A Comparison of Inpatient Cost Per Day in General Surgery Patients with Type 2 Diabetes Treated with Basal-Bolus versus Sliding Scale Insulin Regimens

Use of the Model for Improvement to Reduce Hyperglycemia in Adult Patients Admitted to a Public Tertiary Care Hospital

BACKGROUND

The objective of this study was to reduce by 50% the occurrence of average daily blood glucose (ADBG) > 180 mg/dL among noncritical patients admitted to a surgical ward at a public tertiary care hospital.

METHODS

This project ran from April 2022 to June 2023 and used the Model for Improvement (MFI) method. Health care Failure Modes and Effects Analysis was used to identify and analyze failure modes in hyperglycemia management, and a driver diagram (DD) was used to prioritize and structure changes. The Plan-Do-Study-Act (PDSA) tool facilitated the change process. Data were collected using standardized forms and monitored with run charts, considering process, outcome, and balance indicators. The DD included 12 changes focusing on protocol implementation, adequate medical prescription, correct insulin administration, proper blood glucose monitoring, appropriate diet prescription, safe care transitions between units, routine of publication and discussion of indicators, leadership engagement with frontline workers on hyperglycemia management, educational actions, and defining roles and responsibilities.

RESULTS

A 69.0% reduction in ADBG > 180 mg/dL and a 100% reduction in ADBG > 300 mg/dL were achieved, though hypoglycemic events increased from 8 to 11 per 100 patient-days using insulin or oral antidiabetic medications. Reductions in nonconformities in medical prescription and insulin administration (50.0% and 71.4%, respectively) were also achieved.

CONCLUSION

In this pilot project, use of the MFI led to improved prescription practices, insulin administration, and blood glucose control, reducing the rate of hyperglycemia in hospitalized patients.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Intraoperative Blood Pressure Lability Carries a Higher Risk of Headache after Carotid Endarterectomy

OBJECTIVES

Cerebral hyper-perfusion (CH) is a rare but potentially devastating complication following carotid endarterectomies (CEA). Its symptoms range from new-onset unilateral headache (HA) to intracranial hemorrhage (ICH). Risk factors of CH in the literature to date have not yet yielded a consensus. This study examines intraoperative and postoperative blood pressure variation as a potential risk factor for HA.

METHODS

A single center retrospective review at a tertiary care center from January 2010 to November 2019 was performed. Inclusion criteria were all patients undergoing carotid endarterectomy for symptomatic or asymptomatic carotid disease. Patients with incomplete charts were excluded. Primary endpoints were new-onset unilateral HA or post-operative ICH. Data on intraoperative and post-operative mean arterial blood pressure (MAP), systolic blood pressure (SBP), the mode of endarterectomy, shunt placement, and contralateral carotid status were collected.

RESULTS

735 patients met inclusion criteria: 430 patients underwent modified eversion CEA (59%) vs 305 patients for patch angioplasty (42%). The incidence of HA was 19% (N= 142) in our total cohort. Of the 19% with HA, 1.5% (N=11) demonstrated no relief with analgesics and strict blood pressure control; non-contrast head computed tomography scans were subsequently performed. One patient (0.1%) had an ipsilateral ICH. Univariate analysis demonstrated that greater intra-operative MAP peak had the highest risk for HA (OR 1.014, 95% CI:1.007,1.022 p=0.0002) followed by intra-operative MAP variability (OR 1.011, 95% CI:1.005,1.018 p=<0.0008) and lastly peak intra-operative SBP (OR 1.01, 95% CI:1.004, 1.015 p=0.0011). An unpaired Student's t-test identified change in intra-operative MAP (p<0.005), change in SBP (p<0.005) as well as peak SBP (p<0.001) were significantly associated with HA. Interestingly, there was no significant difference between post-operative MAP variability and HA (p=0.1). Mode of endarterectomy showed no statistically significant difference in risk for developing HA (OR 1.165, 95% CI 0.801, 1.694; p=0.42).

CONCLUSIONS

Greater intra-operative variability in blood pressures are significantly associated with higher risk of HA. Adhering to stricter intra-operative blood pressure parameters and limiting blood pressure variability may be beneficial at reducing the incidence of CH and its complications.

Inpatient Hyperglycemia and Transitions of Care: A Systematic Review

OBJECTIVE

The transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed.

METHODS

A PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included.

RESULTS

With the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care.

CONCLUSION

Pockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay.

Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control

PURPOSE OF REVIEW

The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting.

RECENT FINDINGS

We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoTool^R (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.

Recent advances in diabetes treatments and their perioperative implications

PURPOSE OF REVIEW

The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed.

RECENT FINDINGS

The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes.

SUMMARY

Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

Exploring Trajectories of Health Care Utilization Before and After Surgery

BACKGROUND

Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions.

STUDY DESIGN

Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression.

RESULTS

Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01).

CONCLUSIONS

Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.

Safely Converting an Entire Academic Medical Center From Sliding Scale to Basal Bolus Insulin via Implementation of the eGlycemic Management System

OBJECTIVE

Hyperglycemia is common in the inpatient setting and providers frequently rely on sliding scale insulin. This case study reviews the experience of one hospital moving from high utilization of sliding scale to basal bolus insulin therapy.

METHOD

This Retrospective Quality Improvement Study describes the journey of clinicians at a 580-bed hospital to convert from high usage of SSI to BBI. Hyperglycemic adult patients prescribed insulin, with/without a diagnosis of diabetes, were included.

RESULTS

Data over the first year showed that patients treated with Glucommander (GM) spent more time in the target range of 70-180 mg/dL than patients treated with non-Glucommander (non-GM), with 2,434 fewer hypoglycemic events and 40,589 fewer hyperglycemic events. Prior to implementation of GM, SSI was close to 95%, BBI at 5%. Within the first month of use, 96% usage of BBI was achieved. Reduction of hypoglycemic events (% of BG < 70 mg/dL) by 21% with 2.16% non-GM compared to GM at 1.74% and severe Hypoglycemia (% of BG < 50 mg/dL) by 50% in the ICU 3% non-GM compared to GM at 1.5%. In addition, patients treated with GM had a shorter LOS than patients treated with non-GM by 3.18 days and used 47.4% less point of care tests per patient.

CONCLUSION

Glycemic management improved with use of eGMS. The conversion from SSI to BBI enhanced overall patient safety, eliminated the time and effort otherwise required when manually titrating insulin and reduced overall cost of care for patients on insulin therapy.