Overcoming Clinical Inertia in the Management of Postoperative Patients with Diabetes

doi:10.4158/EP13366.OR

Endocrine Practice

Volume 20, Issue 4, April 2014, Pages 320-328

https://doi.org/10.4158/EP13366.OR Get rights and content

ABSTRACT

Objective

To assess the impact of an intervention designed to increase basal-bolus insulin therapy administration in postoperative patients with diabetes mellitus.

Methods

Educational sessions and direct support for surgical services were provided by a nurse practitioner (NP). Outcome data from the intervention were compared to data from a historical (control) period. Changes in basalbolus insulin use were assessed according to hyperglycemia severity as defined by the percentage of glucose measurements > 180 mg/dL.

Results

Patient characteristics were comparable for the control and intervention periods (all P ≥ .15). Overall, administration of basal-bolus insulin occurred in 9% (8/93) of control and in 32% (94/293) of intervention cases (P < .01). During the control period, administration of basal-bolus insulin did not increase with more frequent hyperglycemia (P = .22). During the intervention period, administration increased from 8% (8/96) in patients with the fewest number of hyperglycemic measurements to 60% (57/95) in those with the highest frequency of hyperglycemia (P < .01). The mean glucose level was lower during the intervention period compared to the control period (149 mg/dL vs. 163 mg/dL, P < .01). The proportion of glucose values > 180 mg/dL was lower during the intervention period than in the control period (21% vs. 31% of measurements, respectively, P < .01), whereas the hypoglycemia (glucose < 70 mg/dL) frequencies were comparable (P = .21).

Conclusion

An intervention to overcome clinical inertia in the management of postoperative patients with diabetes led to greater utilization of basal-bolus insulin therapy and improved glucose control without increasing hypoglycemia. These efforts are ongoing to ensure the delivery of effective inpatient diabetes care by all surgical services. (Endocr Pract. 2014;20:320-328)

Section snippets

INTRODUCTION

Postoperative hyperglycemia is associated with poorer patient outcomes. Poor glucose control can result in an increased incidence of wound infections, longer lengths of stay, greater mortality, and a higher frequency of reoperative interventions 1., 2., 3., 4., 5., 6.. However, available data suggest that treating hyperglycemia can reduce specific complications, such as surgical site infections and reoperative intervention, in some groups of surgical patients 7., 8., 9.. Insulin use on the

Description of Intervention

A multidisciplinary group comprised of endocrinology and surgery representatives met to review the existing guidelines regarding recommended glucose target ranges and other aspects of diabetes management in postoperative patients. When consensus was reached, the team developed an intervention plan. The proposed intervention was reviewed and approved as a proof-of-concept quality improvement project by the institutional Clinical Practice Committee, and its subsequent analysis was approved by the

Patient Characteristics

For the control period (from January 1, 2011 to April 30, 2011), a total of 196 patients with diabetes underwent 206 elective surgical procedures and were subsequently hospitalized after the procedure. For the intervention period (from June 1, 2012 to February 28, 2013), a total of 473 patients with 541 elective surgical procedures were hospitalized. After applying the exclusion criteria (length of stay < 3 days and no endocrinology consultations), there were 87 patients with diabetes who

DISCUSSION

Current guidelines suggest that a scheduled program of basal, mealtime, and correction insulin is the best approach to controlling hyperglycemia in both medical and surgical inpatients with diabetes 10., 11., 12., 13., 14., 15.. Various reports have detailed different approaches to overcome the clinical inertia observed regarding the use of basal-bolus insulin in the hospital, such as computerized insulin orders with built-in algorithms, staff education, and employing specialized diabetes

CONCLUSION

Despite these limitations, we were able to demonstrate greater utilization of recommended basal-bolus insulin therapy in hospitalized patients with diabetes during the postoperative period. An intervention comprised of education, direct support, and feedback from an NP helped members of the surgical teams overcome clinical inertia with regard to insulin regimen choice. This was coupled with improvements in glucose control without increasing hypoglycemia. The intervention included an assessment

DISCLOSURE

The authors have no multiplicity of interest to disclose.

REFERENCES (38)

A.P. Furnary et al.
Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project
Endocr Pract.
(2004)
N.J. Grey et al.
Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control
Endocr Pract.
(2004)
E.S. Moghissi et al.
American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control
Endocr Pract.
(2009)
P.A. Mackey et al.
Care directed by a specialty-training nurse practitioner or physician assistant can overcome clinical inertia in management of inpatient diabetes
Endocr Pract.
(2014)
J.L. Schnipper et al.
Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial
Endocr Pract.
(2010)
N. Michaelian et al.
Perioperative glycemic control: use of a hospital-wide protocol to safely improve hyperglycemia
J Perianesth Nurs.
(2011)
A.C. Donihi et al.
Effect of a targeted glycemic management program on provider response to inpatient hyperglycemia
Endocr Pract.
(2011)
C.B. Cook et al.
Inpatient to outpatient transfer of diabetes care: planning for an effective hospital discharge
Endocr Pract.
(2009)
S.H. Golden et al.
Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes
Diabetes Care.
(1999)
A.E. Duncan et al.
Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery
Anesthesiology.
(2010)

A. Ata et al.

Postoperative hyperglycemia and surgical site infection in general surgery patients

Arch Surg.

(2010)

M. Ramos et al.

Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery

Ann Surg.

(2008)

M.H. Marchant et al.

The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty

J Bone Joint Surg Am.

(2009)

S. Kwon et al.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program

Ann Surg. J

(2013)

K.J. Zerr et al.

Glucose control lowers the risk of wound infection in diabetics after open heart operations

Ann Thorac Surg.

(1997)

G.E. Umpierrez et al.

Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline

J Clin Endocrinol Metab.

(2012)

American Diabetes Association

Standards of medical care in diabetes--2013

Diabetes Care.

(2013)

G.E. Umpierrez et al.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery)

Diabetes Care.

(2011)

G.E. Umpierrez et al.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial)

Diabetes Care.

(2007)

Cited by (24)

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review
2022, Patient Education and Counseling
Citation Excerpt :
We identified 7 systematic and narrative reviews [9,10,41–45] that discussed primary reasons for, and mechanisms to, counter clinical inertia, as well as 40 original research studies that evaluated non-pharmaceutical interventions to address clinical inertia in CVD risk factor control. Of the 40 original research studies, 34 (or 85 %) addressed a single disease [25,29–33,46–73] and 6 (or 15 %) addressed multiple CVD risk factor conditions. [11,74–78] In terms of focusing on a single CVD risk factor, 15 (or 37 %) of articles focused on hypertension, [29,33,46,47,49–51,53,54,57,58,60,67,72,73] 18 (or 45 %) focused on diabetes, [25,30–32,48,55,56,59,61–66,68–71] and 1 (or 2 %) focused on dyslipidemia. [52]
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.
We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.
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.
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.
Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.
Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes
2022, Canadian Journal of Diabetes
The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada.
A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management.
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.
It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
L’objectif du projet sur la qualité était d’élaborer des normes consensuelles sur la prise en charge de la glycémie des patients diabétiques qui subissent des interventions chirurgicales au Canada.
Nous avons utilisé une méthode Delphi modifiée pour recueillir les commentaires d’un grand nombre de parties prenantes et parvenir à un consensus sur la prise en charge périopératoire/péri-interventionnelle du diabète.
Nous avons élaboré les normes sur la prise en charge de la glycémie pour les catégories suivantes : organisation des soins; évaluation préopératoire; préopératoire et intraopératoire immédiate; unité de soins post-anesthésie ou salle de réveil; période postopératoire; transition vers les soins en consultation externe.
On s’attend à ce que ces normes permettent l’élaboration d’outils cliniques pour étayer les recommandations.
Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review
2021, Canadian Journal of Diabetes
Citation Excerpt :
Approximately 33% of strategies used multiple modes of delivery; the most common mode of delivery was the use of an in-person education component, present in over half (54%) of strategies (26–29,33,34,36,39,40,42,44–46,49–53,55–58,61,62,65–67). Technological modes of delivery were also common, with 18% of strategies using a mobile application (29,31,32,35,38,43,50,59), 14% including online learning education (23,25,28,40,54,60) and 8% involving electronic medical records (43,56,65). There was considerable heterogeneity in the outcomes used to measure the effects of the strategies.
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.
Les objectifs de la présente revue étaient les suivants : 1) examiner les stratégies récentes et les interventions à composantes utilisées pour surmonter l’inertie thérapeutique lors de diabète sucré de type 2 (DST2); 2) élaborer les stratégies en fonction des causes de l’inertie thérapeutique qu’elles cernent; 3) déterminer les causes de l’inertie thérapeutique lors de DST2 qui n’ont pas été cernées par les récentes stratégies. Nous avons mené une recherche systématique de la littérature publiée de janvier 2014 à décembre 2019 pour déterminer les stratégies qui cernent l’inertie thérapeutique lors de DST2, et avons extrait et résumé les principales caractéristiques des stratégies. La recherche a permis de relever 46 articles qui portaient au total sur le recours à 50 stratégies visant à surmonter l’inertie thérapeutique. Les stratégies étaient en moyenne composées de 3,3 interventions (écart, 1 à 10) qui cernaient en moyenne 3,6 causes (écart, 1 à 9), dont la plupart (78 %) comportaient un type de stratégie éducative. La plupart des stratégies cernaient les causes de l’inertie liées au patient (38 %) ou au professionnel de la santé (26 %) seulement, et 8 % cernaient les causes liées au système de soins de santé, alors que 28 % cernaient les causes de diverses sources. Aucune stratégie ne portait sur les attitudes des patients face à la maladie ou leur manque de confiance envers les professionnels de la santé; rien ne traitait des préoccupations des professionnels de la santé sur les coûts ou le manque de renseignements sur les effets secondaires et la crainte de causer un préjudice, ou l’absence de registre de maladies dans le système de soins de santé. Les stratégies qui permettent de surmonter l’inertie thérapeutique lors de DST2 ont fréquemment eu recours à de multiples interventions, mais les nouvelles stratégies fondées sur des interventions qui cernent simultanément des causes multiples justifient d’autres études. Bien que nous utilisions souvent les interventions éducatives pour remédier à l’inertie thérapeutique, nous pourrions tirer avantage des stratégies ultérieures qui porteront sur un plus vaste éventail de déterminants des changements de comportement pour surmonter l’inertie thérapeutique.
Identifying gaps in inpatient care of patients with diabetes mellitus: Where do we go from here?
2017, Joint Commission Journal on Quality and Patient Safety
A Study of Root Causes and Countermeasures for Clinical Inertia in Type 2 Diabetes Patients in Community Based on Healthcare Failure Mode and Effect Analysis Framework
2024, Chinese General Practice
Glycemic Management for Hospitalized Patients with Diabetes in Non-endocrine Wards
2023, Chinese General Practice

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Original ArticleOvercoming Clinical Inertia in the Management of Postoperative Patients with Diabetes

ABSTRACT

Objective

Methods

Results

Conclusion

Section snippets

INTRODUCTION

Description of Intervention

Patient Characteristics

DISCUSSION

CONCLUSION

DISCLOSURE

Endocr Pract.

Endocr Pract.

Endocr Pract.

Endocr Pract.

Endocr Pract.

J Perianesth Nurs.

Endocr Pract.

Endocr Pract.

Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes

Diabetes Care.

Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery

Anesthesiology.

Postoperative hyperglycemia and surgical site infection in general surgery patients

Arch Surg.

Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery

Ann Surg.

The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty

J Bone Joint Surg Am.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program

Ann Surg. J

Glucose control lowers the risk of wound infection in diabetics after open heart operations

Ann Thorac Surg.

Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline

J Clin Endocrinol Metab.

Standards of medical care in diabetes--2013

Diabetes Care.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery)

Diabetes Care.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial)

Diabetes Care.

Original Article
Overcoming Clinical Inertia in the Management of Postoperative Patients with Diabetes