Improvement in Inpatient Glycemic Care: Pathways to Quality

Abstract

The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.

Comparison of an Electronic Glycemic Management System Versus Provider-Managed Subcutaneous Basal Bolus Insulin Therapy in the Hospital Setting

“…Several commercially available programs have FDA clearance and have been studied for efficacy and safety for intravenous (IV) insulin guidance in hospitalized patients including Glucommander™ (Glytec, Waltham, MA), EndoTool System™ (MD Scientific LLC, Charlotte, NC), and GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA). [10][11][12][13][14][15][16][17] These technologies are now expanding to include subcutaneous (SubQ) insulin therapy. Glucommander and EndoTool System are FDA cleared for SubQ insulin therapy in US hospitals and GlucoTab™ (Joanneum Research GmbH, Graz, Austria) is currently being investigated in clinical trails.…”

“…Several commercially available programs have FDA clearance and have been studied for efficacy and safety for intravenous (IV) insulin guidance in hospitalized patients including Glucommander™ (Glytec, Waltham, MA), EndoTool System™ (MD Scientific LLC, Charlotte, NC), and GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA). 10 -17…”

Effectiveness of standardised preoperative assessment and patient instructions on admission blood glucose for patients with diabetes undergoing orthopaedic surgery at a tertiary referral hospital

“…It is somewhat validating that, subsequent to our improvement efforts, work has been published with more definitive, explicit recommendations for insulin dosing in the perioperative period very consistent with our approach 1. In addition to the challenges around evidence for clear targets and insulin management, establishing a clear link to clinical outcomes has been even more elusive which made physician buy-in even more difficult 25. In spite of these barriers, the increased number of blood glucose tests for patients without diabetes supports a high rate of implementation of the standard work.…”

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia

“…Although blood glucose is a discrete value, extracting these data from the EHR with the appropriate relevant clinical information was technically complex. Also, our inability to establish a direct link to clinical outcomes, although not surprising, 37 increased the challenge of obtaining buy-in from providers and staff. Finally, some of our interventions required changes in the EHR or other information technology input.…”