Challenges and Opportunities In Managing Diabetes and Hyperglycemia Module 2

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Challenges and Opportunities In Managing
Diabetes and Hyperglycemia Module 2
Diabetes Special Interest Group Georgia
Hospital Association
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Learning Modules
This module will describe current knowledge of
our hospital diabetes care and ongoing efforts to
improve
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Objectives

• Discuss the challenges to managing hyperglycemia
  in the hospitalized patient
• Describe the current status of diabetes
  management
• Use operational definitions for inpatient glucose
  control

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Challenges to Managing Hyperglycemia in the
Hospital

• Type of hyperglycemic patients
• Patients with preexisting diabetes
• Patients with undiagnosed diabetes
• Patients with stress hyperglycemia
• Types of hospitalized patients
• Short stay
• Elective/Urgent/Emergent
• Post-surgical
• Critically ill

The patient population with hyperglycemia is
heterogeneous.
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Challenges to Control

• Variables exacerbating hyperglycemia
• Increased counter-regulatory hormones
• Decreased insulin secretion
• Decreased insulin sensitivity
• Accelerated glucose production
• Increased protein catabolism
• Increased lipolysis
• Medications (steroids, vasopressors)

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Other Things to Consider

• Care-related issues
• Incorrect classification of diabetes
• Problem overlooked or not addressed
• Fear of hypoglycemia
• Nutrition
• Type of nutritional support
• Missed injections/missed meals
• Mismatching of insulin with meals
• Unpredictable timing of procedures

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Lets Look at One Hospitals Data

• To identify barriers to glucose control
• To encourage you to identify the barriers to care
  at your facility

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Distribution of Diabetes Cases, by Discharge
Service, at X Community Hospital
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Distribution () of bedside glucose, non-ICU,
2001 to 2004 at X community hospital
Staying hyperglycemic
Admitted hyperglycemic
42 of patients were admitted with poor control
(?200 mg/dl) and remained in poor control at time
of discharge
Discharged hyperglycemic
X needs to do a better job treating hyperglycemia
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Results of similar survey regarding operational
definitions of hyperglycemia among attending
physicians at X hospital
X needs to develop a consensus of what
hyperglycemia is and establish common goals.
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Frequency of Hypoglycemia and Hyperglycemia
Hypoglycemia is rare at X. Hyperglycemia is
common.
Which is the bigger problem?
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Units of insulin delivered, last vs. first 24
hours of hospitalization
Hospital X has clinical inertia (failure to
intensify treatment).
It also has negative therapeutic momentum
(decrease in treatment despite hyperglycemia).
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Documentation of Diabetes
N 90 charts reviewed
Diabetes or hyperglycemia in daily progress note
Diabetes or hyperglycemia in discharge note
Diabetes in admission note
Need for diabetes or hyperglycemia follow-up
Diabetes is often overlooked after admission.
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Diabetes and Assessment of Inpatient Glucose
Control
Bedside glucose values recorded in progress notes
Assessment of glucose control
Beside glucose measurements ordered
Bedside glucose is frequently ordered, but often
is not tracked.
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X is not the only hospital with opportunities
for improvement.
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A Quality and Safety Concern!

• Insulin is one of the five highest risk
  medications in the hospital setting
• Common sources of error include
• Uncoordinated feedings and medication
  administration leading to mistiming of insulin
  action
• Insufficient glucose monitoring frequency
• Unrecognized need for changes in insulin
  requirements
• Strategies to reduce errors include
• Written protocols
• Improved communication between caregivers,
  especially in transitions of care including
  discharge

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Overcoming System Barriers and Challenges

• Cultural change is needed
• Long-standing practice patterns need to change
• Processes of care need to be coordinated
• Work-flow habits need to be adjusted
• Increased nursing time and effort is needed
• Skepticism about benefits of inpatient glycemic
  control persists
• Fear of hypoglycemia exists
• Lack of ownership of glycemia management
• Lack of diabetes education

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Final Summary

• Hyperglycemia is common in hospitalized patients
  
• you will see these patients
• Good glycemic control is essential for good
  outcomes
• There is room to improve inpatient diabetes care
  at most hospitals
• Glucose control requires a team effort between,
  physicians, nurses, pharmacists and food service
  employees.