Johns Hopkins endocrinologists propose new protocol for inpatient glucose management

Borrowing a page from a winning team’s playbook, Johns Hopkins endocrinologist Nestoras Mathioudakis, M.D., and his colleagues are taking on the topic of managing hospital patients’ diabetes.

The Joint Commission Journal on Quality and Patient Safety this month published Mathioudakis’ article — co-authored by Peter Pronovost, M.D., director of Johns Hopkins’ Armstrong Institute for Patient Safety and Quality — proposing a model for inpatient glucose management based on successful models built to control hospital-acquired infections.

Poor glucose management often leads to longer, costlier hospital stays. Beginning with standardized policies, procedures and data collection, many of the tools that helped hospitals reduce infections would be useful to better care for inpatients with diabetes, says Mathioudakis.

When patients with diabetes are admitted to hospitals, their disease often takes a back seat to other illnesses or injuries. Hospital care teams often are not fully prepared or properly trained to monitor and treat patients with diabetes, Mathioudakis says. He and his co-authors propose that hospitals employ glucose management teams to standardize the care that patients with diabetes receive during hospital stays.

A leader in the field of patient safety, Pronovost developed a checklist protocol adopted by hospitals around the world. Through steps as simple as hand-washing, antiseptic wash and sterile drapes, masks, gowns, hats, gloves and dressings, the checklist has saved countless lives by reducing unnecessary central line infections. Hospitals across America now employ teams of patient safety experts devoted to controlling infections and keeping hospitals safe for patients, visitors and staff.

Mathioudakis says that similar teams could manage the glucose levels of patients with diabetes, potentially shortening hospital stays, saving money and providing better care.

Quality improvement interventions also have played a key role in reducing hospital infections. Many similar interventions, says Mathioudakis, can be imposed on the field of inpatient glucose management. Among the authors’ recommendations:

• Centralized glucose management programs chaired by endocrinologists or hospitalists
• Standardized policies on things like insulin pump use and hypoglycemia management
• Computerized order sets
• Clinical decision support tools, such as insulin-dosing algorithms
• Prescriber education
• Pharmacist-driven interventions
• Nutrition interventions

Since hospitals committed to reduce infections, particularly bloodstream infections caused by contaminated central lines and urinary tract infections related to catheters, infection numbers across the U.S. have fallen dramatically. Collecting and analyzing data, emphasizing hand hygiene, and instituting checklists all have helped reduce the numbers of hospital-acquired infections.

As more and more Americans are diagnosed with diabetes, the number of diabetes-related adverse hospital events continues to rise.

“About eight percent of the U.S. population has diabetes, and one in four hospital patients has a diagnosis of diabetes,” says Mathioudakis. “It is extremely common.”

Mathioudakis cites a 2011 study that found between 10 and 13 percent of U.S. patients who receive medications to control blood sugar during a hospital stay experience hypoglycemia.

These medications are the leading source of “adverse drug events” in U.S. hospitals. “Even greater than blood thinners,” says Mathioudakis. “About half of all hypoglycemic events in U.S. hospitals are a result of medications administered in the hospital.”

Low blood sugar is associated with significant problems, including cardiac ischemia and arrhythmia, stroke, seizures and even coma.

Mathioudakis says there are numerous reasons that glucose can be hard to manage in hospital patients. The stress of acute illness, issues of nausea or vomiting, kidney problems, tube feedings and medications like steroids all can affect blood glucose. He says physicians, nurses and other hospital care staff have varying degrees of training with diabetes.

“There’s a significant variability in provider knowledge about glucose management,” he says. “A glucose management team would focus specifically on keeping blood sugar levels under good control.”

Source: http://www.hopkinsmedicine.org/