Overcoming clinical inertia in the management of postoperative patients with diabetes

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review

OBJECTIVE

Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain.

METHODS

We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.

RESULTS

Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices.

CONCLUSION

To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs.

PRACTICE IMPLICATIONS

Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.

Efficacy and Safety of Intensive Versus Nonintensive Supplemental Insulin With a Basal-Bolus Insulin Regimen in Hospitalized Patients With Type 2 Diabetes: A Randomized Clinical Study

OBJECTIVE

Administration of supplemental sliding scale insulin for correction of hyperglycemia in non-intensive care unit (ICU) patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. In this noninferiority randomized controlled trial we tested whether glycemic control is similar with and without aggressive sliding scale insulin treatment before meals and bedtime in patients treated with basal-bolus insulin regimens.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes with admission blood glucose (BG) 140-400 mg/dL treated with basal-bolus insulin were randomized to intensive (correction for BG >140 mg/dL, n = 108) or to nonintensive (correction for BG >260 mg/dL, n = 107) administration of rapid-acting sliding scale insulin before meals and bedtime. The groups received the same amount of sliding scale insulin for BG >260 mg/dL. Primary outcome was difference in mean daily BG levels between the groups during hospitalization.

RESULTS

Mean daily BG in the nonintensive group was noninferior to BG in the intensive group with equivalence margin of 18 mg/dL (intensive 172 ± 38 mg/dL vs. nonintensive 173 ± 43 mg/dL, P = 0.001 for noninferiority). There were no differences in the proportion of target BG readings of 70-180 mg/dL, <70 or <54 mg/dL (hypoglycemia), or >350 mg/dL (severe hyperglycemia) or total, basal, or prandial insulin doses. Significantly fewer subjects received sliding scale insulin in the nonintensive (n = 36 [34%]) compared with the intensive (n = 98 [91%] [P < 0.0001]) group with no differences in sliding scale insulin doses between the groups among those who received sliding scale insulin (intensive 7 ± 4 units/day vs. nonintensive 8 ± 4 units/day, P = 0.34).

CONCLUSIONS

Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG <260 mg/dL), a less intensive sliding scale insulin treatment did not significantly affect glycemic control.

Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes

OBJECTIVES

The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada.

METHODS

A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management.

RESULTS

Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care.

CONCLUSIONS

It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.

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.

An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes

AIMS

This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes.

BACKGROUND

Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery.

DESIGN

This study used a systematic integrative review by using Torraco's approach.

DATA SOURCES

Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019.

REVIEW METHODS

A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers.

RESULTS

Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes.

CONCLUSION

The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.

Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review

The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.

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.

Basal-bolus insulin therapy in postoperative inpatients with diabetes mellitus: directions for future quality-improvement initiatives

Aim

To determine variables associated with hyperglycemia and insulin therapy in postoperative inpatients with diabetes mellitus following a quality-improvement initiative.

Materials & methods

Patients with diabetes mellitus following an elective surgical procedure (n = 782; 877 surgical procedures) were selected.

Results

Age, hemoglobin A_1c corticosteroids, insulin therapy and year of surgery were associated (p < 0.01) with hyperglycemia. Hemoglobin A_1c, hyperglycemia, case mix index and corticosteroids were associated (p ≤ 0.03) with insulin therapy. Hyperglycemia and use of insulin varied by surgical specialty.

Conclusion

Data could be used to modify current treatment algorithms. Variations in hyperglycemia and insulin use by surgical specialty require further investigation.

Glucometrics and Insulinometrics

PURPOSE OF REVIEW

Glucometrics is the systematic analysis of inpatient glucose data and is of key interest as hospitals strive to improve inpatient glycemic control. Insulinometrics is the systematic analysis and reporting of inpatient insulin therapy. This paper reviews some of the questions to be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines.

RECENT FINDINGS

There remains a lack of standardization on how glucometircs should be measured and reported. Before hospitals can commit resources to compiling and extracting data, consensus must be reached on such questions as which measures to report, definitions of glycemic targets, and how data should be obtained. Examples are provided on how insulin administration can be measured and reported. Hospitals should begin assessment of glucometrics and insulinometrics. However, consensus and standardization must first occur to allow for a national benchmarking process.

Remote Monitoring and Consultation of Inpatient Populations with Diabetes

PURPOSE OF REVIEW

Inpatient hyperglycemia is common and is linked to increased morbidity and mortality. We review current and innovative ways diabetes specialists consult in the management of inpatient diabetes.

RECENT FINDINGS

With electronic medical records (EMRs), remote monitoring and intervention may improve the management of inpatient hyperglycemia. Automated reports allow monitoring of glucose levels and allow diabetes teams to intervene through formal or remote consultation. Following a 2-year transition of our complex paper-based insulin order sets to be EMR based, we leveraged this change by developing new daily glycemic reports and a virtual glucose management service (vGMS). Based on a daily report identifying patients with two or more glucoses over 225 mg/dl and/or a glucose <70 mg/dl in the past 24 h, a vGMS note with management recommendations was placed in the chart. Following the introduction of the vGMS, the proportion of hyperglycemic patients decreased 39% from a baseline of 6.5 per 100 patient-days to 4.0 per 100 patient-days The hypoglycemia proportion decreased by 36%. Ninety-nine percent of surveyed medical and surgical residents said the vGMS was both important and helpful.

Relationship between the timing of preoperative medical visits and day-of-surgery glucose in poorly controlled diabetes

BACKGROUND

This study evaluated referral patterns for preoperative evaluations of patients with poorly controlled diabetes mellitus (DM) and determined whether intervals between evaluations and surgery day were associated with preoperative glucose levels.

RESULTS/METHODOLOGY

In this retrospective analysis of DM patients with a hemoglobin A_1c level greater than 8.0%, of the 163 patients who underwent preoperative medical evaluation, only 45% were evaluated by endocrinology. Patients who had surgery earlier than 10 days after the preoperative medical evaluation had preoperative glucose levels 18% higher than those of patients who waited more than 10 days. Preoperative outpatient contact with endocrinology was not associated with preoperative glucose level (p = 0.90).

CONCLUSION

For poorly controlled DM, more than 10 days are needed to achieve preoperative glycemic control.

Hyperglycemia during the immediate period following liver transplantation

Aim:

High blood glucose levels in the hospital are common among transplant recipients.

Methods:

Retrospective analysis, stratified by diagnosis of pretransplant diabetes mellitus (DM).

Results:

Of 346 patients, 96 had pretransplant DM (insulin, n = 60; no insulin, n = 36) and 250 did not. Patients with pretransplant DM had higher inpatient mean glucose levels and more hyperglycemia and hypoglycemia (all p < 0.01). For patients without pretransplant DM, the need for insulin at discharge increased 23% for every 5-year age increase (odds ratio: 1.23; 95% CI: 1.06–1.44; p = 0.007) and 51% for every five units of glucose measurements >180 mg/dl (OR: 1.51; 95% CI: 1.23–1.95; p < 0.01).

Conclusion:

Inpatient hyperglycemia was common in liver transplant recipients. Hospital practitioners must anticipate the need to teach self-management skills to liver transplant recipients.

Lay abstract: High blood glucose levels (also known as hyperglycemia) in the hospital are common among patients who have received a transplant. The authors conducted a study to determine how often high blood glucose values occurred in patients who received a liver transplant and found that values were highest in people who had diabetes before the transplant. However, even patients who did not have a history of diabetes had hyperglycemia and needed insulin treatment. Providers caring for these patients in the hospital must be prepared to provide education in diabetes self-management skills to virtually all patients undergoing a liver transplant.

Perioperative Management of Patients with Diabetes and Hyperglycemia Undergoing Elective Surgery

Diabetes mellitus (DM) and hyperglycemia are associated with increased surgical morbidity and mortality. Hyperglycemia is a determinant of risk of surgical complications and should be addressed across the continuum of surgical care. While data support the need to address hyperglycemia in patients with DM in the ambulatory setting prior to surgery and in the inpatient setting, data are less certain about hyperglycemia occurring during the perioperative period-that part of the process occurring on the day of surgery itself. The definition of "perioperative" varies in the literature. This paper proposes a standardized definition for the perioperative period as spanning the time of patient admission to the preoperative area through discharge from the recovery area. Available information about the impact of perioperative hyperglycemia on surgical outcomes within the framework of that definition is summarized, and the authors' approach to standardizing perioperative care for patients with DM is outlined, including the special case of patients receiving insulin pump therapy. The discussion is limited to adult ambulatory non-obstetric patients undergoing elective surgical procedures under general anesthesia.

Update on a Quality Initiative to Standardize Perioperative Care for Continuous Subcutaneous Insulin Infusion Therapy

OBJECTIVE

The objective of the analysis was to review the effectiveness of a care process model (CPM) developed to guide management of patients on insulin pump therapy undergoing elective surgical procedures.

METHODS

Electronic medical records were reviewed to assess the impact of the CPM on documentation of insulin pump status, glucose monitoring, and safety during the perioperative phase of care. Post-CPM care was compared with management provided before CPM implementation.

RESULTS

We reviewed 45 cases on insulin pump therapy in the pre-CPM cohort and 106 in the post-CPM cohort. Demographic characteristics, categories of surgery, and perioperative times were not significantly different between the 2 groups. Recommended hemoglobin A1c monitoring occurred in 73% of cases in the pre-CPM cohort but improved to 94% in the post-CPM group (P < .01). There was a higher frequency of documentation of the insulin pump during the preoperative, intraoperative, and postanesthesia care unit segments of care in the post- vs pre-CPM periods (all P < .01). The number of cases with intraoperative glucose monitoring increased (57% pre-CPM vs 81% post-CPM; P < .01). Glycemic control was comparable between the 2 CPM periods. Hypoglycemia was rare, with only 3 episodes in the pre-CPM group and 4 in the post-CPM. No adverse events associated with perioperative insulin pump use were observed.

CONCLUSIONS

This analysis adds to previous data on use of insulin pump therapy during the perioperative period. Some processes require additional attention, but data continue to indicate that a standardized approach to care can lead to a successful and safe transition of insulin pump therapy throughout the perioperative period.