Effect Of A Targeted Glycemic Management Program On Provider Response To Inpatient Hyperglycemia

doi:10.4158/EP10330.OR

Endocrine Practice

Volume 17, Issue 4, July–August 2011, Pages 552-557

https://doi.org/10.4158/EP10330.OR Get rights and content

ABSTRACT

Objective

To report the results of implementation of a Targeted Glycemic Management (TGM) Service pilot, with the goals of improving clinician awareness of available inpatient glycemic management protocols and improving responsiveness to and frequency of severe hyperglycemia.

Methods

Patients with a blood glucose (BG) level ≥ 300 mg/dL who were hospitalized on a general medicine unit during three 12-week periods before, during, and after the TGM pilot were compared for responsiveness by the primary team, percentage of subsequent BG measurements between 80 and 180 mg/dL, and frequency of subsequent severe hyperglycemia (BG levels ≥ 300 mg/dL) and hypoglycemia (BG values < 70 mg/dL).

Results

In comparison with pre-TGM and post-TGM periods, more patients during the TGM pilot had a modification of their glycemic regimen in response to severe hyperglycemia (49% versus 73% versus 50%, before, during, and after TGM, respectively; P = .044), and the percentage of patients with ≥ 50% of subsequent BG measurements in the desired range (27% versus 53% versus 32%; P = .035) was greatest during the TGM period. The incidence of subsequent severe hyperglycemia (20% versus 9% versus 16%; P = .0004) was lowest during the TGM period; however, the incidence of hypoglycemia was similar in all 3 periods (3.9% versus 3.7% versus 3.7%).

Conclusion

These results indicate that a TGM Service can favorably influence glycemic management practices and improve glycemic control, but ongoing intervention is necessary for maintenance of these results. (Endocr Pract. 2011;17:552-557)

Section snippets

INTRODUCTION

Hyperglycemia in noncritically ill hospitalized patients with or without a prior history of diabetes has been linked to poor clinical outcomes (1,2). Hyperglycemia is associated with an increased frequency of postoperative infections, neurologic events, and intensive care unit admissions and a longer hospital length of stay (LOS) (1,2). Despite these associations, hyperglycemia often remains either untreated or poorly treated during periods of hospitalization (3,4). Thus, it is important that

METHODS AND DEFINITIONS

The plans for this study were reviewed by the University of Pittsburgh Institutional Review Board and approved as a quality improvement project by the Quality Improvement Committee of the University of Pittsburgh Medical Center (UPMC).

UPMC Presbyterian is an 800-bed adult tertiary and quaternary academic medical center. At the time of this project, a computerized physician order entry had not yet been implemented. Through the work of the UPMC Diabetes Inpatient Safety Committee, order sets for

DESCRIPTION OF THE TGM SERVICE

The TGM Service was composed of a diabetes nurseeducator, 2 nurse-practitioners, a pharmacist, and a dietitian. Each weekday, one member of the TGM Service reviewed the medical records of patients who had a BG level ≥ 300 mg/dL during the previous 24 hours to determine both what caused the hyperglycemia and whether appropriate action was taken by the primary team. Appropriate action is defined in Table 1. If a determination was made that the primary team had responded to the hyperglycemic event

Occurrence of Hyperglycemia

Severe hyperglycemia was identified in 188 of 654 patients (29%) on the general medicine inpatient units during the TGM pilot, and 96 of these patients were assessed by the TGM Service. The most common causes of hyperglycemia were discontinuation of preadmission diabetes medications, inadequate insulin dose adjustments, initiation of corticosteroid therapy, and use of correction insulin alone for > 48 hours (Table 2). (See Table 1.)

Recommendations of the TGM Service

Review of medical records indicated that appropriate action was

DISCUSSION

This project demonstrates that a TGM Service has the potential to reduce clinical inertia related to inpatient glycemic management. We observed an increase in provider responsiveness to hyperglycemia, an increase in the percentage of patients meeting minimal criteria for good glycemic control, and a reduction in the percentage of subsequent BG measurements ≥ 300 mg/dL without an increase in hypoglycemia while the TGM program was in place. The modifications in the glycemic management regimen made

CONCLUSION

In summary, we found that the availability of inpatient protocols and order sets for guiding glycemic management is not sufficient to change current practice. Rather, ongoing reminders to adjust therapy in response to hyperglycemia remain necessary to ensure acceptable attention to severe hyperglycemia and to achieve the desired glycemic control. A TGM Service provides one approach to overcoming clinical inertia and improving glycemic control.

DISCLOSURE

The husband of Michelle L. Noschese is employed by Novo Nordisk Inc. During the past year, Dr. Mary T. Korytkowski has worked on protocol development for a multicenter clinical trial with Eli Lilly and Company and served as an ad hoc grant reviewer for Pfizer Inc. There are no other potential conflicts of interest relevant to this article. The other authors have no multiplicity of interest to disclose.

ACKNOWLEDGMENT

This project was sponsored by funding from the US Air Force administered by the US Army Medical Research Acquisition Activity, Fort Detrick, Maryland, Award Number W81XWH-04-2-0030.

Some of this material was presented as a poster at the 68th Annual Scientific Sessions of the American Diabetes Association; June 8, 2008; San Francisco, California.

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Importance: Diabetes is common amongst hospitalised patients and contributes to increased length of stay and poorer outcomes. Digital transformation, particularly the implementation of electronic medical records (EMRs), is rapidly occurring across the healthcare sector and provides an opportunity to improve the safety and quality of inpatient diabetes care. Alongside this revolution has been a considerable and ongoing evolution of digital interventions to optimise care of inpatients with diabetes including optimisation of EMRs, digital clinical decision support systems (CDSS) and solutions utilising data visibility to allow targeted patient review.
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Pubmed, Embase and Cochrane databases were searched for suitable articles. Selected articles underwent quality assessment and analysis with results grouped by intervention type.
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Original ArticleEffect Of A Targeted Glycemic Management Program On Provider Response To Inpatient Hyperglycemia

ABSTRACT

Objective

Methods

Results

Section snippets

INTRODUCTION

METHODS AND DEFINITIONS

DESCRIPTION OF THE TGM SERVICE

Occurrence of Hyperglycemia

Recommendations of the TGM Service

DISCUSSION

CONCLUSION

DISCLOSURE

ACKNOWLEDGMENT

Am J Med

Endocr Pract

Endocr Pract

Endocr Pract

Endocr Pract

Management of diabetes and hyperglycemia in hospitals [published corrections appear in

Diabetes Care

American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control

Diabetes Care

Original Article
Effect Of A Targeted Glycemic Management Program On Provider Response To Inpatient Hyperglycemia