Managing Hyperglycemia in Hospitalized Adult Patients

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Managing Hyperglycemia in Hospitalized Adult Patients
Loyola University Health System
Maywood, Illinois, USA

Team
Mary Ann Emanuele, MD, Professor of Medicine, Division of Endocrinology and Metabolism
William M. Barron, MD, MMM, Vice President, Quality and Patient Safety
Fadi Nabhan, MD, Assistant Professor of Medicine, Division of Endocrinology and Metabolism
Rose Lach, PhD, RN, Administrative Director of Medicine
Rita A. Vercruysse, RN, MPH, Medicine Case Manager Health Services
Terese M. Bertucci, APN/CNP, CDE, Nurse Practitioner Coordinator, Diabetes Care Center
Donna M. Murphy, APN/CNS, BC-ADM, CDE , Diabetes Clinical Nurse Specialist
Theresa Pavone, RN, MSN, Staff Nurse
Barbara Rumick, RN, CCRN, Staff Nurse
Allison E. Schriever, PharmD, Clinical Pharmacist, Trauma/Critical Care Service
Barbara M. Murphy, PharmD, Clinical Pharmacist
Jill Whitney, RD, LDN, CNSD, BS in Nutrition, Dietetics and Food Science, Clinical Nutrition Manager
Michael J. Wall, PharmD, Senior Clinical Quality Improvement Analyst
Barbara T. Pudelek, RN, CS, MSN, ACNP, Clinical Quality Improvement Specialist
Camille Robinson, RN, BSN, Systems Analyst Medical Information Systems

Aim

To decrease the occurrence of days with hyperglycemia in patients with diabetes from 62 percent of inpatient days to less than 50 percent of inpatient days without significantly increasing hypoglycemia episodes.

Measures

Incidence of hyperglycemia:
Number of inpatient days in which a patient with a discharge diagnosis of diabetes has at least one glucose measurement above 200mg/dL, divided by the total number of inpatient days for patients with a discharge diagnosis of diabetes and a valid glucose measurement.
Results between 40 and 400 were considered valid.
Incidence of hypoglycemia:
Number of inpatient days in which a patient with a discharge diagnosis of diabetes has at least one glucose measurement below 70mg/dL, divided by the total number of inpatient days for patients with a discharge diagnosis of diabetes and a valid glucose measurement.
Results between 40 and 400 were considered valid.

Changes

After review of scientific literature and analysis, a multidisciplinary committee was established and consensus for developing standardized insulin protocols and guidelines was agreed upon.

Developed protocols and guidelines for intravenous insulin infusion, and transition from intravenous to subcutaneous insulin in adult patients.
Initiated ongoing, hospital-wide nurse, physician and pharmacist education opportunities for adoption of protocols.
Implemented protocol changes based on medical staff feedback and clinical outcomes.
Replaced outdated intermediate basal insulin and sliding scale short acting insulin practices with the newly identifiable concept of Basal Bolus insulin (i.e., insulin Glargine as a basal insulin, and rapid acting Lispro as post meal and correction factor bolus insulin).
Removed sliding scale regular insulin from pharmacy ordering for better physiologic hyperglycemia control.
Changed nursing practice of administrating insulin prior to meals, to the more accurate method of adjusting the meal time dose based on what the patient actually ate.
Changed unnecessary Food and Nutrition department practice of ordering evening snacks for all diabetic patients to selective physician-ordered snacks.
Implemented non-intensive care unit (ICU) hyperglycemia insulin therapy in adult diabetic patients who are eating.
Established insulin protocol order sets in the electronic medical record.
Formed a Diabetes Quality & Safety Steering Committee and unit-based nursing “Train the Trainer” program.
Developed physician and nurse quick reference, pocket-sized fact sheets on new insulin management protocols.
Changed hypoglycemia treatment targets from 60mg/dL to 70mg/dL, according to the American Diabetes Association (ADA) and American Association of Clinical Endocrinologist (AACE) guidelines.
Added glycosylated hemoglobin test (HgbA1c) lab order to all insulin protocols for patients with an admission glucose above 180mg/dL or if not drawn in the last month to better manage patient’s medications upon discharge.

Results

Summary of Results / Lessons Learned / Next Steps

We used a consistent, evidence-based approach to create standardized insulin protocols to normalize and standardize the management of hyperglycemia in hospitalized adult diabetes patients. This approach significantly lowered the incidence of hyperglycemia from 62 percent to 46 percent of inpatient days with a reading above 200mg/dL, without significantly affecting hypoglycemia incidence (10.4 percent to 10.8 percent).

Lessons Learned

Managing hyperglycemia in the adult hospitalized patient through house-wide implementation of insulin protocols has significantly decreased hyperglycemia without increasing hypoglycemia episodes. Physicians, nurses, pharmacists, data analysts and many other ancillary staff have been vital in the success of managing hyperglycemia through embracing change, commitment to the protocols, feedback, clinical outcomes and enthusiasm. Loyola University Health System has planned a half-day seminar to share our success with other hospitals and health care providers.
Gain a strong commitment from senior leadership. Their support of both cultural and medical practice change was vital to the implementation and compliance of the project.
Identify the key people who will be directly involved in the process of change. A strong team that feels empowered will embrace change, ensuring compliance and target deadlines for protocol implementation.
Do your research, review scientific literature and adopt evidence-based practices that benefit your patient the most through standardized procedures.
Establish a communication process that is clear, concise, and to the point. Be sure that everyone involved has the information necessary to implement protocol change in an educated and professional manner.
Establish education opportunities, both mandatory and optional, including: education blitzes, ongoing inservices, meetings, hospital publications and written information. Train experts who are enthusiastic and passionate about the project to get your message out.
Share you knowledge and success, both inside and out. Publish results, present at seminars, write abstracts, and submit storyboard proposals that can help others succeed.
Reinforce the project aims with those in your institution that are already familiar, and introduce the aims to others not familiar with the process. This can be done at an annual Quality & Safety Fair, or through your institution’s publications.
Don’t be afraid of change or to fail. Change through ongoing measurement, feedback, and analysis is good and necessary when trying to deliver quality of care which is both safe and cost effective.

Contact Information

Rita A. Vercruysse, RN, MPH,
Medicine Case Manager Health Services
Loyola University Health System
rvercru@lumc.edu