Evolution of a diabetes inpatient safety committee

16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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.

Hypoglycemia symptoms are reduced in hospitalized patients with diabetes

AIMS

Hospitalized patients with diabetes are have an impaired ability to detect hypoglycemia events. The purpose of this study was to compare hypoglycemia symptom scores (HSS) in hospitalized patients with diabetes after a documented blood glucose (BG) <70mg/dl with recalled HSS with outpatient hypoglycemia events.

METHODS

Non-critically ill hospitalized patients with diabetes grouped as symptomatic (n=23) or asymptomatic (n=32) at time of index hypoglycemia completed a standardized HSS-Questionnaires (HSS-Q) related to the inpatient event and to recall of symptoms with outpatient hypoglycemia.

RESULTS

After controlling for BG at time of index hypoglycemia (49.8±11.4 vs. 57.4±6.8mg/dl, p=0.02), symptomatic patients reported higher HSS than asymptomatic patients with the inpatient event (11.6±7.3 vs. 1.5±3.4, p<0.001) and in the outpatient setting (13.9±8.6 vs. 10.1±10.6, p<0.01). Recurrent hypoglycemia was more frequent in asymptomatic patients (13% vs. 44%, p=0.015) during the hospitalization.

CONCLUSIONS

Compared to symptomatic patients, asymptomatic patients had lower inpatient and outpatient HSS and more frequent recurrent hypoglycemia events. These results suggest modification of glycemic management strategies in high risk patients to reduce risk for hypoglycemia events.

The Endocrine Hospitalist: Enhancing the Quality of Diabetes Care

The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.

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.

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 impact of glycaemic variability on the surgical patient

PURPOSE OF REVIEW

Diabetes is the most prevalent long-term metabolic condition and its incidence continues to increase unabated. Patients with diabetes are overrepresented in the surgical population. It has been well recognized that poor perioperative diabetes control is associated with poor surgical outcomes. The outcomes are worst for those people who were not recognized as having hyperglycaemia.

RECENT FINDINGS

Recent work has shown that preoperative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimize the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home. The early involvement of the diabetes specialist team is important if the glycated haemoglobin is more than 8.5%, and advice sought if the preoperative assessment team is not familiar with the drug regimens. To date the glycaemic targets for the perioperative period have remained uncertain, but recently a consensus is being reached to ensure glucose levels remain between 108 and180 mg/dl (6.0 and 10.0 mmol/l). There have been a number of ways to achieve these - primarily by manipulating the patients' usual diabetes medications, to also allow day of surgery admission.

SUMMARY

glycaemic control remains an important consideration in the surgical patient.

Challenges of Inpatient Glycemic Control

Hyperglycemia occurs in more than 30% of hospitalized patients. The condition has been associated with higher mortality and poor outcomes. Systems to effectively treat dysglycemia have been put into place, although many focus on critical care areas. The purpose of this article is to provide an overview of the challenges for glycemic control in non-critical care areas. Standardized order sets, critical pathways, professional education, and collaborative systems can support improved control.

The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes

PURPOSE OF REVIEW

The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes.

RECENT FINDINGS

Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.

Development of a cross-disciplinary continuous insulin infusion protocol for non-critically ill patients in a French university hospital

RATIONALE, AIMS AND OBJECTIVES

In non-critically ill patients, the use of an insulin syringe pump allows the management of temporary situations during which other therapies cannot be used (failure of subcutaneous injections, awaiting advice from the diabetes team, emergency situations, prolonged corticosteroid therapy, initiation of an artificial nutrition, need for a fasting status, etc.). To manage the risks related to this «never event», the use of a standard validated protocol for insulin administration and monitoring is an essential prerequisite. To this end, a multidisciplinary approach is recommended.

METHOD

With the support of our subcommission «Endocrinology-Diabetology», we proceeded with a «step-by-step process» to create such a standardized protocol: (1) review of all existing protocols in our hospital; (2) overview of the literature data concerning insulin infusion protocols developed by multidisciplinary teams in France and abroad; (3) development of a standardized protocol for non-intensive care unit patients, respecting the current recommendations and adapting it to the working habits of health teams; and (4) validation of the protocol

RESULTS

Two protocols based on the same structure but adapted to the health status of the patient have been developed. The protocols are divided in to three parts: (1) golden rules to make the use of the protocol appropriate and safe; (2) the algorithm (a double entry table) corresponding to a dynamic adaptation of insulin doses, clearly defining the target and the 'at risk situations'; and (3) practical aspects of the protocol: preparation of the syringe, treatment initiation and traceability. The protocols have been validated by the institution.

CONCLUSION

Our standardized insulin infusion protocol is simple, easy to implement, safe and is likely to be applicable in diverse care units. However, the efficiency, safety and the workability of our protocols have to be clinically evaluated.

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children

OBJECTIVE

Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.

METHODS

Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.

RESULTS

After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.

CONCLUSIONS

Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.

Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia

Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.

Predictors of recurrent hypoglycemia following a severe hypoglycemic event among hospitalized patients

OBJECTIVES

Severe hypoglycemia is associated with poor hospital outcomes, but variables contributing to the adequacy of treatment have not been described. The objective of this study was to determine predictors of recurrent hypoglycemia among hospitalized patients with a severe hypoglycemic event.

METHODS

Patients with severe hypoglycemia (glucose <40 mg/dl) with a concomitant insulin order were identified using the study institution's Information Warehouse. The primary outcome was the prevalence of recurrent hypoglycemia (defined as <70 mg/dl within 24 hours) and to identify independent predictors of recurrent hypoglycemia. Secondary outcomes included time to blood glucose recheck, time to blood glucose ≥ 70 mg/dl, and rebound hyperglycemia (defined as glucose >300 mg/dl within 24 hours). Multivariable linear and logistic regression models were performed.

RESULTS

A total of 129 patients with severe hypoglycemia were identified. The median time to repeat glucose measurement was 29 (IQR 15-61) minutes, while the time to resolution of hypoglycemia was 49 (IQR 26-103) minutes. Recurrent hypoglycemia occurred in 49% of patients, while 19% of patients experienced rebound hyperglycemia. Independent predictors of recurrent hypoglycemia included lower repeat glucose (p = 0.025), low glomerular filtration rate (p = 0.033), and lack of insulin adjustment (p = 0.012). Independent predictors of maximum glucose post-event were type 1 diabetes (p = 0.0003), history of any diabetes (p = 0.013), and total bolus dose of insulin (p < 0.0001). Overnight timing of events was the only predictor of shorter time to hypoglycemia resolution (p < 0.0001).

CONCLUSIONS

Recurrent hypoglycemia following severe hypoglycemia is common in the hospital, suggesting the need for enhanced monitoring in such patients. Further research is needed to identify methods to reduce the incidence of recurrent hypoglycemia.

SAFETY AND EFFICACY OF A PERI-OPERATIVE PROTOCOL FOR PATIENTS WITH DIABETES TREATED WITH CONTINUOUS SUBCUTANEOUS INSULIN INFUSION WHO ARE ADMITTED FOR SAME-DAY SURGERY

OBJECTIVE

The number of people with diabetes using continuous subcutaneous insulin infusions (CSII) with an insulin pump has risen dramatically, creating new challenges when these patients are admitted to the hospital for surgical or other procedures. There is limited literature guiding CSII use during surgical procedures.

METHODS

The study was carried out in a large, urban, tertiary care hospital. We enrolled 49 patients using insulin pump therapy presenting for 57 elective surgeries. We developed a CSII peri-operative glycemic management protocol (PGMP) to standardize insulin pump management in patients admitted to a same-day surgery unit (SDSU). The purpose was evaluate the safety (% capillary blood glucose (CBG) <70 mg/dL and/or pump incidents) and efficacy (first postoperative CBG ≤200 mg/dL) of the CSII PGMP. We determine the contribution of admission CBG, type of anesthesia, surgery length, and peri-operative steroid use on postoperative glycemic control.

RESULTS

Overall, 63% of patients treated according to the CSII PGMP had a first postoperative CBG ≤200 mg/dL. There were no episodes of intra- or postoperative hypoglycemia. For patients treated with the CSII PGMP, the mean postoperative CBG was lower in patients with anticipated or actual surgical length ≤120 minutes (158.1 ± 53.9 vs. 216 ± 77.7 mg/dL, P<.01). No differences were observed with admission CBG, type of anesthesia, or steroid use.

CONCLUSIONS

This study demonstrates that a CSII PGMP is both safe and effective for patients admitted for elective surgical procedures and provides an example of a standardized protocol for use in clinical practice.

Addressing Inpatient Glycaemic Control with an Inpatient Glucometry Alert System

Background. Poor inpatient glycaemic control has a prevalence exceeding 30% and results in increased length of stay and higher rates of hospital complications and inpatient mortality. The aim of this study was to improve inpatient glycaemic control by developing an alert system to process point-of-care blood glucose (POC-BG) results. Methods. Microsoft Excel Macros were developed for the processing of daily glucometry data downloaded from the Cobas IT database. Alerts were generated according to ward location for any value less than 4 mmol/L (hypoglycaemia) or greater than 15 mmol/L (moderate-severe hyperglycaemia). The Diabetes Team provided a weekday consult service for patients flagged on the daily reports. This system was implemented for a 60-day period. Results. There was a statistically significant 20% reduction in the percentage of hyperglycaemic patient-day weighted values >15 mmol/L compared to the preimplementation period without a significant change in the percentage of hypoglycaemic values. The time-to-next-reading after a dysglycaemic POC-BG result was reduced by 14% and the time-to-normalization of a dysglycaemic result was reduced from 10.2 hours to 8.4 hours. Conclusion. The alert system reduced the percentage of hyperglycaemic patient-day weighted glucose values and the time-to-normalization of blood glucose.

In-patient diabetes care: the impact of diabetes outreach team on long-term glycaemic control

AIM

Our aim is to assess the impact of inpatient diabetes services on glycaemic control in patient with diabetes admitted to a secondary care hospital in UK.

METHODS

We performed a retrospective analysis of all diabetes mellitus (DM) in-patients who were seen by our Diabetes Outreach Team from June 2007 to December 2010. Those with an admission diagnosis of hypoglycaemia were excluded. Blood samples including HbA1c at the initial visit and subsequent outpatient follow-up at 3-6 months were collected. Patients admitted with newly diagnosed diabetes were analysed separately.

RESULTS

In total 2002 patient data were captured. 778 patients were eliminated initially because of failure to attend follow-up clinic, lack of follow-up HbA1c data, and because of planned discharge to the community. Complete blood samples were available for 1224 patients. Of this, 235 patients (19.2% of those with complete data) were analysed separately as their primary diagnosis was hypoglycaemia. In the remaining 989 patients, 31 (3.1%) new onset Type 1 DM patients and 91 (9.2%) new onset Type 2 patients were analysed separately. In patients with known DM (n = 867) HbA1c improved from 75 mmol/mol (9.0% ± 2.39) to 69 mmol/mol (8.46% ± 2.0) (p < 0.001). In the newly diagnosed Type 1 DM (n = 31) patients HbA1c improved from 114 mmol/mol (12.55% ± 2.27) to 58 mmol/mol (7.43% ± 2.05) (p < 0.001). In the newly diagnosed Type 2 DM (n = 91) patients HbA1c improved from 93 mmol/mol (10.70% ± 3.04) to 56 mol/mol (7.29% ± 1.74) (p < 0.001). In those who presented with hypoglycaemia (n = 235) HbA1c changed from 58 mmol/mol (7.48% ± 1.59) to 59 mmol/mol (7.59% ± 1.57) (p = 0.2).

CONCLUSION

By providing a comprehensive care, structured education and appropriate intervention through our Diabetes Outreach Team, we have shown a significant reduction in HbA1c for recently hospitalised patients.

Pilot trial of diabetes self-management education in the hospital setting

AIMS

Diabetes self-management education (DSME) is recommended for all patients with diabetes. Current estimates indicate that <50% of patients receive DSME, increasing risk for hospitalization which occurs more frequently with diabetes. Hospitalization presents opportunities to provide DSME, potentially decreasing readmissions. To address this, we investigated the feasibility of providing DSME to inpatients with diabetes.

METHODS

Patients hospitalized on four medicine units were randomized to receive DSME (Education Group) (n=9) prescribed by a certified diabetes educator and delivered by a registered nurse, or Usual Care (n=12). Participants completed Diabetes Knowledge Tests (DKT), Medical Outcomes Short Form (SF-36), Diabetes Treatment Satisfaction Questionnaire (DTSQ), and the DTSQ-inpatient (DTSQ-IP). Bedside capillary blood glucoses (CBG) on day of admission, randomization and discharge were compared.

RESULTS

There were no group differences in demographics, diabetes treatment, admission CBG (186±93 mg/dL vs. 219±84 mg/dL, p=0.40), DKT scores (Education vs. Usual Care 48±25 vs. 68±19, p=0.09), SF-36, and DTSQ scores (28±6 vs. 25±7, p=0.41). Patients receiving education reported more satisfaction with inpatient treatment (83±13 vs. 65±19, p=0.03), less hyperglycemia prior to (2.7±4.5 vs. 4.5±1.4, p=0.03) and during hospitalization (3.9±1.9 vs. 5.5±1.2, p=0.04); and had lower mean discharge CBG (159±38 mg/dL vs. 211±67 mg/dL, p=0.02).

CONCLUSIONS

Inpatient diabetes education has potential to improve treatment satisfaction, and reduce CBG.

Construction of a clinical decision support system for undergoing surgery based on domain ontology and rules reasoning

OBJECTIVE

To construct a clinical decision support system (CDSS) for undergoing surgery based on domain ontology and rules reasoning in the setting of hospitalized diabetic patients.

MATERIALS AND METHODS

The ontology was created with a modified ontology development method, including specification and conceptualization, formalization, implementation, and evaluation and maintenance. The Protégé-Web Ontology Language editor was used to implement the ontology. Embedded clinical knowledge was elicited to complement the domain ontology with formal concept analysis. The decision rules were translated into JENA format, which JENA can use to infer recommendations based on patient clinical situations.

RESULTS

The ontology includes 31 classes and 13 properties, plus 38 JENA rules that were built to generate recommendations. The evaluation studies confirmed the correctness of the ontology, acceptance of recommendations, satisfaction with the system, and usefulness of the ontology for glycemic management of diabetic patients undergoing surgery, especially for domain experts.

CONCLUSIONS

The contribution of this research is to set up an evidence-based hybrid ontology and an evaluation method for CDSS. The system can help clinicians to achieve inpatient glycemic control in diabetic patients undergoing surgery while avoiding hypoglycemia.

Inpatient hypoglycemia: a challenge that must be addressed

Hypoglycemia in the inpatient setting is a common occurrence with potentially harmful outcomes. Large trials in both the inpatient and outpatient settings have found a correlation between hypoglycemia and morbidity and mortality. The incidence of hypoglycemia is difficult to assess, due to a lack of standardized definitions and different methods of data collection between hospital systems. Risk factors that predispose to hypoglycemia involve the changing clinical statuses of patients, nutrition issues, and hospital processes. Mechanisms contributing to morbidity due to hypoglycemia may include an increase in sympathoadrenal responses, as well as indirect changes affecting cytokine production, coagulation, fibrinolysis, and endothelial function. Prevention of hypoglycemia requires implementation of several strategies that include patient safety, quality control, multidisciplinary communication, and transitions of care. In this article, we discuss all of these issues and provide suggestions to help predict and prevent hypoglycemic episodes during an inpatient stay. We address the issues that occur upon admission, during the hospital stay, and around the time of discharge. We believe that decreasing the incidence of inpatient hypoglycemia will both decrease costs and improve patient outcomes.

In-patient management of diabetes: Controversies and guidelines

Hyperglycemia is associated with adverse outcomes in hospitalized patients with and without previously known diabetes. Some therapies that are used in the in-patient setting, including glucocorticoids, enteral and parenteral nutrition are associated with new onset hyperglycemia even in previously normoglycemic patients. Current guidelines advise that fasting and premeal blood glucose (BG) be maintained at < 140 mg/dl, with maximal random BG < 180 mg/dl in non-critically ill-patients. In critically ill-patients, intravenous (IV) insulin infusion therapy with BG targets of 140-180 effectively maintains glycemic control with a low risk for hypoglycemia. Protocols targeting "tight" glycemic control, defined as BG 80-110 mg/dl, are no longer recommended due to the high frequency of severe hypoglycemia. Rational use of basal bolus insulin (BBI) regimens in non-critical care and IV insulin infusions in critical care settings has been demonstrated to effectively achieve and maintain recommended BG targets with low risk for hypoglycemia. The safety of BBI relies upon provider awareness of prescribing recommendations for initiating and adjusting insulin regimens according to changes in overall clinical and nutritional status, as well as careful review of daily BG measurements. Smooth transition of care to the out-patient setting is facilitated by providing oral and written instructions regarding the timing and dosing of insulin as well as education in basic skills for home management.

Insulin order sets improve glycemic control and processes of care

OBJECTIVE

The study objective was to evaluate the impact of a standardized preprinted subcutaneous correctional insulin order set on glycemic control, processes of care, and nursing satisfaction.

METHODS

This was a controlled before/after, qualitative study using focus group interviews. The intervention group consisted of patients with diabetes who were admitted to the cardiovascular surgery ward. The control group consisted of patients with diabetes who were admitted to the vascular surgery ward. Registered nurses on the cardiovascular surgery floor participated in focus groups and completed surveys. We used a multifaceted intervention including standardized insulin order sheet, educational workshops, verbal and printed reminders, printed enabler, reference sheet, and overnight helpline. Glycemic control and hypoglycemia were assessed through chart review, and nursing satisfaction with the insulin order sets was assessed through surveys and nursing focus groups, performed before and 6 months after implementation of the insulin order set.

RESULTS

There was a 39% reduction in proportion of blood glucose>11.0 mmol/L (198 mg/dL) in the intervention group compared with the control group (0.17 vs 0.28, P=.03). The proportion of hypoglycemia (blood glucose<4.0 mmol/L [72 mg/dL]) was no different between the 2 groups. Nurse satisfaction increased significantly (P<.02); order sets were easy to use and improved glycemic control, processes, and efficiency of care, and reduced the number of pages between nursing and medical staff.

CONCLUSIONS

Standardized insulin order sets reduced hyperglycemia and improved nursing satisfaction and processes of care. Successful implementation required stakeholder engagement, identification of barriers and facilitators in local practice, and tailoring the intervention to target these factors.

Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice

BACKGROUND

Strategies for successful implementation of hospitalwide glucose control efforts were addressed in a conceptual model for the development and implementation of an institutional inpatient glucose management program. CONCEPTUAL MODEL COMPONENTS: The Glucose Steering Committee incrementally developed and implemented hospitalwide glucose policies, coupled with targeted education and clinical decision support to facilitate policy acceptance and uptake by staffwhile incorporating process and outcome measures to objectively assess the effectiveness of quality improvement efforts. The model includes four components: (1) engaging staff and hospital executives in the importance of inpatient glycemic management, (2) educating staff involved in the care of patients with diabetes through structured knowledge dissemination, (3) executing evidence-based inpatient glucose management through development of policies and clinical decision aids, and (4) evaluating intervention effectiveness through assessing process measures, intermediary glucometric outcomes, and clinical and economic outcomes. An educational curriculum for nursing, provider, and pharmacist diabetes education programs and current glucometrics were also developed.

OUTCOMES

Overall the average patient-day-weighted mean blood glucose (PDWMBG) was below the currently recommended maximum of 180 mg/dL in patients with diabetes and hyperglycemia, with a significant decrease in PDWMBG of 7.8 mg/dL in patients with hyperglycemia. The program resulted in an 18.8% reduction in hypoglycemia event rates, which was sustained.

CONCLUSION

Inpatient glucose management remains an important area for patient safety, quality improvement, and clinical research, and the implementation model should guide other hospitals in their glucose management initiatives.

Insulin therapy for the management of hyperglycemia in hospitalized patients

It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients and that goal-directed insulin therapy can improve outcomes. This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, and beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.

What is the value and impact of quality and safety teams? A scoping review

BACKGROUND

The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.

METHODS

Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.

RESULTS

Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.

CONCLUSIONS

Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.

Patient outcomes after implementation of a protocol for inpatient insulin pump therapy

OBJECTIVE

To determine the safety and the results of use of an inpatient insulin pump protocol (IIPP).

METHODS

In this quality improvement initiative, review of medical records of bedside capillary blood glucose (CBG) levels and pump-related adverse events was performed on 50 consecutive inpatients admitted to the hospital with continuous subcutaneous insulin infusion (CSII) after implementation of our IIPP. Patients were categorized in 3 groups on the basis of evidence in the medical records for IIPP in combination with inpatient diabetes service consultation (group 1; n = 34), for IIPP alone (group 2; n = 12), or for usual care (group 3; n = 4). Patients identified during hospital admission as using CSII therapy were invited to complete a satisfaction questionnaire for inpatient CSII use.

RESULTS

Mean CBG levels were similar among the 3 groups (groups 1, 2, and 3: 173 +/- 43 mg/dL versus 187 +/- 62 mg/dL versus 218 +/- 46 mg/dL, respectively). Although there were more patient-days with blood glucose >300 mg/dL in group 3 (P = .02), there were no significant group differences in the frequency of hypoglycemia (CBG <70 mg/dL). Only 1 pump malfunction and 1 infusion site problem were reported among all study patients. No serious adverse events related to CSII therapy occurred. The majority of patients (86%) reported satisfaction with their ability to continue CSII use in the hospital.

CONCLUSION

Patients using CSII as outpatients are candidates for inpatient diabetes self-management. Inexperience with these devices on the part of hospital personnel together with the limited studies of patient experience with CSII in the hospital contributes to inconsistencies in management of these patients. An IIPP provides a standardized and safe approach to the use of CSII in the hospital.

Improving insulin ordering safely: the development of an inpatient glycemic control program

This report describes a Glycemic Control Program instituted at an academic regional level-one trauma center. Key interventions included: 1) development of a subcutaneous insulin physician order set, 2) use of a real-time data report to identify patients with out-of-range glucoses, and 3) implementation of a clinical intervention team. Over four years 18,087 patients admitted to non-critical care wards met our criteria as dysglycemic patients. In this population, glycemic control interventions were associated with increased basal and decreased sliding scale insulin ordering. No decrease was observed in the percent of patients experiencing hperglycemia. Hypoglycemia did decline after the interventions (4.3% to 3.6%; p = 0.003). Distinguishing characteristics of this Glycemic Control Program include the use of real-time data to identify patients with out-of-range glucoses and the employment of a single clinician to cover all non-critical care floors.

Impact of improvement efforts on glycemic control and hypoglycemia at a university medical center

BACKGROUND

Great emphasis is placed on optimizing treatment of hospitalized patients with diabetes and hyperglycemia.

OBJECTIVE

This study was conducted to determine if the application of hospital-wide insulin order sets improved inpatient safety by reducing the number of actual hypoglycemic and hyperglycemic events and increasing at-target blood glucose.

DESIGN

A retrospective chart review was conducted of hypoglycemic and hyperglycemic events and at-target blood glucose occurring before and after institution of the insulin order sets and blood glucose protocols.

SETTING

The Medical University of South Carolina (MUSC) Medical Center is a 709-bed hospital and tertiary referral center for partnering hospitals in the southeastern United States.

PATIENTS

All patients were evaluated who had a documented history of diabetes or who had at least 1 finger-stick blood glucose above 180 mg/dL who were admitted for care to the MUSC adult main hospital (minimum of 18 years-of-age; maximum 100 years-of-age) during June 2004, June 2005, June 2006, and June 2007.

INTERVENTION

The intervention involved institution of hospital-wide hypoglycemia, hyperglycemia, subcutaneous insulin, and intravenous insulin treatment protocols.

MEASUREMENTS

Retrospective data on hypoglycemia, hyperglycemia, and at-target blood glucose incidence and frequency were collected via a computerized repository for all inpatients.

RESULTS

The percent time in range improved by 10% with no increase in the amount of severe hypoglycemic episodes for the blood glucose results.

CONCLUSIONS

Implementing standardized insulin order sets including hypoglycemia and hyperglycemia treatment protocols at MUSC produced expected benefits for patient safety for this patient population.

Surgical Resident and Attending Physician Attitudes toward Glucose Control in the Surgical Patient

Hyperglycemia is a common occurrence in postoperative surgical patients and has been related to adverse outcomes, including increased infections, delayed wound healing, and increased postoperative mortality. Therefore, the management of hyperglycemia has become an increasingly important part of surgical practice. A 16-point questionnaire was distributed to general surgery housestaff and attending physicians at three teaching hospitals in southern California. The survey was scaled 1 to 5 (1, strongly disagree; 5, strongly agree). Answers of 1 and 2 were considered a negative response, whereas 4 and 5 were considered affirmative responses. There were 105 survey respondents (60 surgical residents, 45 surgical attendings). Only half of respondents were confident in their ability to adequately control blood sugar in their hospitalized patients. Approximately 60 per cent of attendings rely on residents to manage glucose control. Less than half of the attendings (49%) and less than one-third of residents (27%) stated they were current with the latest guidelines for glucose control. Only one-third of the attendings would consult an internist or endocrinologist to assist in glycemic management. This study reveals an important knowledge deficit among surgical resident and attending physicians. Focused education on glycemic control in the perioperative patient should be a mandatory component of surgical training.

The medical emergency team and rapid response system: finding, treating, and preventing hypoglycemia

Administrative and quality improvement processes that occurred in response to one patient's series of critical hypoglycemic events ultimately contributed to systematic improvements in patient safety.