Working to improve care of hospital hyperglycemia through statewide collaboration: the Georgia Hospital Association Diabetes Special Interest Group

Addressing hyperglycemia from hospital admission to discharge

BACKGROUND

This review examines glycemia management practices in hospitalized patients. Optimal glycemic control remains a challenge among hospitalized patients. Recent studies have questioned the benefit of tight glycemic control and have raised concerns regarding the safety of this approach. As a result, medical societies have updated glycemic targets and have published new consensus guidelines for management of glycemia in hospitalized patients. This review highlights recent inpatient glycemic trials, the new glycemic targets and recommended strategies for management of glycemia in hospitalized patients.

METHODS

Medline and PubMed searches (diabetes, hyperglycemia, hypoglycemia, intensive therapy insulin, tight glycemic control, and hospital patients) were performed for English-language articles on treatment of diabetes, insulin therapy, hyperglycemia or hypoglycemia in hospitalized patients published from 2004 to present. Earlier works cited in these papers were surveyed. Clinical studies, reviews, consensus/guidelines statements, and meta-analyses relevant to the identification and management of diabetes and hyperglycemia in hospitalized patients were included and selected. This is not an exhaustive review of the published literature.

RESULTS

Insulin remains the most appropriate agent for a majority of hospitalized patients. In critically ill patients insulin is given as a continuous intravenous (IV) infusion and in non-critically ill inpatients hyperglycemia is best managed using scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring. Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program. Modern insulin analogs offer advantages over the older human insulins (e.g., regular and neutral protamine Hagedorn [NPH] insulin) because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations. Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses. Sliding-scale insulin (SSI) regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.

CONCLUSIONS

Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia. Insulin is the most appropriate agent for management of hyperglycemia for the majority of hospitalized patients. Intravenous insulin infusion is still preferred during and immediately after surgery, but s.c. basal insulin analogs with prandial or correction doses should be used after the immediate post-operative period, and also should be used in non-critically ill patients. Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, which under a recently promulgated consensus guideline currently range between 140 mg/dL and 180 mg/dL. Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients.

Development of computer-based training to enhance resident physician management of inpatient diabetes

BACKGROUND

Treating hyperglycemia promotes better outcomes among inpatients. Knowledge deficits about management of inpatient diabetes are prevalent among resident physicians, which may affect the care of a substantial number of these patients.

METHODS

A computer-based training (CBT) curriculum on inpatient diabetes and hyperglycemia was developed and implemented for use by resident physicians and focuses on several aspects of the management of inpatient diabetes and hyperglycemia: (1) review of importance of inpatient glucose control, (2) overview of institution-specific data, (3) triaging and initial admission actions for diabetes or hyperglycemia, (4) overview of pharmacologic management, (5) insulin-dosing calculations and ordering simulations, (6) review of existing policies and procedures, and (7) discharge planning. The curriculum was first provided as a series of lectures, then formatted and placed on the institutional intranet as a CBT program.

RESULTS

Residents began using the inpatient CBT in September 2008. By August 2009, a total of 29 residents had participated in CBT: 8 in family medicine, 12 in internal medicine, and 9 in general surgery. Most of the 29 residents confirmed that module content met stated objectives, considered the information valuable to their inpatient practices, and believed that the quality of the online modules met expectations. The majority reported that the modules took just the right amount of time to complete (typically 30 min each).

CONCLUSIONS

Improvement in inpatient diabetes care requires continuous educational efforts. The CBT format and curriculum content were well accepted by the resident physicians. Ongoing assessment must determine whether resident practice patterns are influenced by such training.

Inpatient glucose control: a glycemic survey of 126 U.S. hospitals

BACKGROUND

Despite increased awareness of the value of treating inpatient hyperglycemia, little is known about glucose control in U.S. hospitals.

METHODS

The Remote Automated Laboratory System-Plus (RALS-Plus Medical Automation Systems, Charlottesville, VA) was used to extract inpatient point-of-care bedside glucose (POC-BG) tests from 126 hospitals for the period January to December 2007. Patient-day-weighted mean POC-BG and hypoglycemia/hyperglycemia rates were calculated for intensive care unit (ICU) and non-ICU areas. The relationship of POC-BG levels with hospital characteristics was determined.

RESULTS

A total of 12,559,305 POC-BG measurements were analyzed: 2,935,167 from the ICU and 9,624,138 from the non-ICU. Patient-day-weighted mean POC-BG was 165 mg/dL for ICU and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% for ICU and 31.7% for non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was low at 10.1% for ICU and 3.5% for non-ICU. For ICU and non-ICU there was a significant relationship between number of beds and patient-day-weighted mean POC-BG levels, with larger hospitals (> or = 400 beds) having lower patient-day weighted mean POC-BG per patient day than smaller hospitals (<200 beds, P < 0.001). Rural hospitals had higher POC-BG levels compared to urban and academic hospitals (P < 0.05), and hospitals in the West had the lowest values.

CONCLUSIONS

POC-BG data captured through automated data management software can support hospital efforts to monitor the status of inpatient glycemic control. From these data, hospital hyperglycemia is common, hypoglycemia prevalence is low, and POC-BG levels vary by hospital characteristics. Increased hospital participation in data collection and reporting may facilitate the creation of a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.

Hyperglycemia during the immediate period after kidney transplantation

BACKGROUND AND OBJECTIVES

Hyperglycemia and new-onset diabetes occurs frequently after kidney transplantation. The stress of surgery and exposure to immunosuppression medications have metabolic effects and can cause or worsen preexisting hyperglycemia. To our knowledge, hyperglycemia in the immediate posttransplantation period has not been studied.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective, observational study to characterize the prevalence and assess the pharmacologic management of hyperglycemia in kidney transplant recipients who underwent transplantation at our center between June 1999 and December 2006. Data were abstracted from electronic and pharmacy databases.

RESULTS

The study cohort included 424 patients (mean age 51 yr; 58% men; 25% with pretransplantation diabetes). All patients with and 87% without pretransplantation diabetes had evidence of hyperglycemia (bedside glucose >or=200 mg/dl or physician-instituted insulin therapy), whereas the prevalence of hypoglycemia was low (4.5%). Hyperglycemia was sustained throughout hospitalization. All patients with and 66% without pretransplantation diabetes required insulin at hospital discharge. Patients with pretransplantation diabetes were treated primarily with short-acting insulin during the first 24 h after transplantation but were transitioned to long-acting insulin as the hospital stay progressed.

CONCLUSIONS

Investigators have historically attempted to identify hyperglycemia after hospital discharge. Our data indicate that a substantial number of patients without pretransplantation diabetes develop hyperglycemia and require insulin during the hospital phase of their care immediately after kidney transplantation. Prospective studies are needed to delineate factors that contribute to development of new-onset diabetes after transplantation among patients with transient hyperglycemia.

Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital

BACKGROUND

Information regarding practitioner beliefs about inpatient diabetes care is limited.

OBJECTIVE

To assess resident physician attitudes about inpatient hyperglycemia and determine perceived barriers to optimal glycemic control in an urban hospital setting.

DESIGN

A previously developed questionnaire was modified and administered. Residents were asked about the importance of inpatient glucose control, desirable glucose ranges, and problems encountered when managing hyperglycemia.

SETTING

Urban teaching hospital.

RESULTS

Of 85 resident physicians, 66 completed the survey (mean age, 31 years; 47% men; 33% in first residency year). Most respondents categorized glucose control as "very important" in critically-ill and perioperative patients but only "somewhat important" in non-critically-ill patients. Most residents said they would target a therapeutic glucose range within the recommended levels. Most residents (88%) also said they felt "very comfortable" or "somewhat comfortable" using subcutaneous insulin therapy, whereas some were "not at all comfortable" with either subcutaneous (11%) or intravenous (18%) administration. In general, respondents were not very familiar with existing institutional policies and preprinted order sets. The most commonly reported barrier to management of inpatient hyperglycemia was lack of knowledge about appropriate insulin regimens and their use. Anxiety about hypoglycemia was only the third most frequent concern.

CONCLUSION

Most residents acknowledged the importance of good glucose control in hospitalized patients and chose target glucose ranges consistent with existing guidelines. Lack of knowledge about insulin treatment options was the most commonly cited barrier to ideal management. Educational programs should emphasize inpatient treatment strategies for glycemic control.

Understanding and improving management of inpatient diabetes mellitus: the Mayo Clinic Arizona experience

We present an overview of strategies our institution has taken to understand the state of its inpatient diabetes management. We first describe how we utilized information systems to assess inpatient glycemic control and insulin management in noncritically ill patients and discuss our findings regarding mean bedside glucose levels, the prevalence and frequency hypoglycemic and hyperglycemic events, the patterns of insulin therapy, and evidence of inpatient clinical inertia. We also review the development of a survey to determine practitioner attitudes and beliefs about inpatient diabetes. Results of this survey study found that, in general, practitioners believed in the importance of controlling hyperglycemia but were not comfortable with many aspects of inpatient diabetes care, particularly with the use of insulin. Finally, we suggest steps to follow in developing a quality-improvement program for hospitals.

Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital: a review of one institution's experience

BACKGROUND

This article reviews the performance of our hospital's inpatient insulin pump policy.

METHODS

Twenty-five hospital admissions of 21 unique patients receiving outpatient insulin pump therapy were reviewed.

RESULTS

Between November 1, 2005, and November 30, 2006, there were 25 hospital admissions involving 21 patients receiving outpatient insulin pump therapy. The average age and duration of diabetes among these 21 patients was 50 and 29 years, respectively; 67% were women, 90% had type 1 diabetes, and all were white. The mean length of hospital stay was 4 days, and the average reported length of insulin pump therapy was 4 years. Patients in 16 of the admissions were identified as candidates for continued use of the insulin pump during the hospital stay. Over 90% of patients remaining on the insulin pump had documentation by nursing of the presence of the pump at the time of admission; 100% of the patients had an admission glucose recorded; 88% had a record of signed patient consent; 81% had evidence of completed preprinted insulin pump orders; 75% received a required endocrine consultation; and 75% of cases had documentation of completed bedside flow sheet. A high frequency of both hypoglycemic and hyperglycemic events occurred in the patients; however, no adverse events were related directly to the insulin pump.

CONCLUSIONS

Insulin pump therapy can be safely continued in the hospital setting. While staff compliance with required procedures was high, there was still room for improvement. More data are needed, however, on whether this method of insulin delivery is effective for controlling hyperglycemia in hospitalized patients.

Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practitioners

PURPOSE

The purpose of this study is to explore attitudes among inpatient midlevel practitioners about hospital hyperglycemia and to identify perceived barriers to care.

METHODS

A questionnaire previously applied to resident physicians was administered to midlevel providers (physician assistants and nurse practitioners) to determine their beliefs about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in the hospital. Barriers to care reported in this study were also combined with responses from the prior resident survey.

RESULTS

Most respondents indicated that glucose control was very important in critically ill, noncritically ill, and perioperative patients. However, most felt only somewhat comfortable treating hyperglycemia and hypoglycemia and with using subcutaneous insulin; respondents expressed the least amount of confidence with using insulin infusions and insulin pumps. Respondents were not familiar with existing institutional polices and preprinted order sets relating to glucose management. The most commonly reported barrier to hyperglycemia management in the hospital was lack of familiarity with how to useinsulin, a finding that persisted after analyzing composite resident and midlevel responses.

CONCLUSIONS

Most midlevel providers acknowledged the importance of good glucose control in the hospital. Lack of familiarity with how to use insulin in the hospital was the most commonly cited barrier to care. Educational programs should heavily emphasize inpatient treatment strategies.

Inpatient point-of-care bedside glucose testing: preliminary data on use of connectivity informatics to measure hospital glycemic control

BACKGROUND

Point-of-care (POC) bedside glucose (BG) testing and timely evaluation of its effectiveness are important components of hospital inpatient glycemic control programs. We describe a new technology to evaluate inpatient POC-BG testing and report preliminary results of inpatient glycemic control from 10 U.S. hospitals.

METHODS

We used the Remote Automated Laboratory System RALS-Tight Glycemic Control Module (TGCM) (Medical Automation Systems, Charlottesville, VA) connected to the RALS-Plus to extract and analyze inpatient POC-BG tests from 10 U.S. hospitals for a 3-month period. POC-BG measurements were evaluated in aggregate from all 10 facilities for intensive care unit (ICU), non-ICU, and ICU + non-ICU combined.

RESULTS

A total of 742,154 POC-BGs were analyzed. The combined (ICU + non-ICU) mean POC-BG was 159 mg/dL, compared with 146 mg/dL for the ICU and 164 mg/dL for non-ICU. The proportion of hypoglycemic values (<70 mg/dL) was low at 4%, but the percentage of measurements that would be considered hyperglycemic (>180 mg/dL) was high, with more than 30% of values in the non-ICU and 20% in the ICU being elevated.

CONCLUSIONS

POC-BG data can be captured through automated data management software and can support hospital efforts to evaluate and monitor the status of inpatient glycemic control. These preliminary data suggest that there is a need to conduct broad-based efforts to improve inpatient glucose management. Increasing hospital participation in data collection has the potential to create a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.