An Individualized Inpatient Diabetes Education and Hospital Transition Program for Poorly Controlled Hospitalized Patients with Diabetes

ObjectiveTo evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%).MethodsPatients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed.ResultsThere were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbAlc at follow-up (-2.8%, P < .0001), while those with type 1 diabetes (T1D, n = 19) did not (+ 0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar.ConclusionThe study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care. (Endocr Pract. 2014;20:1265-1273)     

Management Of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols

ObjectiveTo provide insulin protocols and adjustment guidance for management of hyperglycemia in common inpatient clinical scenarios.MethodsWe performed a PubMed search of pertinent existing literature published between 1980 and 2010.ResultsHyperglycemia is frequently encountered in general medical and surgical wards and has been linked to adverse clinical outcomes, prolonged hospital length of stay, and increased institutional care needs after discharge. No randomized controlled trial has been conducted to define optimal glycemic goals or to investigate the effects of intensive glycemic control in the non-intensive care unit (ICU) setting. Nonetheless, it is advocated by the American Association of Clinical Endocrinologists and the American Diabetes Association, in their 2009 Consensus Statement on Inpatient Glycemic Control, that optimization of glycemia in hospitalized patients with diabetes and hyperglycemia be judiciously offered. This approach is clinically sound, in light of the known deleterious consequences of hyperglycemia in critically and noncritically ill patients and the benefits observed with improved glycemic control in intensive care settings. The approach to hyperglycemiain non-ICU inpatients should follow the principles of provision of basal-nutritional-supplemental insulin. Herein we provide insulin protocols and adjustment guidance for management of hyperglycemia in common clinical scenarios. Recommendations reflect the opinion of national experts in the field and our departmental consensus at Penn State Institute for Diabetes and Obesity.ConclusionGlycemic control in the non-ICU setting is a relevant clinical situation that should be addressed and managed effectively and prudently. We present a practical guide for management of hyperglycemia individualized to various clinical scenarios encountered in the general hospital wards. (Endocr Pract. 2011;17:249-260)     

Effects of a Computerized Order Set on the Inpatient Management of Hyperglycemia: A Cluster-Randomized Controlled Trial

ObjectiveTo determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia.MethodsWe conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital’s computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL.ResultsBetween April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose < 40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58).ConclusionThe use of an order set built into a hospital’s CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program. (Endocr Pract. 2010;16:209-218)     

The Effects of a Comprehensive Multidisciplinary Outpatient Diabetes Program on Hospital Readmission Rates in Patients with Diabetes: A Randomized Controlled Prospective Study

Objective: The diagnosis of diabetes mellitus is associated with an increased risk of hospital readmissions. The goal of this study was to determine whether there was a difference in the rates of 30-day and 365-day hospital readmissions between diabetic patients who, upon their discharge, received diabetes care in a standard primary care setting and those who received their care in a specialized multidisciplinary diabetes program.Methods: This was a randomized controlled prospective study.Results: One hundred and ninety two consecutive patients were recruited into the study, 95 (49%) into standard care (control group) and 97 (51%) into a multidisciplinary diabetes program (intervention group). The 30-day overall hospital readmission rates (including both emergency department and hospital readmissions) were 19% in the control group and 7% in the intervention group (P = .02). The 365-day overall hospital readmission rates were 38% in the control group and 14% in the intervention group (P = .0002).Conclusion: Patients with diabetes who are assigned to a specialized multidisciplinary diabetes program upon their discharge exhibit significantly reduced hospital readmission rates at 30 days and 365 days after discharge.     

Inpatient Hyperglycemia and Transitions of Care: A Systematic Review

ObjectiveThe transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed.MethodsA PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included.ResultsWith the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care.ConclusionPockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay.     

Knowledge,Attitudes, and Decision Making in Hospital Glycemic Management: are Faculty up to Speed?

Objective: Knowledge and confidence deficits in the management of hospital glucose abnormalities are prevalent among resident physicians. However, it is unclear whether such gaps prevail among faculty within different professional fields. In this study, we examined faculty knowledge and explored perceptions of challenges related to the management of inpatient hyperglycemia and diabetes.Methods: We conducted a survey that examined management decisions about inpatient hyperglycemia and diabetes among Medicine, Medicine/Pediatrics, Family and Community Medicine, Surgery, and Neurology faculty clinicians. All participating faculty had teaching and patient care responsibilities.Results: Responses from 69 faculty participants revealed gaps in several areas, including biomedical and contextual knowledge, familiarity with resources, clinical decision making, and self-efficacy. We identified important factors perceived as barriers to optimal glycemic management in the inpatient settings.Conclusion: The results of this study enhance our insight about the limitations existing among faculty related to the management of hyperglycemia and diabetes in hospitalized patients. We suggest that these barriers may impede optimization of patient care. Faculty play a crucial role in the clinical decision-making process and quality of care delivered by trainees. Therefore, attending physicians are likely to impact trainees' clinical performance and competency in the management of inpatient diabetes during training and beyond. Education in this subject should be a priority among trainees and faculty alike.Abbreviation: ICU = intensive care unit     

Glucocorticoid-Induced Hyperglycemia

ObjectiveTo review the current literature on glucocorticoid-induced hyperglycemia and provide a strategy for its treatment.MethodsWe undertook an electronic (MEDLINE) and a library review of the existing pertinent literature published from 1950 to March 2009.ResultsGlucocorticoid-induced hyperglycemia is common in patients with and without diabetes. The odds ratio for new-onset diabetes mellitus in patients treated with glucocorticoids ranges from approximately 1.5 to 2.5. Total glucocorticoid dose and duration of therapy are strong predictors of diabetes induction. Other risk factors include age and body mass index. Failure to treat glucocorticoid-induced hyperglycemia is related to the presumed short duration of administration of glucocorticoid treatment and the emphasis on fasting plasma glucose only. Understanding the pharmacodynamics of glucocorticoids can lead to increased recognition and improved treatment of the condition. Recent demonstrations that even shortterm elevations in blood glucose level may be associated with adverse sequelae argue for greater attention to the condition.ConclusionGlucocorticoid-induced hyperglycemia is an important clinical finding that, if recognized, can be effectively treated. We propose a relatively simple schema for the proactive management of corticosteroid-induced hyperglycemia that has been effective and easily adaptable to both the inpatient and the outpatient setting. (Endocr Pract. 2009;15:469-474)     

Impact of Multidisciplinary Process Improvement Interventions on Glucometrics in a Noncritically Ill Setting

Objective: This study aimed to assess the impact of multidisciplinary process improvement interventions on glycemic control in the inpatient setting of an urban community hospital, utilizing the daily simple average as the primary glucometric measure.Methods: From 2010–2014, five process of care interventions were implemented in the noncritical care inpatient units of the study hospital. Interventions included education of medical staff, implementation of hyperglycemia and hypoglycemia protocols, computerized insulin order entry, and coordination of meal tray delivery with finger stick and insulin administration. Unpaired t tests compared pre- and postintervention process measures. Simple average daily glucose measure was the primary glucometric outcome. Secondary outcome measures included frequency of hyperglycemia and hypoglycemia. Glucose outcomes were compared with an in-network hospital that did not implement the respective interventions.Results: A total of 180,431 glucose measurements were reported from 4,705 and 4,238 patients from the intervention and comparison hospitals, respectively. The time between bolus-insulin administration and breakfast tray delivery was significantly reduced by 81.7 minutes (P<.00005). The use of sliding scale insulin was sustainably reduced. Average daily glucose was reduced at both hospitals, and overall rates of hypoglycemia were low.Conclusion: A multidisciplinary approach at an urban community hospital with limited resources was effective in improving and sustaining processes of care for improved glycemic control in the noncritical care, inpatient setting.Abbreviations: IQR = interquartile range; JMC = Jacobi Medical Center; NCBH = North Central Bronx Hospital     

Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy can be Safely Used in the Hospital in Select Patients

ObjectiveTo analyze data on inpatient insulin pump use and examine staff compliance with hospital procedures, glycemic control, and safety.MethodsWe conducted a retrospective review of charts and bedside glucose data for patients who had been receiving outpatient insulin pump therapy and were admitted to our teaching hospital between November 1, 2005, and February 8, 2008.ResultsDuring the study period, there were 50 hospitalizations involving 35 patients who had been receiving outpatient insulin pump therapy. The mean age and duration of diabetes of the 35 patients was 55 years and 32 years, respectively. Sixty-six percent were women, and 91% had type 1 diabetes. Patients in 31 of the hospitalizations (62%) were deemed candidates for continued insulin pump therapy during their stay. Of the 31 hospitalizations, 80% had the presence of the pump documented at admission; 100% had an admission glucose value; 77% had documentation of signed patient consent; 81% had evidence of completed preprinted insulin pump orders; 77% received an endocrine consultation; and 68% had a completed bedside flow sheet. Patients continuing insulin pump therapy had mean bedside glucose levels similar to those whose pump therapy was discontinued (P = .11); however, the proportion of hypoglycemic events was lower among insulin pump users (P < .01) than among nonusers.ConclusionsInsulin pump therapy is safe for select inpatients. Overall, staff compliance with procedures was high, although we identified areas for improvement. Continued study is needed on the effectiveness of insulin pump therapy in controlling inpatient hyperglycemia. (Endocr Pract. 2009;15:24-29)     

Patient Outcomes after Implementation of a Protocol for Inpatient Insulin Pump Therapy

ObjectiveTo determine the safety and the results of use of an inpatient insulin pump protocol (IIPP).MethodsIn 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.ResultsMean 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.ConclusionPatients 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. (Endocr Pract. 2009;15:415-424)     

Care Directed by a Specialty-Trained Nurse Practioner or Physician Assistant can Overcome Clinical Inertia in Management of Inpatient Diabetes

ObjectiveThe study’s objective was to determine the impact of care directed by a specialty-trained nurse practitioner (NP) or physician assistant (PA) on use of basal-bolus insulin therapy and glycemic control in a population of noncritically ill patients with diabetes.MethodsA retrospective review of diabetes patients evaluated between July 1, 2011 and December 31, 2011 was conducted. Patients cotreated by a specialty-trained NP/PA were compared with patients who did not receive such care.ResultsIn total, 171 patients with 222 hospitalizations were cotreated by an NP/PA and 543 patients with 665 hospitalizations were not. Patients with NP/PA involvement were younger, and had more frequent hyperglycemia, and had greater corticosteroid use than patients without NP/PA involvement (P < .01 for all). Basal-bolus insulin therapy was administered to 80% of patients with NP/PA involvement and 34% of patients without it (P < .01). After adjustment for age, sex, hyperglycemia measures, and corticosteroid use, the odds of basal-bolus insulin therapy being administered were increased significantly through NP/PA care (odds ratio, 3.66; 95% confidence interval, 2.36-5.67; P < .01). After adjustment for these variables and insulin regimen, NP/PA care was significantly correlated with lower mean point-of-care glucose levels at 24 hours before discharge (P = .042).ConclusionDiabetes care assisted by an NP/PA trained in inpatient diabetes management results in greater use of recommended basal-bolus insulin therapy and is correlated with lower mean glucose levels before discharge. Adapting this model for use outside an endocrinology consult service needs to be explored so that the expertise can be brought to a broader inpatient population with diabetes. (Endocr Pract. 2014;20:112-119)     

The Efficacy and Safety of Co-Administration of Sitagliptin With Metformin in Patients With Type 2 Diabetes at Hospital Discharge

Objective: Few randomized controlled trials have focused on the optimal management of patients with type 2 diabetes (T2D) during the transition from the inpatient to outpatient setting. This multicenter open-label study explored a discharge strategy based on admission hemoglobin A1c (HbA1c) to guide therapy in general medicine and surgery patients with T2D.Methods: Patients with HbA1c ≤7% (53 mmol/mol) were discharged on sitagliptin and metformin; patients with HbA1c between 7 and 9% (53–75 mmol/mol) and those >9% (75 mmol/mol) were discharged on sitagliptinmetformin with glargine U-100 at 50% or 80% of the hospital daily dose. The primary outcome was change in HbA1c at 3 and 6 months after discharge.Results: Mean HbA1c on admission for the entire cohort (N = 253) was 8.70 ± 2.3% and decreased to 7.30 ± 1.5% and 7.30 ± 1.7% at 3 and 6 months (P<.001). Patients with HbA1c <7% went from 6.3 ± 0.5% to 6.3 ± 0.80% and 6.2 ± 1.0% at 3 and 6 months. Patients with HbA1c between 7 and 9% had a reduction from 8.0 ± 0.6% to 7.3 ± 1.1% and 7.3 ± 1.3%, and those with HbA1c >9% from 11.3 ± 1.7% to 8.0 ± 1.8% and 8.0 ± 2.0% at 3 and 6 months after discharge (both P<.001). Clinically significant hypoglycemia (<54 mg/dL) was observed in 4%, 4%, and 7% among patients with a HbA1c <7%, 7 to 9%, and >9%, while a glucose <40 mg/dL was reported in <1% in all groups.Conclusion: The proposed HbA1c-based hospital discharge algorithm using a combination of sitagliptin-metformin was safe and significantly improved glycemic control after hospital discharge in general medicine and surgery patients with T2D.Abbreviations: BG = blood glucose; DPP-4 = dipeptidyl peptidase-4; eGFR = estimated glomerular filtration rate; HbA1c = hemoglobin A1c; T2D = type 2 diabetes     

Development,Validation and Deployment of a Real Time 30 Day Hospital Readmission Risk Assessment Tool in the Maine Healthcare Information Exchange

ObjectivesIdentifying patients at risk of a 30-day readmission can help providers design interventions, and provide targeted care to improve clinical effectiveness. This study developed a risk model to predict a 30-day inpatient hospital readmission for patients in Maine, across all payers, all diseases and all demographic groups.MethodsOur objective was to develop a model to determine the risk for inpatient hospital readmission within 30 days post discharge. All patients within the Maine Health Information Exchange (HIE) system were included. The model was retrospectively developed on inpatient encounters between January 1, 2012 to December 31, 2012 from 24 randomly chosen hospitals, and then prospectively validated on inpatient encounters from January 1, 2013 to December 31, 2013 using all HIE patients.ResultsA risk assessment tool partitioned the entire HIE population into subgroups that corresponded to probability of hospital readmission as determined by a corresponding positive predictive value (PPV). An overall model c-statistic of 0.72 was achieved. The total 30-day readmission rates in low (score of 0–30), intermediate (score of 30–70) and high (score of 70–100) risk groupings were 8.67%, 24.10% and 74.10%, respectively. A time to event analysis revealed the higher risk groups readmitted to a hospital earlier than the lower risk groups. Six high-risk patient subgroup patterns were revealed through unsupervised clustering. Our model was successfully integrated into the statewide HIE to identify patient readmission risk upon admission and daily during hospitalization or for 30 days subsequently, providing daily risk score updates.ConclusionsThe risk model was validated as an effective tool for predicting 30-day readmissions for patients across all payer, disease and demographic groups within the Maine HIE. Exposing the key clinical, demographic and utilization profiles driving each patient’s risk of readmission score may be useful to providers in developing individualized post discharge care plans.     

Impact of Glucose Management Team on Outcomes of Hospitalization in Patients With Type 2 Diabetes Admitted to the Medical Service

Objective: To improve glycemic control of hospitalized patients with diabetes and hyperglycemia, many medical centers have established dedicated glucose management teams (GMTs). However, the impact of these specialized teams on clinical outcomes has not been evaluated.Methods: We conducted a retrospective study of 440 patients with type 2 diabetes admitted to the medical service for cardiac or infection-related diagnosis. The primary endpoint was a composite outcome of several well-recognized markers of morbidity, consisting of: death during hospitalization, transfer to intensive care unit, initiation of enteral or parenteral nutrition, line infection, new in-hospital infection or infection lasting more than 20 days of hospitalization, deep venous thrombosis or pulmonary embolism, rise in plasma creatinine, and hospital re-admissions.Results: Medical housestaff managed the glycemia in 79% of patients (usual care group), while the GMT managed the glycemia in 21% of patients (GMT group). The primary outcome was similar between cohorts (0.95 events per patient versus 0.99 events per patient in the GMT and usual care cohorts, respectively). For subanalysis, the subjects in both groups were stratified into those with average glycemia of <180 mg/dL versus those with glycemia >180 mg/dL. We found a significant beneficial impact of glycemic management by the GMT on the composite outcome in patients with average glycemia >180 mg/dL during their hospital stay. The number of patients who met primary outcome was significantly higher in the usual care group (40 of 83 patients, 48%) than in the GMT-treated cohort (8 of 33 patients, 25.7%) (P<.02).Conclusion: Our data suggest that GMTs may have an important role in managing difficult-to-control hyperglycemia in the inpatient setting.Abbreviations:BG = blood glucoseGMT = glucose management teamHbA1c = hemoglobin A1cICU = intensive care unitPOC = point of careT2D = type 2 diabetes     

公立医院多学科整合门诊服务模式的实践探索

通过对某公立医院门诊开展多学科整合研究的管理服务实践,及患者满意度调查分析,提出提高医院门诊服务水平、优化学科建设、建立整合门诊同绩效考核评价之间关联等建议,旨在进一步创新医疗试点改革服务。     

Outcomes Associated With Insulin Therapy Disruption After Hospital Discharge Among Patients with Type 2 Diabetes Mellitus who Had Used Insulin Before and During Hospitalization

ObjectiveTo evaluate outcomes associated with insulin therapy disruption after hospital discharge in patients with type 2 diabetes mellitus who had used insulin before and during hospitalization.MethodsIn this observational, retrospective analysis of medical records obtained from a coordinated health system in the United States, patients with type 2 diabetes mellitus who had used insulin 30 days before and during hospitalization were included. Clinical and cost outcomes were compared between patients who continued insulin therapy and those who had disrupted insulin therapy after hospital discharge.ResultsIn total, 2160 records were analyzed (851 patients with continued insulin therapy and 1309 patients with disrupted insulin therapy). Mean baseline glycated hemoglobin A_1c levels were 8.56% and 7.73% in patients who continued insulin therapy and patients who disrupted insulin therapy, respectively (P <.001), suggesting that patients who discontinued insulin therapy had better glycemic control at baseline. Continued insulin therapy was associated with an expected greater reduction in glycated hemoglobin A_1c (P <.001); similar hypoglycemia rates; lower risks of all-cause hospital readmission, diabetesrelated readmission, and all-cause emergency department visits; and improved survival. Continued insulin therapy was associated with $3432 lower total medical service costs than disrupted therapy over the 6-month postdischarge period.ConclusionEnsuring adherence to insulin therapy in patients who require insulin therapy after hospitalization should be a priority for postdischarge patient care programs. However, the clinical implications of this study are limited by the fact that it could not be determined whether all patients required insulin therapy after hospital discharge. (Endocr Pract. 2012;18:651-659)     

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2,598 Incidents from a Voluntary Electronic Error-Reporting Database

ObjectiveTo describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care.MethodsWe conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care.ResultsThe median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported < 2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports).ConclusionAn e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm. (Endocr Pract. 2008;14:535-542)     

Evaluation of Total Daily Dose and Glycemic Control for Patients Taking U-500 Regular Insulin Admitted to the Hospital

Objective: Patients using U-500 regular insulin are severely insulin resistant, requiring high doses of insulin. It has been observed that a patient's insulin requirements may dramatically decrease during hospitalization. This study sought to systematically investigate this phenomenon.Methods: We performed a retrospective chart review of patients with U-500 insulin outpatient regimens who were admitted to the San Antonio Military Medical Center over a 5-year period. Each patient's outpatient total daily dose (TDD) of insulin was compared to the average inpatient TDD. The outpatient estimated average glucose (eAG) was calculated from the glycated hemoglobin (HbA1c) and compared to the average inpatient glucose.Results: There were 27 patients with a total of 62 separate admissions. The average age was 64.4 years, with a mean body mass index of 38.9 kg/m² and eAG of 203 mg/dL (HbA1c, 8.7%, 71.6 mmol/mol). All patients were converted from U-500 to U-100 upon admission. The average inpatient TDD of insulin was 91 units, versus 337 units as outpatients (P<.001). Overall, 89% of patients received ≤50% of their outpatient TDD. The average inpatient glucose was slightly higher than the outpatient eAG, 234 mg/dL versus 203 mg/dL (P = .003).Conclusion: U-500 insulin is prone to errors in the hospital setting, so conversion to U-100 insulin is a preferred option. Despite a significant reduction in insulin TDD, these patients had clinically similar glucose levels. Therefore, patients taking U-500 insulin as an outpatient can be converted to a U-100 basal-bolus regimen with at least a 50% reduction of their outpatient TDD.Abbreviations:BG = blood glucoseeAG = estimated average glucoseHbA1c = glycated hemoglobinNPO = nil per osSPSS = Statistical Package for the Social SciencesTDD = total daily dose     

Improving Ambulatory Diabetes Care In High-Risk Racial Minorities:Use Of Culture-Specific Education And Close Follow-Up

ObjectiveTo describe a project aimed at improving diabetes care in the ambulatory setting among 2 high-risk racial minorities (African American and Hispanic patients) by using culture-specific education provided by trained diabetes educators from the same racial groups as the targeted patients.MethodsTwo nurse educators, 1 Hispanic and 1 African American, completed a standardized chronic disease management program, as did 2 patients with diabetes from each of the aforementioned ethnic groups in preparation for training other patients. The study patients participated in group classes or one-on-one sessions to learn about appropriate management of their diabetes, related complications, and improved lifestyle habits. Close follow-up by telephone and regular appointments ensured that appropriate glucose monitoring and laboratory tests were performed. Outcome measures before and after the intervention were recorded, with final project follow-up at 24 months. A control group was identified during the same period, which received standard care (follow-up with a physician every 3 to 6 months).ResultsAn improvement in control of diabetes occurred, as determined by a significant decline in hemoglobin A1c levels in both minority study groups. Emergency department visits also decreased significantly.Lipid profiles and microalbumin showed improvement as well. More than 90% of patients kept appointments and had all laboratory studies performed.Conclusion: The project intervention had a notable effect, physically and psychologically, on the 2 ethnic sample populations studied. These results have major implications, both clinically and financially, for public health policy planning for diabetes care in minority populations. (Endocr Pract 2010;16:171-177)     

Working to Improve Care of Hospital Hyperglycemia Through Statewide Collaboration: The Georgia Hospital Association Diabetes Special Interest Group

ObjectiveTo review the efforts of the Georgia Hospital Association Diabetes Special Interest Group (DSIG) to develop and disseminate sample clinical guidelines on management of inpatient hyperglycemia.MethodsBeginning in February 2003, a consortium of physicians and allied health professionals from throughout the state of Georgia began meeting on a frequent basis to formulate a plan to enhance the care of hospitalized patients with hyperglycemia. The immediate goals of the DSIG were the identification and organization of interested stakeholders, the development of consensus sample clinical guidelines, and the dissemination of information.ResultsSince its inception, the DSIG has accomplished the following: development of 7 consensus sample clinical guidelines, construction of a Web site that posts these clinical guidelines and other useful related information and educational materials, and sponsorship of workshops throughout the state of Georgia.ConclusionAs the importance of glucose control in the hospital setting has become increasingly recognized, institutions must find ways of applying results of clinical trials to “real-world” hospital environments. The DSIG is an example of a successful collaboration that could serve as a model for other state hospital organizations that wish to develop programs to enhance the care of inpatients with hyperglycemia. (Endocr Pract. 2007;13:45-50)