

PURPOSE OF REVIEW

Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients.

RECENT FINDINGS

To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators. In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization's structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.

The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios

•

Interdisciplinary teams (IDTs) should aim to implement a patient-centred approach.

•

IDTs can enable improved glycaemic control and reduced cardiometabolic risk.

•

Successful IDTs require strong leadership, good communication and shared goals.

The Global Partnership for Effective Diabetes Management has previously recommended the implementation of an interdisciplinary team (IDT) approach to type 2 diabetes (T2DM) management as one of 10 practical steps for health care professionals to help more people achieve their glycaemic goal. This article discusses some of the key contributors to success and also the challenges faced when applying IDT care, by examining case studies and examples from around the world. The real-world practices discussed show that implementing successful interdisciplinary care in diabetes is possible despite significant barriers such as established hierarchal structures and financial resource constraints. Instituting collaborative, integrated working relationships among multiple disciplines under strong leadership, together with enhanced and active communication and improved patient access to appropriate specialties is essential. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical. IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT, in whatever form, is paramount to enable the best care to be delivered.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care

BACKGROUND

A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines.

OBJECTIVES

To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care).

SEARCH METHODS

We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed.

MAIN RESULTS

We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed.

AUTHORS' CONCLUSIONS

The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

The difficulties of interprofessional teamwork in diabetes care: a questionnaire survey

Background

Diabetes is a multifactorial disease and its nature means that interprofessional teamwork is essential for its treatment. However, in general, interprofessional teamwork has certain problems that impede its function. To clarify these problems in relation to diabetes care, a questionnaire survey was conducted.

Methods

The participants who were involved in diabetes-related educational seminars, and medical personnel who were engaged in diabetes care from the National Center for Global Health and Medicine, were asked to complete the questionnaire about perceptions of, and satisfaction with, interprofessional teamwork across multiple health care providers, who were actually involved in diabetes care.

Results

From 456 people who were asked to take the questionnaire, 275 people answered. The percentages of the respondents according to profession who considered multidisciplinary teamwork sufficient were as follows: physicians, 20.5%; nurses, 12.7%; registered dietitians, 29.6%; pharmacists, 21.9%; physiotherapists, 18.2%; and clinical laboratory technicians 15.4%. Insufficient interprofessional communication and inconsistency in motivation levels among staff were frequently cited as causes of insufficient teamwork. All professions considered interprofessional meetings or conferences necessary and essential for teamwork.

Conclusion

The survey revealed that interprofessional teamwork in diabetes care is currently insufficient. Continuous efforts to change each profession’s perceptions about interprofessional teamwork and efforts to improve the quality of interprofessional meetings are necessary.

Pharmacy management of postoperative blood glucose in open heart surgery patients: evaluation of an intravenous to subcutaneous insulin protocol

PURPOSE

To develop and implement a protocol to improve blood glucose (BG) control during transition from intravenous (IV) to subcutaneous (SC) insulin, increase compliance with Surgical Care Improvement Project (SCIP) measures, and decrease sternal wound infections post open heart surgery (OHS).

METHODS

An IV to SC protocol was developed and implemented. A retrospective chart review of patients who underwent OHS was conducted from January 2, 2009 to September 30, 2010 (pre protocol) and from October 1, 2010 to December 31, 2011 (post protocol). Data collected included age, sex, history of diabetes mellitus (DM), BG values, hypoglycemia incidence, length of stay, and incidence of sternal wound infections.

RESULTS

A total of 243 patients were included in the study. Compliance with SCIP postoperative day 1 and 2 BG goals was similar pre and post protocol (P = .24 and .248). One sternal wound infection occurred after protocol implementation, whereas 6 occurred pre protocol (P = .046). Change in BG when transitioning from IV to SC insulin was similar between the groups, however there were significantly fewer hypoglycemia episodes post protocol (P < .001).

CONCLUSION

Though differences were not found in compliance with SCIP postoperative day 1 and 2 measures, fewer sternal wound infections and hypoglycemic episodes were reported, indicating that the pharmacy protocol may have a positive impact on patient outcomes.