Amy C. Donihi

Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients.

OBJECTIVE To investigate the prevalence of and risk factors for hyperglycemia in hospitalized patients receiving corticosteroids, which have been identified as an independent predictor of hyperglycemia. METHODS We conducted a retrospective review of electronic medical records of patients admitted to the general medicine service at a university hospital during a 1-month period. Pharmacy charges were used to identify patients receiving high doses (> or = 40 mg/day of prednisone or the equivalent) of corticosteroids for at least 2 days. Occurrence of hyperglycemia and the presence of risk factors, including history of diabetes, duration of corticosteroid therapy, concurrent parenteral nutrition, antibiotic therapy, use of medications associated with hyperglycemia, severity of illness scores, and hospital length of stay, were determined. Patients experiencing multiple episodes of hyperglycemia (glucose levels > or = 200 mg/dL) were compared with those who had < or = 1 hyperglycemic episode. Patients without a history of diabetes were assessed separately. RESULTS During the 1-month study period, 66 of 617 patients received high doses of corticosteroids, but only 50 of the 66 had glucose measurements. Hyperglycemia was documented in 32 of these 50 patients (64%), and multiple hyperglycemic episodes occurred in 26 (52%). A history of diabetes was documented in 12 of 26 patients who experienced multiple episodes, in comparison with 4 of 24 patients with < or = 1 episode of hyperglycemia (P = 0.035). Among patients without a history of diabetes, 19 of 34 (56%) had hyperglycemia at least once. Patients with multiple episodes of hyperglycemia had more comorbid diseases, longer duration of corticosteroid therapy, and longer duration of hospital stay. CONCLUSION Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids. In light of the poor outcomes associated with hyperglycemia, protocols targeting its detection and management should be available for patients who receive corticosteroid therapy.

EVOLUTION OF A DIABETES INPATIENT SAFETY COMMITTEE

OBJECTIVE 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. METHODS The development, implementation, and successes of the DPSC are described. RESULTS 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. CONCLUSION 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.

Patient outcomes after implementation of a protocol for inpatient insulin pump therapy.

OBJECTIVE To determine the safety and the results of use of an inpatient insulin pump protocol (IIPP). METHODS In this quality improvement initiative, review of medical records of bedside capillary blood glucose (CBG) levels and pump-related adverse events was performed on 50 consecutive inpatients admitted to the hospital with continuous subcutaneous insulin infusion (CSII) after implementation of our IIPP. Patients were categorized in 3 groups on the basis of evidence in the medical records for IIPP in combination with inpatient diabetes service consultation (group 1; n = 34), for IIPP alone (group 2; n = 12), or for usual care (group 3; n = 4). Patients identified during hospital admission as using CSII therapy were invited to complete a satisfaction questionnaire for inpatient CSII use. RESULTS Mean CBG levels were similar among the 3 groups (groups 1, 2, and 3: 173 +/- 43 mg/dL versus 187 +/- 62 mg/dL versus 218 +/- 46 mg/dL, respectively). Although there were more patient-days with blood glucose >300 mg/dL in group 3 (P = .02), there were no significant group differences in the frequency of hypoglycemia (CBG <70 mg/dL). Only 1 pump malfunction and 1 infusion site problem were reported among all study patients. No serious adverse events related to CSII therapy occurred. The majority of patients (86%) reported satisfaction with their ability to continue CSII use in the hospital. CONCLUSION Patients using CSII as outpatients are candidates for inpatient diabetes self-management. Inexperience with these devices on the part of hospital personnel together with the limited studies of patient experience with CSII in the hospital contributes to inconsistencies in management of these patients. An IIPP provides a standardized and safe approach to the use of CSII in the hospital.

Effect of a diabetes order set on glycaemic management and control in the hospital

Problem: Insulin can have favourable effects on patient outcomes when used appropriately; however, it is considered among the top five medications associated with errors in the hospital setting. Setting: Tertiary care centre. Methods : A diabetes order set with prescribing guidelines was developed by a multidisciplinary diabetes patient safety committee, and introduced on an inpatient unit (the order set unit) following educational sessions with doctors/nurses. To determine the safety and efficacy of the order set, all orders for diabetes medications on patients with 3 days of bedside blood glucose data were recorded and reviewed for types and appropriateness of orders and compared with those written on a unit not using the order set (control unit). An expert panel not involved in the project reviewed and determined appropriateness according to criteria that included evidence of insulin adjustments for hyperglycaemia, hypoglycaemia, or steroid therapy. Satisfaction with the order set among clinical personnel was elicited by a four-item questionnaire. Results: There were more orders for scheduled basal/bolus insulin therapy (p = 0.008) and fewer orders for correctional insulin alone on the order set unit than the control unit. A trend toward more appropriate orders (91% vs 80%) was observed on the order set unit. A high degree of satisfaction for the diabetes order set was elicited from doctors, nurse practitioners, nurses and clerical staff using a four-item survey. Conclusions: A diabetes order set with prescribing guidelines can safely and effectively be implemented in hospitals. The success of this intervention is attributed to the contribution of nurses, pharmacists and prescribers in the design and implementation of the order set, the provider education accompanying order set implementation and the feedback following implementation.

Standardized glycemic management and perioperative glycemic outcomes in patients with diabetes mellitus who undergo same-day surgery.

OBJECTIVE To assess the safety and effectiveness of a standardized glycemic management protocol in patients with diabetes mellitus who undergo same-day surgery. METHODS The perioperative glycemic management protocol consisted of preoperative instructions and perioperative order sets for management of subcutaneous and intravenous insulin. Patients with known diabetes admitted to same-day surgery during a 10-month period were observed. Patient demographic information and all capillary blood glucose (CBG) values obtained during the same-day surgery visit were collected. Hyperglycemia, defined as a CBG concentration of 200 mg/dL or greater, prompted notification of the attending anesthesiologist. While use of the perioperative order sets was encouraged, the attending anesthesiologist retained the prerogative to treat according to these order sets or their usual care. Physician compliance with the standardized order sets was determined by chart review in the patients who had a documented blood glucose value of 200 mg/dL or greater. RESULTS Patients managed with the standardized order sets had greater reductions in CBG values (percentage change, 35 ± 20.5% vs 18 ± 24%, P<.001) and lower postoperative CBG values (186 ± 53 mg/dL vs 208 ± 63 mg/dL, P<.05) than patients who received usual care. No cases of intraoperative or postoperative hypoglycemia (CBG <70 mg/dL) were observed in either group. CONCLUSIONS A systematic approach to glycemic management that includes instructions for preoperative adjustments to home diabetic medications and order sets for treatment of perioperative hyperglycemia is safe and can be more effective than usual care for ambulatory surgery patients with diabetes.

Hypoglycemia in hospitalized patients treated with sulfonylureas.

To identify the incidence of and risk factors associated with hypoglycemia in hospitalized patients taking sulfonylureas.

Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: a randomized controlled trial.

OBJECTIVE To investigate the effectiveness of an Inpatient Diabetes Management Program (IDMP) on physician knowledge and inpatient glycemic control. METHODS Residents assigned to General Internal Medicine inpatient services were randomized to receive the IDMP (IDMP group) or usual education only (non-IDMP group). Both groups received an overview of inpatient diabetes management in conjunction with reminders of existing order sets on the hospital Web site. The IDMP group received print copies of the program and access to an electronic version for a personal digital assistant (PDA). A Diabetes Knowledge Test (DKT) was administered at baseline and at the end of the 1-month rotation. The frequency of hyperglycemia among patients under surveillance by each group was compared by using capillary blood glucose values and a dispersion index of glycemic variability. IDMP users completed a questionnaire related to the program. RESULTS Twenty-two residents participated (11 in the IDMP group and 11 in the non-IDMP group). Overall Diabetes Knowledge Test scores improved in both groups (IDMP: 69% ± 1.7% versus 83% ± 2.1%, P = .003; non-IDMP: 76% ± 1.2% versus 84% ± 1.4%, P = .02). The percentage of correct responses for management of corticosteroid-associated hyperglycemia (P = .004) and preoperative glycemic management (P = .006) improved in only the IDMP group. The frequency of hyperglycemia (blood glucose level >180 mg/dL) and the dispersion index (5.3 ± 7.6 versus 3.7 ± 5.6; P = .2) were similar between the 2 groups. CONCLUSION An IDMP was effective at improving physician knowledge for managing hyperglycemia in hospitalized patients treated with corticosteroids or in preparation for surgical procedures. Educational programs directed at improving overall health care provider knowledge for inpatient glycemic management may be beneficial; however, improvements in knowledge do not necessarily result in improved glycemic outcomes.

Effect of a targeted glycemic management program on provider response to inpatient hyperglycemia.

OBJECTIVE To report the results of implementation of a Targeted Glycemic Management (TGM) Service pilot, with the goals of improving clinician awareness of available inpatient glycemic management protocols and improving responsiveness to and frequency of severe hyperglycemia. METHODS Patients with a blood glucose (BG) level ≥300 mg/dL who were hospitalized on a general medicine unit during three 12-week periods before, during, and after the TGM pilot were compared for responsiveness by the primary team, percentage of subsequent BG measurements between 80 and 180 mg/dL, and frequency of subsequent severe hyperglycemia (BG levels ≥300 mg/dL) and hypoglycemia (BG values <70 mg/dL). RESULTS In comparison with pre-TGM and post-TGM periods, more patients during the TGM pilot had a modification of their glycemic regimen in response to severe hyperglycemia (49% versus 73% versus 50%, before, during, and after TGM, respectively; P = .044), and the percentage of patients with ≥50% of subsequent BG measurements in the desired range (27% versus 53% versus 32%; P = .035) was greatest during the TGM period. The incidence of subsequent severe hyperglycemia (20% versus 9% versus 16%; P = .0004) was lowest during the TGM period; however, the incidence of hypoglycemia was similar in all 3 periods (3.9% versus 3.7% versus 3.7%). CONCLUSION These results indicate that a TGM Service can favorably influence glycemic management practices and improve glycemic control, but ongoing intervention is necessary for maintenance of these results.

U-500 Insulin as a Component of Basal Bolus Insulin Therapy in Type 2 Diabetes

BACKGROUND Changes in hemoglobin A1c (A1C), weight, and total daily insulin dose (TDD) were investigated following initiation of insulin U-500 (U500) alone or as part of a basal/bolus insulin (BBI) regimen. SUBJECTS AND METHODS Records of patients with type 2 diabetes who were prescribed U500 were retrospectively reviewed. Logistic regression analysis was used to investigate relationships between changes in A1C and use of U500 alone or as BBI. RESULTS Twelve patients were identified as using U500 alone (n=2) or in combination with long-acting (LAI) (n=7) or rapid-acting (RAI) (n=3) insulin. Reductions in A1C (9.5% at baseline vs. 7.7% at 6-9 months, P<0.0001) and increases in weight (128.8±32.7 vs. 131.5±31.3 kg, P<0.014) and TDD (260±111 to 333±106 units/day, P<0.0002) were observed. Concurrent use of LAI or RAI with U500 did not predict improvements in A1C. CONCLUSIONS U500 resulted in improvements in A1C and weight gain and increased TDD when used alone or as part of combination insulin therapy. Further investigations to define the optimal use of U500 are recommended.

SAFETY AND EFFICACY OF A PERI-OPERATIVE PROTOCOL FOR PATIENTS WITH DIABETES TREATED WITH CONTINUOUS SUBCUTANEOUS INSULIN INFUSION WHO ARE ADMITTED FOR SAME-DAY SURGERY

OBJECTIVE The number of people with diabetes using continuous subcutaneous insulin infusions (CSII) with an insulin pump has risen dramatically, creating new challenges when these patients are admitted to the hospital for surgical or other procedures. There is limited literature guiding CSII use during surgical procedures. METHODS The study was carried out in a large, urban, tertiary care hospital. We enrolled 49 patients using insulin pump therapy presenting for 57 elective surgeries. We developed a CSII peri-operative glycemic management protocol (PGMP) to standardize insulin pump management in patients admitted to a same-day surgery unit (SDSU). The purpose was evaluate the safety (% capillary blood glucose (CBG) <70 mg/dL and/or pump incidents) and efficacy (first postoperative CBG ≤200 mg/dL) of the CSII PGMP. We determine the contribution of admission CBG, type of anesthesia, surgery length, and peri-operative steroid use on postoperative glycemic control. RESULTS Overall, 63% of patients treated according to the CSII PGMP had a first postoperative CBG ≤200 mg/dL. There were no episodes of intra- or postoperative hypoglycemia. For patients treated with the CSII PGMP, the mean postoperative CBG was lower in patients with anticipated or actual surgical length ≤120 minutes (158.1 ± 53.9 vs. 216 ± 77.7 mg/dL, P<.01). No differences were observed with admission CBG, type of anesthesia, or steroid use. CONCLUSIONS This study demonstrates that a CSII PGMP is both safe and effective for patients admitted for elective surgical procedures and provides an example of a standardized protocol for use in clinical practice.