Improving Glucose Management by Redesigning the Care of Diabetic Inpatients Using a Nurse Practitioner Service

Abstract

H yperglycemia in hospitalized patients has been associated with poor outcomes in retrospective studies.1,2 This association has been found in patients admitted to medical, surgical, intensive care, and neurological care units. The association of poor outcomes and hyperglycemia upon admission to the hospital is usually stronger in patients without a prior diagnosis of diabetes, but it also extends to patients with known diabetes.1,2 Although such retrospective data cannot prove causality, it is generally agreed that hyperglycemia in patients who are significantly ill is detrimental to recovery and healing.3-5 As a partial explanation for this, in vitro data indicate poor immune cell and inflammatory cell function in a hyperglycemic environment.6-8 Intervention studies in surgical intensive care units have suggested improved outcomes when hyperglycemia is controlled.9 However, there have been no randomized trials of in-hospital, noncritical care intensive management to demonstrate better outcomes from improved control. Based primarily on intervention studies in critical care units,9-12 two major professional organizations and many review articles in influential journals have recommended that blood glucose control in the hospital be maintained between 90 and 130 mg/dl before meals and < 180 mg/dl 2 hours after meals, with care to avoid hypoglycemia.13-15 A recent meta-analysis of tight glucose control in intensive care units has called these recommendations into question, finding small benefits and a high risk of hypoglycemia.16 Nonetheless, no study to date has suggested that higher glucose levels during illness confer any advantage to patients, and good control of glucose (blood glucose levels consistently < 150 mg/dl) without hypoglycemia is likely to constitute optimal care.15 Many medical centers have adopted the recommendations of professional societies for inpatient glucose control. These targets have often been achieved …