Original ArticleEffect Of A Targeted Glycemic Management Program On Provider Response To Inpatient Hyperglycemia
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.
REFERENCES (14)
- et al.
Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes
Am J Med
(1995) - et al.
Inpatient management of hyperglycemia: the Northwestern experience
Endocr Pract
(2006) - et al.
Financial implications of glycemic control: results of an inpatient diabetes management program
Endocr Pract
(2006) - et al.
Evolution of a diabetes inpatient safety committee
Endocr Pract
(2006) - et al.
Patient outcomes after implementation of a protocol for inpatient insulin pump therapy
Endocr Pract
(2009) - et al.
Management of diabetes and hyperglycemia in hospitals [published corrections appear in
Diabetes Care
(2004) - et al.
American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control
Diabetes Care
(2009)
Cited by (20)
Digital interventions to improve safety and quality of inpatient diabetes management: A systematic review
2022, International Journal of Medical InformaticsOvercoming clinical inertia in the management of postoperative patients with diabetes
2014, Endocrine PracticeImplementing and evaluating a multicomponent inpatient diabetes management program: Putting research into practice
2012, Joint Commission Journal on Quality and Patient SafetyGlycemic Management for Hospitalized Patients with Diabetes in Non-endocrine Wards
2023, Chinese General PracticeA Multi-professional Approach for Transition of Care at Discharge in Hyperglycemic Inpatients with COVID-19: A Single Center Study
2022, Endocrine, Metabolic and Immune Disorders - Drug Targets