Inpatient Glycemic Management Research Articles

An Internet Service Supporting Quality Assessment of Inpatient Glycemic Control

Several studies have linked the maintenance of normoglycemia in acutely ill inpatients with improved clinical outcomes. We previously proposed a few standard definitions for monitoring inpatient glycemic control, or "glucometrics." In clinical practice, limited data management resources for developing and refining measurement protocols can slow quality improvement efforts. With regard to glucometrics, there are few baseline data regarding the quality of hospital glycemic management. Furthermore, there are no reliable methods for hospitals to gauge the progress of their quality improvement efforts. We built a novel Web application that calculates glucometrics on anonymized blood glucose data files uploaded by registered users. This Web site also collects many key characteristics of the users and institutions utilizing the service. This application will allow us to pool data from several institutions to calculate aggregate glucometrics, providing baseline data for quality improvement efforts and ongoing metrics for institutions to gauge their progress. The application, accessible at http://metrics.med.yale.edu, has already drawn visitors from several countries. A number of users have registered formally, and some have begun to upload institutional glucose data. The application delivers detailed glucometrics reports to registered users, complete with visual displays. Quality improvement staff from large health systems have been the predominant users. We have created an open access Web application to facilitate quality monitoring and improvement efforts-as well as clinical research-regarding inpatient glycemic management. If employed widely, this application could help establish national performance standards for glycemic control.

Evolution of a Diabetes Inpatient Safety Committee

To develop a multidisciplinary team, the Diabetes Inpatient Safety Committee (DPSC), to effectively address the many barriers to achieving glycemic control in the inpatient setting. The development, implementation, and successes of the DPSC are described. By focusing on prevention of severe hypoglycemia, the DPSC identified and addressed areas related to inpatient management that contributed to uncontrolled glucose levels. The introduction of a hypoglycemia treatment protocol was followed by the development of a standardized order set for use of sliding scale insulin, with the eventual introduction of an Insulin Order Set guiding the use of scheduled and correctional insulin. Protocols and guidelines addressing more specific areas of inpatient glycemic management (insulin pump therapy, perioperative management, diabetic ketoacidosis, intravenous insulin) also have been developed. The successes of the DPSC to date have been directly related to strong institutional support, the dedication of a multidisciplinary team to address specific areas of glycemic management, the programmed introduction of order sets in conjunction with structured educational programs that accompany each protocol, and the use of quality improvement measures to evaluate the safety and efficacy of these protocols. Effective committees such as this will be instrumental in preventing errors and maximizing euglycemia.

Management of Diabetes During Acute Stroke and Inpatient Stroke Rehabilitation

Golden SH, Hill-Briggs F, Williams K, Stolka K, Mayer RS. Management of diabetes during acute stroke and inpatient stroke rehabilitation. Objectives To summarize evidence on the impact of hyperglycemia on stroke outcomes and to present therapy algorithms for inpatient management in diabetic stroke patients. Data Sources Guidelines for inpatient management of diabetes were reviewed and extracted from a technical review and recommendations from 2 national diabetes and endocrine organizations. MEDLINE database searches were conducted using key words: stroke, diabetes, hyperglycemia, hypoglycemia, inpatient, hospitalized, treatment, outcomes, disability, self-management, and education. Study Selection Studies were selected that specifically addressed the impact of the following in stroke patients: hyperglycemia and diabetes on rehabilitation outcomes, management strategies for hyperglycemia and diabetes, and strategies for facilitating diabetes self-management. Data Extraction Two authors independently extracted data and management practices from selected articles and published practice guidelines. Data Synthesis Diabetes is prevalent in stroke patients and results in poorer inpatient hospital and rehabilitation outcomes. Management of diabetes in stroke patients is further complicated by impairments in mobility and vision, necessitating accommodation strategies and tools for self-management. Optimal management of hyperglycemia using insulin or oral hypoglycemic agents results in reduced morbidity and mortality among diabetic inpatients. Conclusions To achieve inpatient glycemic management targets, use of clinical management algorithms, self-management tools, and systems approaches such as diabetes management teams are useful.

Glucose Control in a Hospitalized Person With Diabetes

Hyperglycemia in hospitalized people with diabetes contributes to increased mortality and morbidity by increasing the susceptibility to infection and lengthening hospital stays. The underlying causes of hyperglycemia range from decompensated diabetes with metabolic changes associated with stress and illness to alterations in medications or therapeutic interventions that increase glucose levels. No matter what the cause, hyperglycemia in the hospital setting has not been treated in the aggressive manner seen in the outpatient setting. Fear of hypoglycemia and its ability to trigger life-threatening complications such as cardiac arrhythmias contributes to the reluctance to set target goals < 200 mg/dl for inpatient glycemic management. With the recent American Diabetes Association (ADA) publication of the technical review “Management of Diabetes and Hyperglycemia in Hospitals,”1 the importance of glucose control in achieving positive outcomes in hospitalized patients has been underscored. Aggressive glucose goals aimed at reducing hyperglycemia and its negative effects on recovery are identified and supported by research such as the DIGAMI study.2 A review of published studies indicates that elevated glucose levels increase post-surgical infection rates, reduce the ability to heal, contribute to increased cardiac morbidity and mortality, increase intensive care unit admissions, and increase lengths of stay. The following case study illustrates the pitfalls in diabetes care frequently seen in hospitalized patients and identifies ways in which hospital management must change to achieve positive outcomes. The need for aggressive treatment of hyperglycemia and the importance of diabetes education within this setting is addressed. J.M. is a 69-year-old man who presents to the emergency room (ER) with fever, shortness of breath, and persistent cough for 4 days. Based on his chest X-ray findings, co-morbidities, age, and medical history, he has been admitted to the hospital with the diagnosis of community-acquired pneumonia. He has had type 2 diabetes for 8 years, …