Inpatient Glycemic Control Research Articles

Enhancing inpatient glycemic education and management with a SMILE SBAR: A quantitative study

AimTo examine the effectiveness of a comprehensive diabetes education class on improving nurses' self-efficacy in glycemic management and physician communication, with a focus on using the SMILE (Sugar Trend, Medications, Intravenous fluid, Labs, and Eating) SBAR (Situation, Background, Assessment, Recommendation) as a communication tool. The secondary aim of this study was to investigate the translation of knowledge into practice, in this case, inpatient glycemic control. BackgroundInpatient glycemic management for patients living with diabetes can be challenging. Therefore, as patient advocates, nurses must be able to identify what clinical data warrants a call to the physician to facilitate timely decisions and interventions. MethodsData was collected from a purposive sample of 28 registered nurses from a single general medicine unit. A t-test was used to analyze nurses' pretest-posttest perceptions of self-efficacy in nine content areas. Kruskal-Wallis H analysis was also conducted on patients' median blood glucose values over four months (July–October 2023). ResultsThe results suggest the class was effective in improving nurses' perceived knowledge and self-efficacy in all nine content areas, with the highest mean difference increase of 1.46 for I have sufficient knowledge regarding the SMILE SBAR and [will] use it as a tool for communicating with the physician, p < 0.05. A comparison of 403 patients' median blood glucose values were also statistically significantly different across four months, χ2(3) = 21.088, p < 0.0001. ConclusionsContinued efforts to prevent and manage inpatient glycemic control should focus on enhancing nurse-physician communication and teamwork with simple yet effective tools such as the SMILE SBAR.

1124-P: It Takes a Village—Enhancing the Nurse–Physician Communication on Inpatient Glycemic Control

1124-P: It Takes a Village—Enhancing the Nurse–Physician Communication on Inpatient Glycemic Control

1023-P: Predictive Value of Admission Plasma Glucose and Hemoglobin A1c on Inpatient Glycemic Control Assessed by Continuous Glucose Monitoring (CGM) in Medicine and Surgery Persons with Diabetes

1023-P: Predictive Value of Admission Plasma Glucose and Hemoglobin A1c on Inpatient Glycemic Control Assessed by Continuous Glucose Monitoring (CGM) in Medicine and Surgery Persons with Diabetes

Assessment on Inpatient Glycaemic Control in General Medical Wards, Putrajaya Hospital.

Inpatient hyperglycaemia is common and associated with poor outcomes such as increased mortality and prolonged hospital stay. This study aimed to determine the prevalence of inpatient hyperglycaemia and glycaemic control in Putrajaya Hospital, Malaysia. Secondary objectives were to compare the length of stay (LOS), 30-day readmission rate, and death between controlled and uncontrolled glycaemic groups. This cross-sectional study was conducted between 1 July and 31 December 2019 among patients in medical wards who had a blood glucose (BG) level of > 7.8 mmol/L and stayed in the wards for ≥ 24 h. We retrieved information on demographics, diabetes history and BG profiles. The definition of controlled glycaemic status is when ≥ 80% of BG readings were between 4.0 mmol/L and 10.0 mmol/L during the hospital stay. The prevalence of inpatient hyperglycaemia was 55.2%. There were 841 patients who met the eligibility criteria; their mean age was 60 (13.8) years old. Most (79.4%) of the patients were Malay and 53.9% were male. There were 452 (53.7%) patients in the uncontrolled group. They were younger and admitted with more kidney complications compared to those in the controlled group. The median LOS for both groups was 3 (2) days. The uncontrolled group showed a higher percentage of readmission within 30 days (7.5% versus 4.6 %) and death during admission (3.3% versus 1.6 %) (P = 0.100 and P = 0.082). The prevalence of inpatient hyperglycaemia was high. More than half of them had uncontrolled BG. Both groups had a similar average length of stay. The 30-day readmission rate and death during admission were higher in the uncontrolled group, although statistically not significant.

Novel Automated Self-adjusting Subcutaneous Insulin Algorithm Improves Glycemic Control and Physician Efficiency in Hospitalized Patients.

Hyperglycemia occurs in 22% to 46% of hospitalized patients, negatively affecting patient outcomes, including mortality, inpatient complications, length of stay, and hospital costs. Achieving inpatient glycemic control is challenging due to inconsistent caloric intake, changes from home medications, a catabolic state in the setting of acute illness, consequences of acute inflammation, intercurrent infection, and limitations in labor-intensive glucose monitoring and insulin administration. We conducted a retrospective cross-sectional analysis at the University of California San Francisco hospitals between September 3, 2020 and September 2, 2021, comparing point-of-care glucose measurements in patients on nil per os (NPO), continuous total parenteral nutrition, or continuous tube feeding assigned to our novel automated self-adjusting subcutaneous insulin algorithm (SQIA) or conventional, physician-driven insulin dosing. We also evaluated physician efficiency by tracking the number of insulin orders placed or modified. The proportion of glucose in range (70-180 mg/dL) was higher in the SQIA group than in the conventional group (71.0% vs 69.0%, P = .153). The SQIA led to a lower proportion of severe hyperglycemia (>250 mg/dL; 5.8% vs 7.2%, P = .017), hypoglycemia (54-69 mg/dL; 0.8% vs 1.2%, P = .029), and severe hypoglycemia (<54 mg/dL; 0.3% vs 0.5%, P = .076) events. The number of orders a physician had to place while a patient was on the SQIA was reduced by a factor of more than 12, when compared with while a patient was on conventional insulin dosing. The SQIA reduced severe hyperglycemia, hypoglycemia, and severe hypoglycemia compared with conventional insulin dosing. It also improved physician efficiency by reducing the number of order modifications a physician had to place.

THU325 Covid-19 Outcomes In Cancer Patients With Diabetes

Abstract Disclosure: E.T. Ngo: None. S. Thosani: None. Diabetes mellitus and cancer are risk factors for poor outcomes in patients with Covid-19 (Covid). In this study, we compare Covid outcomes in patients with diabetes and cancer in relation to their inpatient glucose control. We conducted a retrospective review of cancer patients with diabetes hospitalized at our institution from 12/1/2020-7/31/2021 for Covid (n=117). Readmissions were excluded (n=13). Apart from demographic data, other variables reviewed included cancer type, stage, treatment, comorbidities, laboratory data for glucose and inflammatory markers, and Covid-related management. Utilizing average daily glucose for each patient, we calculated percentage of inpatient days with glucose values with euglycemia (average daily glucose within target range of 70-180 mg/dL) and hyperglycemia (average daily glucose values above target of 180 mg/dL). Wilcoxon rank-sum test for contiguous variables and Fisher’s exact test for categorical variables were done to compare the distribution of variables between groups. Kaplan-Meier curve was generated for survival analysis. Of the 104 patients, 73% were age ≥60, 54.8% were male, 49% had BMI &amp;gt;30, and majority (88.5%) were not vaccinated for Covid. 81.7% had type 2 diabetes, 14.4% had drug-induced (i.e. steroid) diabetes, and the remaining had type 1 diabetes. The most common comorbidities were hypertension (56.7%) and heart failure (8.65%). Hematologic malignancies (40.4%) were the prevailing cancer diagnosis. Of patients with cancer staging available (n=50), 33.7% were stage 4, and 66.3% were on active cancer treatment at the time of hospitalization. 49% of the entire cohort had severe Covid on presentation; 21% (n=22) died during hospital stay. Comparison of Covid-related variables and inflammatory markers between euglycemic (n-18) vs. hyperglycemic (n=86) group noted significant differences in LDH, Hba1c and use of steroids which was significantly higher in hyperglycemic group. There was no difference in overall survival (p=0.46) and non-ICU length of stay (p=0.06) noted between groups. Our study confirms high mortality rate from Covid in hospitalized patients with diabetes and cancer. As noted, inpatient glycemic control to achieve targets in this patient population was not associated with reduction in mortality or improvement in Covid-related outcomes, which is in alignment with previously published studies. Presentation: Thursday, June 15, 2023

Clinical impact after implementing an insulin protocol involving a switch to insulin glargine 300 U/ml as basal insulin for inpatient glycaemic control: A retrospective single-centre study

AimsTo evaluate the benefit and safety of a switch in the basal insulin protocol to glargine 300 U/ml (Gla-300) on inpatients' overall dysglycemic events. Efficacy and safety data on insulin Gla-300 in the inpatient setting are limited. MethodsRetrospective observational study conducted on 7455 patients admitted to acute care (n = 5414) or geriatric and social healthcare (n = 2041) units of the Regional Hospital of Amposta (Spain) between January 2017 and December 2020 who received basal insulin during hospitalization. Hypo- and hyperglycaemic events were indirectly assessed through hospital pharmacy usage of intravenous glucose and vials of rapid-acting intravenous insulin for 27 months after the switch, and the impact on overall dysglycemic events was analysed. ResultsAfter protocol implementation, patients were mostly treated with Gla-300 (83.06 % in acute care; and 83.44 % in geriatric and social healthcare), and presented a significant decrease in the use of intravenous insulin (−60.80 %, P = 0.005) and glucose (−62.13 %, P < 0.001), which translated into a significantly reduced overall dysglycemic events (−62.25 %, P < 0.001), with a good safety and tolerability profile. ConclusionsOverall inpatient dysglycemic events were improved upon the introduction of the new insulin protocol, which calls for the use of Gla-300 as one of the choices of basal insulin for inpatient care.

515-P: Study to Evaluate the Relationship between Inpatient Glycemic Control as Measured by CGM and Wound Healing in Patients Admitted for Diabetic Foot Ulcer (DFU)

We performed a post-hoc analysis of hospitalized patients admitted with DFU enrolled in an inpatient continuous glucose monitor (CGM) study. Bivariate analysis was conducted between those with wound healing vs. non-healing over a 16-week period. Logistic regression was performed to assess the following CGM metrics and likelihood of wound healing: TIR (70-180 mg/dl), TAR (&amp;gt;180 mg/dl) and TBR (&amp;lt;70 mg/dl). Potential confounders included in the multivariate analysis were age, race and sex, history of peripheral arterial disease, renal failure, prior amputation, and ulcer duration. Results of patient characteristics are summarized in the Table. Of 230 patients enrolled in our CGM studies, 62 (27%) were admitted for DFU. Sixteen weeks after discharge, 9 (15%) patients were lost to follow-up, 13 (21%) had healed, and 39 (62%) had not healed. Of the non-healed, 10 (15%) had an amputation, 3 (4.7%) died, and 26 (41%) had a persistent ulcer. We did not find an association between the likelihood of healing and CGM derived glycemic metrics: fully adjusted models for TIR (OR 0.99, 95% CI 0.96-1.02), TAR (1.01 95% CI 0.98-1.04), and TBR (0.85; 95% CI 0.52-1.40). While glycemic control remains an important predictor of diabetes complications, we did not find an association between glycemic control in the hospital based on CGM metric and post-discharge healing. Disclosure K.K.Rogers: None. A.A.Rashied: None. M.Schechter: None. M.Fayfman: None. Funding Dexcom, Inc.

859-P: Study of Oral Antihyperglycemic Agents in the Hospital—A Multinational Perspective

Oral antidiabetic drugs (OAD) are commonly used in the hospital setting despite limited safety and efficacy data. To better understand the safety and efficacy of inpatient use of OAD, we pooled data from three healthcare systems in the US and Israel between from 2008-2018 (N=78,947). Treatment with OAD in the hospital was compared to Insulin (I) and OAD+Insulin (OAD+I). Patients on OAD were slightly older than those on I or OAD+I (67 vs 64 vs 65, respectively), more likely to admitted to surgical services (OAD: 33%; I: 21%, OAD+I: 23%, p&amp;lt;0.0001), and to have lower admission blood glucose (Blood glucose (BG): (161 vs 200 vs 192 mg/dl, p&amp;lt;0.0001). The average length of stay was 4-5 days for all groups. We performed propensity score matching by age, sex, Carlson Comorbidity Index, service (medicine or surgery), admission BG and creatinine to assess glycemic control and outcomes (Table). The primary outcome was good glycemic control with defined as mean hospital BG of 80-180 mg/dL and no hypoglycemia. Compared to I, patients treated with OAD were more likely to have good glycemic control [Odds Ratio (OR): 2.07 (95% CI: 1.85, 2.31)] and less hypoglycemia defined by BG &amp;lt;70mg/dL [OR: 0.63 (95% CI: 0.54, 0.74)]. No differences in rate of lactic acidosis were observed. In summary, patients treated with OAD had better in-hospital inpatient glycemic control, lower rates of hypoglycemia and no difference in lactic acidosis as compared to Insulin. Disclosure M.Fayfman: None. I.Hochberg: Other Relationship; Eli Lilly and Company, Novo Nordisk. M.F.Magee: None. A.A.Rashied: None. R.Jagannathan: None. G.Blanco: None. E.Moreno: None. F.J.Pasquel: Consultant; Dexcom, Inc., Medscape, Research Support; Dexcom, Inc., Ideal Medical Technologies. G.Umpierrez: Research Support; Abbott, Dexcom, Inc., Baxter.

The effects of aging and frailty on inpatient glycemic control by continuous glucose monitoring in patients with type 2 diabetes

BackgroundOlder adults with diabetes in the hospital are generally managed similarly to younger adults, however, it is unknown if the degree of frailty can affect glucose control among hospitalized patients. MethodsWe examined glycemic parameters derived from continuous glucose monitoring (CGM) in older adults with type 2 diabetes and frailty who were hospitalized in non-acute settings. Data was pooled from 3 prospective studies using CGM including 97 patients wearing Libre CGM sensors and 166 patients wearing Dexcom G6 CGM. Glycemic parameters (time in range (TIR) 70–180; time below range (TBR) <70 and 54 mg/dl) by CGM were compared between 103 older adults ≥60 years and 168 younger adults <60 years. Frailty was assessed using validated laboratory and vital signs frailty index FI-LAB (n = 85), and its effect on hypoglycemia risk was studied. ResultsOlder adults, as compared to younger adults, had significantly lower admission HbA1c (8.76% ± 1.82 vs. 10.25% ± 2.29, p < 0.001), blood glucose (203.89 ± 88.65 vs. 247.86 ± 124.17 mg/dl, p = 0.003), mean daily BG (173.9 ± 41.3 vs. 183.6 ± 45.0 mg/dl, p = 0.07) and higher percent TIR 70–180 mg/dl (59.0 ± 25.6% vs. 51.0 ± 26.1%, p = 0.02) during hospital stay. There was no difference in hypoglycemia occurrence between older and younger adults. Higher FI-LAB score was associated with higher % CGM < 70 mg/dl (0.204) and % CGM < 54 mg/dl (0.217). ConclusionOlder adults with type 2 diabetes have better glycemic control prior to admission and during hospital stay compared to younger adults. Frailty is associated with longer presence of hypoglycemia in non-acute hospital settings.

PSUN219 Increasing Frequency of Hemoglobin A1c (Hba1c) Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma

Abstract Background Studies have shown the predictive value of hemoglobin A1c (HbA1c) on inpatient glycemic control, and its value for discharge planning. There is little data on HbA1c testing adherence to American Diabetes Association (ADA) guidelines among inpatient providers, and anecdotal evidence suggests that most inpatient providers do not have a standardized approach to HbA1c measurement. The Lean Six Sigma method is a management system that originated in the automobile industry and has become widely used in healthcare to improve the efficiency of processes. The objective of this study was to determine the impact utilizing Lean Six Sigma methodology to increase frequency of HbA1c measurements among hospitalized patients with a known history of diabetes, in line with ADA guidelines. Methods This was a quality improvement study performed in a 240-bed community hospital, evaluating inpatients (≥16 years) consecutively admitted with a diagnosis of diabetes (ICD-10 code E8-E13 and O24) between January 2016-June 2021. Patients were excluded if they had a HbA1c in the health system electronic health record (EHR) in the prior 3 months. The Lean Six Sigma approach was utilized to define the problem and implement solutions. The intervention bundle delivered between November 2017 and February 2018 included 1) provider and nursing education on the utility of HbA1c in patient care, 2) change in laboratory protocols for more rapid turnaround of HbA1c, 3) modifications to the EHR including a glucose management tab and insulin order set that included HbA1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Demographic characteristics were calculated. Frequency of HbA1c lab sent while inpatient was compared pre- (Jan 2016-Nov 2017) and post-intervention (March 2018-June 2021) using chi-square analysis. Results 17,869 patients were included (7,332 pre- and 10,537 post-intervention). Demographics did not differ between pre and post intervention periods (mean age [range]: 78.1 [16-106] years, sex: 52.3% male, race: 52.1% White, 25.1% Black). Only 53.5% of patients who met criteria had a HbA1c measured during hospitalization before intervention. This frequency increased to 70.2% postintervention. The improvement in the frequency of HbA1c measurement was sustained more than two years following the initial interventions and continued to improve over time. Conclusion This novel approach was successful in improving adherence to guideline-based measurement of HbA1c in hospitalized patients. This is the first quality improvement project in a community hospital utilizing the Lean Six Sigma process for this purpose and may represent a valuable methodology for community hospitals to improve inpatient diabetes care. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSUN224 Resident Education for Improved Quality and Confidence in Inpatient Hyperglycemia Management

Abstract Background Hyperglycemia is widely prevalent in hospitalized patients and has been associated with adverse outcomes and increased mortality. Guidelines for inpatient management of hyperglycemia in non-critically ill adults are inconsistently implemented within our hospital system in a large academic center in New York. Thus, we strove to develop a formal curriculum for our internal medicine program to improve the level of confidence in trainees when managing inpatient hyperglycemia and to promote appropriate subspecialty consultation. Methods We designed a three-phase educational curriculum for internal medicine residents of all training levels. The first phase consisted of a pre-intervention questionnaire distributed online, examining the self-reported level of confidence and knowledge of hyperglycemia management in non-critically ill patients. The second phase consisted of a 50-minute lecture providing background on the prevalence and risk of inpatient hyperglycemia, standard guidelines for inpatient hyperglycemia management, appropriate insulin regimen initiation and adjustment and practice questions reviewed in real time. The third phase consisted of an online post-intervention questionnaire which, in addition to reassessing confidence and knowledge, examined change in individual confidence level in hyperglycemia management and the ability to recognize situations appropriate for endocrinology consultation. In the context of convenience sampling, all residents were eligible to participate in the second questionnaire independent of their participation in the first questionnaire or educational intervention. Results There were 57 total respondents for the pre-intervention questionnaire and 54 total respondents for the post-intervention questionnaire. 26 (48%) of the post-intervention questionnaire respondents completed the initial questionnaire and 22 (41%) attended the lecture. In examining confidence in managing inpatient hyperglycemia on a four-level scale (not comfortable, somewhat comfortable, comfortable, and very comfortable), there was an overall increase in percentage of "comfortable" responses (26% to 52%) with a subsequent decrease in "somewhat comfortable" responses (65% to 37%) when comparing post- to pre-intervention questionnaires. In addition, there was a higher percentage of "comfortable" responses in those who attended the lecture versus those who did not (59% vs. 47%). Furthermore, 21 of the 22 respondents who attended the lecture felt "more confident" in their ability to treat inpatient hyperglycemia. Lastly, those who attended the lecture were more likely to identify situations in which endocrinology should be consulted. Conclusion Currently, there is no formal longitudinal curriculum established for resident education in inpatient diabetes care and hyperglycemia management. The objective of this intervention was to identify and bridge the gap in practical knowledge and confidence level across all training levels. In a small sample size of residents, data revealed higher confidence in management and ability to recognize the necessity of endocrinology consults. Future research will focus on analyzing concrete data in a target unit to assess translation of the intervention to improved quality of inpatient glycemic control. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSUN221 Implementation of Scheduled Mealtimes for Improved Glycemic Control among Hospitalized Patients with Diabetic Meal Plans

Abstract Objective To improve inpatient glycemic control through implementation of scheduled diabetic mealtimes in coordination with standardized bedside glucose checks and insulin administration times Methods We performed a plan-do-study-act (PDSA) trial in which we modified our standard diabetic diet from on-demand service to scheduled mealtimes with a goal to complete bedside glucose monitoring, meal delivery, and insulin administration all within a one-hour window for each meal. Both patients and clinical staff were actively educated regarding the rationale for this approach; prominent visual cues were implemented, and the menu was modified to include patient-centered information regarding mealtime practices. Low-carbohydrate snacks were offered between meals. Electronic medical record integration included defaulting to scheduled insulin dosing rather than as-needed dosing. Results Early PDSA analysis demonstrated a 98% rate of pre-prandial glucose measurement with a 96% rate of correctional insulin doses ordered, while 91% of overall mealtimes successfully coordinated tray delivery, glucose testing, and insulin administration within one hour. Analysis of glycemic data from before and after our intervention demonstrated decreased overall mean daily glucose (167 to 164mg/dL, p = 0.001), fewer patients with any daily glucose greater than 250mg/dL (from 51% to 47%, p=0.001), and more for whom all glucose readings were between 70 and 249mg/dL (from 43% to 47%, p=0.001). Average pre-prandial blood sugars significantly improved before breakfast (156 to 152mg/dL, p=0.003) and dinner (173 to 165mg/dL, p&amp;lt; 0.001), while no effect was noted with pre-prandial lunchtime measurements. Evening blood sugars declined from 186 to 180mg/dL (p&amp;lt; 0.001). Subgroup analyses demonstrated that patients who presented with baseline poor glycemic control (admission blood sugar &amp;gt;250mg/dL) improved the percentage of patients with all glucose readings between 70 and 249mg/dL (from 12% to 19%, p=0.001), as well as the number of patients with any subsequent glucose &amp;gt;250mg/dL (from 85% to 77%, p=0.003). Patients who presented with better initial blood glucose control still improved their mean daily glucose (161 to 158mg/dL, p=0.005). The percentage of patients who had any glucose less than 70mg/dL did not significantly change throughout the intervention overall or with any subgroup analysis. Discussion/Conclusion The implementation of scheduled mealtimes within a diabetic meal plan contributes to improved glycemic control when compared with on-demand meal availability by streamlining the coordination of blood glucose measurement, meal delivery, and insulin administration. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP199 Full Implementation of Automated Self-Adjusting Subcutaneous Insulin Algorithm

Abstract Background - We programmed a self-adjusting subcutaneous insulin algorithm (SQIA) in the electronic medical record for patients who are NPO, on total parenteral nutrition (TPN), or on continuous tube feedings (CTF). The SQIA only requires a nurse to enter a patient's current glucose value and then calculates the next insulin dose based on previous dose, and current and previous glucoses. The SQIA titrates for a goal glucose of 120 -180 mg/dL. The advantage of this automated algorithm is that no new orders are required, even if insulin is added to TPN or tube feeding rate is changed. We previously reported results of a pilot study with 67% of blood glucoses in the 80-180 mg/dL range without any hypoglycemia (glucose &amp;lt; 60 mg/dL). Hypothesis - Following the successful pilot, the SQIA was instituted in September 2020 at our institution's three adult hospitals. We hypothesized that glucose control with the SQIA will be non-inferior to previous inpatient glycemic management and successfully maintain blood glucoses in the goal range. Methods - The SQIA was implemented on September 3, 2020 for patients who were NPO, on TPN, or on CTF. Any clinician placing insulin orders could select the SQIA as an alternate to ordering standard fixed aspart dosing or a sliding scale at four-hour intervals. We performed a prospective analysis on all patients managed with the SQIA during the first year of implementation (9/3/2020–9/2/2021) to evaluate use of the SQIA and resulting glycemic control. Results were compared to patients during the preceding one-year period (9/3/2019-9/2/2020) who were ordered for standard subcutaneous insulin aspart dosing while being NPO, on TPN, or on CTF. Results During the study period, the SQIA was utilized during 2691 time intervals within 1774 hospitalizations. The average duration for each interval was 56.4 hours and glucoses were checked every 3.9 hours while on the SQIA. Average point-of-care blood glucose while on SQIA was 157.5 ± 52.6 mg/dL. In a similar set of 1987 hospitalized patients in the preceding year who were on standard subcutaneous insulin orders, the average blood glucose was 159.4 ± 55.1 mg/dL. Conclusions - A self-adjusting SQIA effectively maintained glucose within the goal inpatient range during our first year of implementation and was non-inferior to prior glycemic control using standard dosing protocols. The SQIA provided an avenue for effective glycemic control while eliminating the need for insulin dosage titration by clinicians. Hospitals and health systems should consider pursuing similar innovations to improve the ease of inpatient glycemic control while continuing to meet glycemic targets. Presentation: No date and time listed

In-Hospital Hyperglycemia Is Associated With Worse Outcomes in Patients Admitted With COVID-19.

Diabetes and the outpatient diabetes treatment regimen have been identified as risk factors for poor outcomes in patients with sepsis. However, little is known about the effect of tight inpatient glycemic control in the setting of coronavirus disease 2019 (COVID-19). Therefore, we examined the effect of hyperglycemia in patients with diabetes hospitalized because of COVID-19. We analyzed data from 1,938 COVID-19 patients with diabetes hospitalized for COVID-19 from March to May 2020 at a large academic medical center in New York City. Patients were divided into two groups based on their inpatient glycemic values, and a Cox proportional hazards regression model was used to assess the independent association of inpatient glucose levels with mortality (primary outcome) and the risk of requiring mechanical ventilation (MV) (secondary outcome). In our analysis, 32% of the patients were normoglycemic and 68% hyperglycemic. Moreover, 31% of the study subjects died during hospitalization, and 14% required MV, with inpatient hyperglycemia being significantly associated with both mortality and the requirement for MV. Additionally, in the Cox regression analysis, after adjustment for potential confounders, including age, sex, race, BMI, HbA1c, comorbidities, inflammatory markers, and corticosteroid therapy, patients with uncontrolled hyperglycemia had a higher risk of dying (hazard ratio [HR] 1.54, 95% CI 1.00-2.36, P = 0.049) and of requiring MV (HR 4.41, 95% CI 1.52-2.81, P = 0.006) than those with normoglycemia. A tight control of inpatient hyperglycemia may be an effective method for improving outcomes in patients with diabetes hospitalized for COVID-19.

Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools

IntroductionHyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes. AimsWe implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA1c > 8%, to improve their metabolic control after hospital admission. MethodsNon-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge. ResultsDuring the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ± 1,5 vs. 7,3 ± 1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program. ConclusionsThe program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.

Inpatient glycemic control and community-acquired pneumonia outcomes in the pre-COVID-19 era: reviewing the evidence to pave the road for future studies

Inpatient glycemic control and community-acquired pneumonia outcomes in the pre-COVID-19 era: reviewing the evidence to pave the road for future studies

InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study.

We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.

697-P: Inpatient Glycemic Control and Glucose Variability by Continuous Glucose Monitoring in Older Adults with Type 2 Diabetes

Few studies have reported on differences in glycemic control and glucose variability by continuous glucose monitoring (CGM) in hospitalized insulin-treated older adults with type 2 diabetes (T2D) . Accordingly, we combined data from 3 inpatient randomized clinical trials using CGM in insulin-treated patients with T2D. Glycemic parameters were compared in 103 older adults (≥60 years) and 160 younger adults (&amp;lt;60 years) . Older adults, as compared to younger adults, had significantly lower HbA1c and blood glucose (BG) upon admission, and had lower overall mean daily CGM glucose values and higher percent time in range between 70-180 mg/dl during hospital stay. Glycemic variability (GV) did not differ between the two groups when assessed through direct univariate comparisons using coefficient of variation (CV) , mean amplitude of glucose excursion (MAGE) , and standard deviation (SD) ; however, a multivariate analysis adjusted for GFR, BMI, admission BG and HbA1c, indicated that older adults have higher GV during the hospital stay compared to younger adults. Conclusion: Our study indicates that older adults with T2D have better glycemic control on admission (BG and HbA1c) and had higher % time in range (70-180 mg/dl) , no difference in hypoglycemia, but greater GV during hospitalization compared to younger adults. Disclosure T.Idrees: None. F.J.Pasquel: Consultant; AI Health LLC, Boehringer Ingelheim International GmbH, Dexcom, Inc., Research Support; Dexcom, Inc., Insulet Corporation, Merck &amp; Co., Inc. L.Peng: None. G.E.Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. R.J.Galindo: Advisory Panel; Sanofi, WW International, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Novo Nordisk. M.A.Urrutia: None. I.A.Castro-revoredo: None. E.Moreno: None. A.L.Migdal: None. G.Davis: Consultant; Medscape, Research Support; Insulet Corporation. P.Vellanki: n/a. M.Fayfman: None.

Basal-bolus insulin therapy for the treatment of non-critically ill patients with type 2 diabetes in Vietnam: effectiveness and factors associated with inpatient glycemic control

PurposeThis study assessed the effectiveness of basal-bolus insulin therapy (BBIT) in non-critically ill patients with type 2 diabetes mellitus (DM) and the factors associated with optimal inpatient glycemic control (IGC) with BBIT.MethodsThis prospective study included 103 patients who were admitted to the University Medical Center and were treated with BBIT. Clinical characteristics, glucose, and glycated hemoglobin (HbA1c) levels at admission, renal function tests, basal-bolus insulin dosing, and other treatments were recorded. The optimal IGC was defined and classified for the analysis.ResultsThe mean age of the patients was 67.2 ± 12.0 years. The blood glucose and HbA1c levels at admission were 319.2 ± 184.8 mg/dL and 10.7 ± 2.6%, respectively. Optimal IGC was defined as patients with ≥60% of in-hospital blood glucose values within the target range (3.9–10 mmol/L). Of the 103 patients, 66 patients (64%) achieved optimal IGC and only 5 patients (4.9%) had at least one hypoglycemic episode. The number of patients consuming snacks was higher in the poor than in the optimal IGC group whereas an estimated glomerular filtration rate (eGFR) <45-mL/min/1.73 m2 was predominant in the optimal IGC group. Multivariate analysis revealed that snack consumption and glucocorticoid (GC) use were factors associated with poor IGC, while eGFR <45 mL/min/1.73 m2 was a favorable factor for optimal IGC.ConclusionBBIT is safe and effective for the treatment of IGC in non-critically ill patients. Moreover, eGFR <45 mL/min/1.73 m2 at admission, snack consumption, and GC therapy were independent factors associated with IGC outcomes.