Pharmacist glycemic control team improves quality of glycemic control in surgical patients with perioperative dysglycemia.

CONTEXT: Perioperative hyperglycemia is a risk factor for increased morbidity and mortality. Improved glycemic control has been demonstrated to reduce surgical site infections, reduce perioperative morbidity, and reduce length of stay. However, safe and effective perioperative glycemic control can be limited by expert clinician availability. OBJECTIVE: To improve quality by reliably providing safe and effective glycemic control to surgical patients with diabetes or stress hyperglycemia. DESIGN: A designated group of pharmacists, the Glycemic Control Team (GCT), worked under protocol, on a consultation basis, to manage perioperative dysglycemia during hospitalization. We used a pre-post, observational study design to assess the effectiveness of the intervention and implementation of the GCT. MAIN OUTCOME MEASURES: The proportion of patients pre- and postintervention with good glycemic control and with hypoglycemia were measured and compared. We defined good glycemic control as having all, or all but one, point-of-care blood glucose values between 70-180 mg/dL in each 24-hour period. We defined hypoglycemia as having any point-of-care test glucose value <70 mg/dL in any of the 3 days evaluated. RESULTS: During the preimplementation period, 77.4% of postoperative patient days demonstrated good glycemic control. In the postimplementation period, this percentage increased to 90.3%. Over the same period, the rate of hypoglycemia decreased from 8.6% to 4.6%. CONCLUSION: Implementation of a pharmacist team to manage glycemic control in hospitalized, postoperative patients led to safer and better quality of glycemic care as measured by improved glycemic control and lower rates of hypoglycemia.

Use of aggressive medical treatments near the end of life: differences between patients with and without dementia.

OBJECTIVE: To analyze whether acute care patients with dementia are more or less likely to receive each of five aggressive medical services near the end of life, compared with patients without dementia. DATA SOURCES: Two years of Veterans Affairs (VA) and Medicare utilization data for all 169,036 VA users nationwide age 67 and older who died between October 1, 1999 and September 30, 2001. STUDY DESIGN: We performed a retrospective analysis of acute care stays discharged in the final 30 days of life. The main outcome measure was the patient's likelihood of receiving each of five aggressive services (intensive care unit [ICU] admission, ventilator, cardiac catheterization, pulmonary artery monitor, and dialysis), controlling for demographic and clinical factors in probit regressions. PRINCIPAL FINDINGS: There were 122,740 acute-stay discharges during the final 30 days of life, representing 94,100 unique patients (31,654 with dementia). In probit models comparing acute care patients with and without dementia, patients with dementia were 7.5 percentage points less likely to be admitted to the ICU (95 percent confidence interval [CI], 6.9-8.1; percent of stays with ICU admission=36.8 percent), 5.4 percentage points less likely to be placed on a ventilator (95 percent CI, 5.0-5.9; percent of stays with ventilator use=17.1 percent), 0.7 percentage points less likely to receive cardiac catheterization (95 percent CI, 0.6-0.8; percent of stays with cardiac catheterization=2.7 percent), 1.4 percentage points less likely to receive pulmonary artery monitoring (95 percent CI, 1.2-1.5; percent of stays with pulmonary artery monitoring=2.6 percent), and 0.6 percentage points less likely to receive dialysis (95 percent CI, 0.4-0.8; percent of stays with dialysis=4.6 percent). CONCLUSIONS: During the final 30 days of life, acute care patients with dementia are treated substantially less aggressively than patients without dementia. Further research is warranted to determine the causes and appropriateness of these patterns of care.