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.

Menu selection, glycaemic control and satisfaction with standard and patient-controlled consistent carbohydrate meal plans in hospitalised patients with diabetes.

PROBLEM: Medical nutrition therapy is an important component of glycaemic management in hospitalised patients with diabetes; however, there is a lack of information guiding the ordering of specific meal plans in this setting. SETTING: University-affiliated academic medical centre. METHODS: An administrative decision to gradually replace standard consistent-carbohydrate (CCMP) (standard group) with patient-controlled meal plans (patient-controlled group) presented the opportunity to compare menu selection, adherence to CCMP, glycaemic control and satisfaction as a quality-improvement initiative. Information was obtained from consecutive inpatients with diabetes admitted to units receiving standard (n=30) or patient-controlled meal plans (n=43). Patients received the meal plan according to unit location. RESULTS: No group differences were observed in adherence to CCMP (70% vs 64%, p=0.1), mean capillary blood glucose (CBG) or hyperglycaemia frequency (CBG>180 mg/dl). Hypoglycaemia (CBG<70 mg/dl) occurred more frequently in the patient-controlled group (0.39 vs 3.23%, p=0.04). There were no episodes of severe hypoglycaemia (CBG<40 mg/dl) in either group. The patient-controlled group reported a greater satisfaction and had more opportunities for nutrition education, with a demonstrated improvement in adherence to CCMP following targeted education in six of nine patients with available menu data. CONCLUSIONS: The standard group experienced less hypoglycaemia and required less clinician oversight. The patient-controlled group allowed for identification of patients who would benefit from education, required more oversight by nutrition services and reported greater satisfaction with their meal plan. Both meal plans may be appropriate for inpatients with diabetes, provided that a sufficient review is available for patients who make inappropriate selections with the patient-controlled meal plan.