Improving Glycemic Control Safely in Non-Critical Care Patients: A Collaborative Systems Approach in Nine Hospitals.

BACKGROUND: Practice variations in insulin management and glycemic adverse events led nine Dignity Health hospitals to initiate a collaborative effort to improve hypoglycemia, uncontrolled hyperglycemia, and glycemic control. METHODS: Non-critical care adult inpatients with ≥4 point-of-care blood glucose (BG) readings in a ≥2-day period were included. Balanced glucometric goals for each hospital were individualized to improve performance by 10%-20% from baseline or achieve top performance derived from Society of Hospital Medicine (SHM) benchmarking studies. Baseline measures (2011) were compared to mature results (postintervention, 2014). Protocols for insulin management and hypoglycemia prevention were piloted at one facility and were then spread to the cohort. Interventions included standardized order sets, education, mentoring from physician experts, feedback of metrics, and measure-vention (coupling measurement of patients "off protocol" with concurrent intervention to correct lapses in care). RESULTS: The day-weighted mean BG for the cohort improved by 11.4 mg/dL (95% confidence interval [CI]: 11.0-11.8]; all nine sites improved. Eight of the sites reduced severe hyperglycemic days, and the percentage of patient-days with any BG > 299 mg/dL for the total cohort improved from 11.6% to 8.8% (relative risk, 0.76 [95% CI: 0.74-0.78]). The percentage of patient-days with any BG < 70 mg/dL remained unchanged at 3.6%. Eight of the sites either reduced hypoglycemia by 20% or achieved SHM best-quartile rates. CONCLUSION: Multihospital improvements in glycemic control and severe hyperglycemia without significant increases in hypoglycemia are feasible using portable low-cost toolkits and metrics.

Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management.

OBJECTIVE: Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. POPULATION: all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS: hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS: Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS: A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION: Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.

Glycemic control mentored implementation: creating a national network of shared information.

BACKGROUND: The Society of Hospital Medicine's (SHM's) Glycemic Control Mentored Implementation (GCMI) program, which, like all MI programs, is conducted as an improvement collaborative, is intended to help hospitals improve inpatient glycemic control in diabetic and nondiabetic patients by educating and mentoring quality teams. METHODS: Hospital quality improvement (QI) teams applied for participation in GCMI from 2009 through 2012. Accepted sites were assigned either a hospitalist or endocrinologist mentor to work through the life cycle of a QI project. SHM's Implementation Guide, online resources, measurement strategies, Web-based Glycemic Control Data Center for Performance Tracking, webinars, interactive list-serve, and other tools help mentors guide these teams through the program. Mentors in GCMI bring expertise in both inpatient glycemic control and QI. RESULTS: One hundred fourteen hospital QI teams were enrolled into the GCMI program in the course of 2.5 years. Of these 114 sites, 90 completed the program, with 63 of them uploading data to the Data Center. Feedback from the sites was consistently positive, with the listserve, Data Center, and mentorship reported as the top three most effective components of the program. Ninety-five percent of respondents stated that they would recommend participation in an SHM-mentored implementation program to a colleague. Participants reported improved leadership skills and increased institutional support for glycemic control. CONCLUSIONS: Hospital quality teams participating in the GCMI program gained support to overcome barriers, focus on improving glycemic control, network with peers and expert mentor physicians, collect and analyze data, and build quality leaders. The features and structure of this program can be used in other multisite QI goals and projects.

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel.

PURPOSE: Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. SUMMARY: Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel's consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. CONCLUSION: A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Maintaining glycemic control when transitioning from infusion insulin: a protocol-driven, multidisciplinary approach.

BACKGROUND: An observational pilot study of 41 medical and surgical intensive care patients on infusion insulin at our own institution found that glycemic control rapidly deteriorated within 48 hours of stopping infusion insulin. This prompted the design and testing of a transition protocol. METHODS: The transition protocol identified appropriate patients for subcutaneous (SC) insulin along with the insulin dose and schedule. A pharmacist-hospitalist improvement team offered protocol guidance but adherence was left to the discretion of the provider. The primary endpoints were mean blood glucose the first and second day after stopping the insulin infusion and the number of patients with hypoglycemia (41-70 mg/dL) and severe hypoglycemia (<40 mg/dL) during the 48-hour transition. Secondary endpoints include severe hyperglycemia (>300 mg/dL), length of stay (LOS), re-initiation of the infusion insulin, day-weighted glucose mean 12 days following transition for patients with diabetes, and identification of a new diagnosis of diabetes. RESULTS: Patients with diabetes transitioned by protocol (n = 33) had better glycemic control than those (n = 39) transitioned without the protocol (Day 1 population glucose mean of 168 mg/dL vs. 211 mg/dL [P<0.001], Day 2 means of 176 mg/dL vs 218 mg/dL [P<0.001]). Severe hypoglycemia occurred once in each group. There were 14 patients newly diagnosed with diabetes based on an A1c ≥6%. Patients with stress hyperglycemia maintained good glycemic control with correctional insulin only. CONCLUSION: Protocol adherence improved glycemic control, reduced unnecessary use of insulin, and identified patients with previously undiagnosed diabetes, without any increase in hypoglycemia.