Glycemic management in the inpatient setting

Glycemic Management in Insulin-Naive Patients in the Inpatient Setting

Objective

The ideal inpatient insulin regimen efficiently attains the target blood glucose range, effectively treats hyperglycemia, and minimizes the risk of hypoglycemia. The objective of this study was to compare glycemic targets achieved by using correctional monotherapy (CM) and basal-bolus therapy (BBT) in insulin-naive patients in the inpatient setting to determine optimal blood glucose management for these patients.

Design

This was a retrospective observational cohort study of 792 patients with diabetes not on home insulin therapy who were admitted to an academic hospital over a 5.5-month period. The percentages of hyperglycemic and hypoglycemic values in each group were compared.

Results

Among the 3,112 measured blood glucose values obtained from 792 patients within the first 24 hours of insulin administration, 28.5% were hyperglycemic in the BBT group compared with 23.5% in the CM group. When adjusted for covariates, there was a 23% decrease in hyperglycemia in the BBT group (incidence rate ratio = 0.77, 95% CI 0.64-0.95, P = 0.006). Increases in A1C and admission blood glucose, as well as decreases in admission creatinine and inpatient steroid use, were independently associated with higher rates of hyperglycemia, adjusted for all other covariates. There was no significant difference between the groups in the rate of hypoglycemia in the first 24 hours, which was 1.9% in the BBT group and 1.4% in the CM group (P = 0.301).

Conclusion

Utilizing BBT in insulin-naive patients admitted to the hospital within the first 24 hours of insulin administration results in lower rates of hyperglycemia without higher rates of hypoglycemia when compared with CM.

Clinical impact after implementing an insulin protocol involving a switch to insulin glargine 300 U/ml as basal insulin for inpatient glycaemic control: A retrospective single-centre study

AIMS

To evaluate the benefit and safety of a switch in the basal insulin protocol to glargine 300 U/ml (Gla-300) on inpatients' overall dysglycemic events. Efficacy and safety data on insulin Gla-300 in the inpatient setting are limited.

METHODS

Retrospective observational study conducted on 7455 patients admitted to acute care (n = 5414) or geriatric and social healthcare (n = 2041) units of the Regional Hospital of Amposta (Spain) between January 2017 and December 2020 who received basal insulin during hospitalization. Hypo- and hyperglycaemic events were indirectly assessed through hospital pharmacy usage of intravenous glucose and vials of rapid-acting intravenous insulin for 27 months after the switch, and the impact on overall dysglycemic events was analysed.

RESULTS

After protocol implementation, patients were mostly treated with Gla-300 (83.06 % in acute care; and 83.44 % in geriatric and social healthcare), and presented a significant decrease in the use of intravenous insulin (-60.80 %, P = 0.005) and glucose (-62.13 %, P < 0.001), which translated into a significantly reduced overall dysglycemic events (-62.25 %, P < 0.001), with a good safety and tolerability profile.

CONCLUSIONS

Overall inpatient dysglycemic events were improved upon the introduction of the new insulin protocol, which calls for the use of Gla-300 as one of the choices of basal insulin for inpatient care.

Estimating the cost of type 1 diabetes in Ireland

BACKGROUND

Type 1 diabetes is a chronic disease, which given its existing and projected prevalence, is likely to pose a significant economic burden, both in terms of directs costs to the healthcare system and indirect costs to society. We aimed to estimate the economic burden of type 1 diabetes in Ireland, which at present, is unknown.

METHODS

A cost of illness study was undertaken to estimate the cost of type 1 diabetes in Ireland for 2018. Data for prevalence, morbidity, mortality, healthcare resource use, absenteeism, and unit costs were obtained from national, and where necessary, international sources. Direct healthcare costs were estimated for primary care, outpatient, emergency and inpatient care, for associated complications, structured education programmes, insulin and related care. Additionally, indirect costs from lost earnings due to premature death and employee absenteeism were estimated.

RESULTS

Type 1 diabetes was estimated to cost €129 million in Ireland in 2018, with direct healthcare costs accounting for €81.5 million or 63% and indirect costs for €47.5 million or 37% of the total. On average, this amounted to €3994 per patient in direct healthcare costs and €2326 per patient in indirect costs.

CONCLUSION

Type 1 diabetes is a leading public health problem. Our study is the first to assess the economic burden of type 1 diabetes in Ireland, and our results should be informative to policymakers tasked with prioritising healthcare and research funding resource allocation.

Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital

OBJECTIVES

Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting.

METHODS

Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error.

RESULTS

Overall, 20 different blank insulin charts with variable designs and significant structural deficits were identified. A medication error occurred in 55% of the 102 audited filled-in insulin charts, consisting of prescription and management errors in 48% and 16%, respectively. Charts of insulin-treated patients had more medication errors relative to patients treated with oral medication (P < 0.01). Chart design did support neither clinical authorization of individual insulin prescription (10%), nor insulin administration confirmed by nurses' signature (25%), nor treatment of hypoglycemia (0%), which resulted in a reduced documentation and treatment quality in clinical practice 7%, 30%, 25%, respectively.

CONCLUSIONS

A multitude of charts with variable design characteristics and structural deficits were in use across the inpatient wards. More than half of the inpatients had a chart displaying a medication error. Lack of structure quality features of the charts had an impact on documentation and treatment quality. Based on identified deficits and international standards, a new insulin chart was developed to overcome these quality hurdles.

Inpatient glycemic management in internal medicine: an observational multicenter study in Nanjing, China

AIMS

To evaluate the prevalence of hyperglycemia among inpatients in internal medicine, and specifically, to assess the glycemic management of inpatients in non-endocrinology departments in three large urban hospitals in China.

METHODS

A multicenter observational study was conducted using electronic health records, and a survey of 1939 patients who were admitted to internal medicine units and followed until discharge. Those with previously diagnosed diabetes, newly diagnosed diabetes, or impaired fasting glucose were included. Aspects of glycemic management examined were (a) hyperglycemia, (b) endocrinology consultation for hyperglycemia and (c) hypoglycemia.

RESULTS

The prevalence of hyperglycemia in internal medicine was 45.7% (886 out of 1939). A total of 741 (83.6%) patients were treated by non-endocrinology departments; of those, 230 (31.1%) were in poor glycemic control and needed an endocrinology consultation. Yet only 57 (24.8%) received one. In 4 cases, the physician did not follow the consultants' advice. Among the remaining 53 consulted patients, 35 (66.1%) were still in poor glycemic control, yet only about half received a second consultation. Finally, among patients treated in non-endocrinology departments, 58 (7.8%) had hypoglycemia; less than half retested their blood glucose after treatment.

CONCLUSIONS

The majority of patients with hyperglycemia were in non-endocrinology departments. Their glycemic management was poor; the endocrinology consultation rate was low and the result was suboptimal. Also, the management of hypoglycemia was not ideal. Therefore, improving glycemic management is urgently needed in Chinese hospitals.

Hypoglycemia in the hospital: systems-based approach to recognition, treatment, and prevention

Hypoglycemia causes immediate adverse reactions and is associated with unfavorable clinical outcomes and increased health care costs. It is also one of the barriers to optimization of inpatient glycemic control. Prioritizing quality improvement efforts to address hypoglycemia in hospitalized patients with diabetes is of critical importance. Acute illness, hospital routine, and gaps in quality care predispose patients to hypoglycemia. Many of these factors can be minimized when approached from a systems-based perspective. This requires creation of a multidisciplinary team to develop strategies to prevent hypoglycemic events by targeting many factors, such as systemic analysis of blood glucometrics, policies and protocols, coordination of nutrition and insulin administration, transitions of care, staff and patient education, and communication. This article reviews recommendations of the American Diabetes Association, the Endocrine Society, and the Society of Hospital Medicine, and highlights our institution's approach in each of these areas. Despite a multitude of challenges, we believe that it is feasible to improve the safety and quality of inpatient diabetes care and avoid hypoglycemia without requiring significant additional hospital resources. Physician leaders play a major role in guiding this process and encouraging participation of interdisciplinary members of the hospital team.