Impact of hyperglycemia on morbidity and mortality, length of hospitalization and rates of re-hospitalization in a general hospital setting in Brazil

Abstract

BackgroundHyperglycemia in hospitalized patients is known to be related to a higher incidence of clinical and surgical complications and poorer outcomes. Adequate glycemic control and earlier diagnosis of type 2 diabetes during hospitalization are cost-effective measures.MethodsThis prospective cohort study was designed to determine the impact of hyperglycemia on morbidity and mortality in a general hospital setting during a 3-month period by reviewing patients' records. The primary purposes of this trial were to verify that hyperglycemia was diagnosed properly and sufficiently early and that it was managed during the hospital stay; we also aimed to evaluate the relationship between in-hospital hyperglycemia control and outcomes such as complications during the hospital stay, extent of hospitalization, frequency of re-hospitalization, death rates and number of days in the ICU (Intensive Care Unit) after admission. Statistical analyses utilized the Kruskall-Wallis complemented by the "a posteriori" d.m.s. test, Spearman correlation and Chi-squared test, with a level of significance of 5% (p < 0.05).ResultsWe reviewed 779 patient records that fulfilled inclusion criteria. The patients were divided into 5 groups: group (1) diabetic with normal glycemic levels according to American Diabetes Association criteria for in-hospital patients (n = 123); group (2) diabetics with hyperglycemia (n = 76); group (3) non-diabetics with hyperglycemia (n = 225); group (4)diabetics and non-diabetics with persistent hyperglycemia during 3 consecutive days (n = 57) and group (5) those with normal glucose control (n = 298). Compared to patients in groups 1 and 5, patients in groups 2, 3 and 4 had significantly higher mortality rates (17.7% vs. 2.8%) and Intensive Care Unit admissions with complications (23.3% vs. 4.5%). Patients in group 4 had the longest hospitalizations (mean 15.5 days), and group 5 had the lowest re-hospitalization rate (mean of 1.28 hospitalizations). Only 184 (51.4%) hyperglycemic patients had received treatment. An insulin "sliding-scale" alone was the most frequent treatment used, and there was a wide variation in glucose target medical prescriptions. Intra Venous insulin infusion was used in 3.8% of patients in the ICU. Glycohemoglobin(A1C) was measured in 11 patients(2.2%).ConclusionsHospital hyperglycemia was correlated with, among other parameters, morbidity/mortality, length of hospitalization and number of re-hospitalizations. Most patients did not have their glycemic levels measured at the hospital; despite the high number of hyperglycemic patients not diagnosed as diabetics, A1C was not frequently measured. Even when patients are assessed for hyperglycemia, they were not treated properly.

Assessing the relationship between admission glucose levels, subsequent length of hospital stay, readmission and mortality

“…Overall, these results reflect similar poor rates of follow up elsewhere. 6 The authors recognise the limitations of this study, in that it was not possible to determine long-term glycaemic control by measuring the level of glycosylated haemoglobin (HbA 1c ) for each admission. Further study in this area would help determine whether the duration of hyperglycaemia affects length of hospitalisation and 28-day outcomes.…”

“…Poor rates of checking blood glucose on admission have been seen in other studies and have been attributed to a low value being placed on its monitoring. 6 However, this study adds weight to the argument for routine testing of blood glucose on admission on economic grounds due to the impact and saving that it can have through predictions of length of stay and short-term prognostication.…”

“…Other centres have highlighted the poor rate of follow up in such individuals. 6 The Norfolk and Norwich University Hospital is a large teaching hospital with a geographical catchment area of about 2,000 square miles and a population of about 600,000 people. The Elsie Bertram Diabetes Centre based at the hospital provides care to nearly 4,000 registered patients, largely those with complex and/or insulin-treated diabetes.…”

Elevated serum glucose levels and survival after acute heart failure: A population-based perspective

“…26,27 In a study of 1886 critically ill patients who were hospitalized at a community teaching hospital in Atlanta, Georgia, 26% had a history of DM and 12% had hyperglycaemia. 27 Patients with hyperglycaemia, as measured by an admission or in-hospital fasting blood glucose level of ⩾ 126 mg/ dL or a random blood glucose level of ⩾ 200 mg/dL on two or more determinations had a higher risk for intensive care unit (ICU) admission, longer hospital stay, higher risk of discharge to extended care and higher in-hospital death rates than persons with either DM or normal serum glucose levels.…”

Clinical Outcomes Associated with Use of Subcutaneous Sliding Scale Insulin Compared to Other Insulin Regimens in Hospitalized Patients

“…Type 2 diabetes can be defined as an impaired utilization or insufficient amount of insulin that is produced by the pancreas which progresses slowly over time. Uncontrolled diabetes in majority of hospitalized patients is associated with increased risk of morbidity and mortality, increased the length of hospital stay and re-hospitalization rate [4] [5] [6].…”