NEW ORLEANS — There are several strategies that clinicians can adopt to help patients with diabetes and hyperglycemia achieve better glycemic control while in the hospital, including specific approaches that appear to improve insulin safety, decrease clinical inertia in acute care and educate health care professionals in the hospital setting.

Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center, and Robert Rushakoff, MD, professor of medicine and medical director of Inpatient Diabetes at the UCSF Medical Center, addressed the issue of inpatient glycemic management during a presentation at AADE 2015, the annual meeting of the American Association of Diabetes Educators.

“Inpatient glycemic management is best accomplished through interdisciplinary collaboration with physicians, NPs, PAs, RNs, RDs, diabetes educators and pharmacists. Errors can be greatly reduced by implementing system changes that make it easier to do the right thing. One example is auto-calculating the basal insulin dose based on weight and expected sensitivity to insulin instead of requiring prescribers to do the math,” said Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center.

Best practices for improving inpatient glycemic control have been identified, but there are many barriers to implementing them, Seley said. The biggest obstacle to coordinating and implementing successful strategies is the need for ongoing staff education. Successful strategies also involve policy changes, infrastructure adaptations and culture change.

Even so, Seley said that in recent years, many institutions across the United States have successfully launched glycemic control programs to improve inpatient insulin safety. One approach that appears to be highly effective is computerized order sets. This approach auto-populates the most recent weight gain into a dosing algorithm that gives a safe yet effective recommendation. This weight-based dosing can significantly reduce insulin dosing errors, she noted. Basal and bolus insulins are also listed in separate sections to avoid mixing up insulin types.

Electronic medical record systems (EMRs) such as Sunrise and Epic have the capability to develop comprehensive insulin order sets and decision support tools such as a medical logic memory to remind prescribers to order basal insulin when a patient with type 1 diabetes is switched from prandial insulin to NPO status,” Seley told Endocrinology Advisor.

She said employing “Diabetes Champions” can be highly beneficial as well. These nurses and dietitians attend an annual meeting that involves 8 hours of education and case studies as well as a monthly 1-hour meeting for updates. Diabetes Champions are instrumental in assisting with diabetes self-management education (DSME) and discharge planning at the bedside.

Another step that can be taken to improve inpatient glycemic management is online mandatory education by discipline for dietitians, pharmacists, nurses and prescribers. Innovative educational programs can include how to follow glycemic control guidelines, such as what are the glycemic targets in both the ICUs and general floors, and insulin titration algorithms to achieve these targets. Algorithms for basal/bolus therapy and patients on steroids and enteral feedings can include which insulin to order and dosing recommendations based on type of diabetes and eating status.

“As the patients are admitted for other reasons and diabetes is a secondary or tertiary problem, the diabetes management historically took a back seat. Providers may write initial insulin orders, but historically would not change the orders after that — no matter what was going on with the glucoses. Educating physicians has only had minimal effects on this,” Rushakoff told Endocrinology Advisor.

“At UCSF, we implemented a virtual diabetes service where the everyday patients with high glucoses are identified, and we remotely will put suggestions in the chart for the medical/surgical teams to follow. With implementation of this service, the number of patients with high glucoses has decreased by 50%, and the providers have learned how to manage the patients better as the notes have given them just-in-time training that has seemed to stick.”

Currently, many hospitals still do not have comprehensive diabetes management programs in place. Seley said that needs to change. Improvements in this area of inpatient care could help lower morbidity, mortality and lead to improved patients outcomes and prevent readmissions. 

“Patients with diabetes carry an overall 31% greater likelihood of being readmitted in 30 days. Improving glycemic control during hospitalization and sending the patient home on a more effective self-care regimen is an important step in reducing readmission,” said Seley.

Reference

  1. Seley JJ, Rushakoff R. W13 – Inpatient Glycemic Management: How We Got Others To Follow Our Lead. Presented at: AADE 2015; Aug. 5-8, 2015; New Orleans.