Diabetes care in the hospital: Is there clinical inertia?

Abstract

BACKGROUND Effective control of hospital glucose improves outcomes, but little is known about hospital management of diabetes. OBJECTIVE Assess hospital‐based diabetes care delivery. DESIGN Retrospective chart review. SETTING Academic teaching hospital. PATIENTS Inpatients with a discharge diagnosis of diabetes or hyperglycemia were selected from electronic records. A random sample (5%, n = 90) was selected for chart review. MEASUREMENTS We determined the percentage of patients with diabetes or hyperglycemia documented in admission, daily progress, and discharge notes. We determined the proportion of cases with glucose levels documented in daily progress notes and with changes in hyperglycemia therapy recorded. The frequency of hypoglycemic and hyperglycemic events was also determined. RESULTS A diabetes diagnosis was recorded at admission in 96% of patients with preexisting disease, but daily progress notes mentioned diabetes in only 62% of cases and 60% of discharge notes; just 20% of discharges indicated a plan for diabetes follow‐up. Most patients (86%) had bedside glucose measurements ordered, but progress notes tracked values for only 53%, and only 52% had a documented assessment of glucose severity. Hypoglycemic events were rare (11% of patients had at least one bedside glucose < 70 mg/dL), but hyperglycemia was common (71% of cases had at least one bedside glucose > 200 mg/dL). Despite the frequency of hyperglycemia, only 34% of patients had their therapy changed. CONCLUSIONS Practitioners were often aware of diabetes at admission, but the problem was often overlooked during hospitalization. The low rate of documentation and therapeutic change suggests the need for interventions to improve provider awareness and enhance inpatient diabetes care. Journal of Hospital Medicine 2006;3:151–160. © 2006 Society of Hospital Medicine.

Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

“…[14][15][16] Clinical inertia is defined as the failure to intensify therapy when needed. 17 We first described clinical inertia in the hospital with regards to insulin administration in 2006, 18 with further evidence found subsequently. 19 Others have also observed clinical inertia in the treatment of inpatient diabetes.…”

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

“…In general medicine and surgery services, however, hyperglycemia is frequently overlooked and inadequately addressed. Several reports from academic institutions have shown that most patients are treated with SSI and that basal insulin is prescribed in less than one-half of patients (16,17). Few clinical trials have focused on the optimal management of inpatient hyperglycemia in the noncritical setting.…”

Control glicémico de pacientes diabéticos hospitalizados en un Servicio de Medicina Interna

“…Estudios similares publicados muestran cifras comparables a nuestra realidad; Schnniper et al, en un estudio prospectivo de 107 pacientes diabéticos en una unidad de medicina no crítica, publicado el año 2006, reporta 76% de pacientes con glicemias sobre 180 mg/dl y 11% de pacientes con un episodio de glicemia inferior a 60 mg/dl 20 ; un estudio de 44 hospitales de Estados Unidos de Norteamérica muestra 77% de pacientes con glicemias superiores a 200 mg/dl, y 12% de episodios de hipoglicemia bajo 60 mg/dl 21 . Sin duda, el control glicémico previo a la hospitalización tiene que ver con la evolución del paciente; sin embargo, también se han invocado factores como la inercia clínica, es decir, la falta de toma de decisiones respecto de la hiper o hipoglicemia, a la tolerancia ante cifras elevadas como grandes responsables de esta situación 5,22 Control glicémico en diabéticos hospitalizados en camas no críticas -I. Solís et al estos hechos. Nuestro trabajo no profundiza en la toma de decisiones ni en diversos esquemas de tratamiento con insulina, aunque el uso de escalas (sliding scales) de insulina cristalina cada 6 horas es una práctica habitual y muy arraigada en nuestra cultura médica y tiene que ver con grandes fluctuaciones glicémicas y un demostrado mayor riesgo de descontrol metabólico 8 .…”

“…XXIX Congreso Chileno de Medicina Interna, Santiago de Chile, 2007). Esta proporción es coincidente con la descrita por otros autores 4,5 y en el sistema público nacional 6 . En los pacientes diabéticos se invierte el doble de los recursos que en los no diabéticos en cuanto a farmacia, insumos y recursos de personal involucrados 7 .…”