An Inpatient Diabetes QI Program

Abstract

The goal of this study was to establish a continuous quality improvement (CQI) program for diabetes which would identify patterns in the problems of care encountered by hospitalized patients with diabetes and improve the in-hospital process of diabetes care delivery. The laboratory information system in an acute and tertiary care 1,000-bed urban teaching hospital provided us on a daily basis with a list of patients on the medical service having blood glucose (BG) levels < 40mg/dl or > 450mg/dl and positive serum acetones. We performed concurrent implicit chart review when BG levels were hypoglycemic (< 40mg/dl) or hyperglycemic (> 450mg/dl on two occasions) or when diabetic ketoacidosis (DKA) was present (acetones were > 1+) using preset indicators for documentation and appropriate medical management. Data were expressed as the ratio of number of cases in compliance with the indicator over total number of cases identified. A test for trend in proportions was used to assess compliance with the indicators over time. Documentation of nursing unit-based capillary blood glucose (CBGM) and insulin infusion monitoring improved significantly over time (p < 0.001 for both). The medical management of hypoglycemia, hyperglycemia and DKA improved (p = 0.1) over the three-year period. Identification of recurrent multidisciplinary process problems in the management of DKA, intravenous insulin infusion constitution and delivery, CBGM determination in the setting of anemia, and recognition of clinical settings conducive to the development of hypo- and hyperglycemia were identified and addressed with standardization in documentation, an insulin infusion protocol, administrative rules, and staff education. Efforts to standardize specific clinical and documentation processes had a positive impact on the care of hospitalized patients with diabetes and resulted in an institutional effort to improve inpatient diabetes care with a CQI team.