Curtiss B. Cook, MD

The prevalence of diabetes mellitus continues to increase, now affecting almost 26 million people in the United States alone.[1] Hospitalizations associated with diabetes also continue to rise,[2] and nearly 50% of the $174 billion annual costs related to diabetes care in the United States are for inpatient hospital stays.[3] In recent years, inpatient glucose control has received considerable attention, and consensus statements for glucose targets have been published.[4, 5, 6]

A number of developments support the rationale for tracking and reporting inpatient glucose control. For instance, there are clinical scenarios where treatment of hyperglycemia has been shown to lead to better patient outcomes.[6, 7, 8, 9] Second, several organizations have recognized the value of better inpatient glucose management and have developed educational resources to assist practitioners and their institutions toward achieving that goal.[10, 11, 12, 13, 14] Finally, pay‐for‐performance requirements are emerging that are relevant to inpatient diabetes management.[15, 16]

Reports on the status of inpatient glucose control in large samples of US hospitals are now becoming available, and their findings suggest differences on the basis of hospital size, hospital type, and geographic location.[17, 18] However, these reports represent cross‐sectional studies, and little is known about trends in hospital glucose control over time. To determine whether changes were occurring, we obtained inpatient point‐of‐care blood glucose (POC‐BG) data from 126 hospitals for January to December 2009 and compared these with glycemic control data collected from the same hospitals for January to December 2007,[19] separately analyzing measurements from the intensive care unit (ICU) and the non‐intensive care unit (non‐ICU).

METHODS

RESULTS

Changes in Glycemic Control

For 2007, we analyzed a total of 12,541,929 POC‐BG measurements for 1,010,705 patients, and for 2009, we analyzed a total of 10,659,418 measurements for 656,206 patients. For ICU patients, a mean of 4.6 POC‐BG measurements per day was obtained in 2009 compared to a mean of 4.7 POC‐BG measurements per day in 2007. For non‐ICU patients, the POC‐BG mean was 3.1 per day in 2009 vs 2.9 per day in 2007.

For non‐ICU data, the patient‐day‐weighted mean POC‐BG values decreased in 2009 by 5 mg/dL compared with the 2007 values (154 mg/dL vs 159 mg/dL, respectively; P < 0.001), and were clinically unchanged in the ICU data (167 mg/dL vs 166 mg/dL, respectively; P < 0.001). For non‐ICU data, the proportion of patient‐day‐weighted mean POC‐BG values in any hyperglycemia category decreased in 2009 compared with those in 2007 among all patients (all P < 0.001) (Figure 1). For the ICU data, there was no significant difference (all P > 0.20; not shown) from 2007 to 2009.

Figure 1

In the ICU data, 2.9% of patient days on average had at least 1 POC‐BG value <70 mg/dL in both 2007 and 2009 (P = 0.67). There were fewer patient days with values <40 mg/dL in 2009 (1.1%) compared to 2007 (1.4%) in the ICU (P < 0.001). In the non‐ICU data, the mean percentage of patient days with a value <70 mg/dL was higher in 2009 (5.1%) than in 2007 (4.7%) (P < 0.001); however, there were actually fewer patient days in 2009 on average with a value <40 mg/dL (0.84% vs 1.1% for 2009 vs 2007; P < 0.001).

DISCUSSION

Optimal management of hospital hyperglycemia is now advocated by a number of professional societies and organizations.[10, 11, 12, 13] One of the next major tasks in the area of inpatient diabetes management will be how to identify and evaluate changes in glycemic control among US hospitals over time. Respondents to a recent survey of hospitals indicated that most institutions are now attempting to initiate quality improvement programs for the management of inpatients with diabetes.[21] These initiatives may translate into objective changes that could be monitored on a national level. However, few data exist on trends in glucose control in US hospitals. In our analysis, POC‐BG data from 126 hospitals collected in 2009 were compared to data obtained from the same hospitals in 2007. Our findings, and the methods of data collection and analysis described previously,[18, 19] demonstrate how such data can be used as a national benchmarking process for inpatient glucose control.

At all levels of hyperglycemia, significant decreases in patient‐day‐weighted mean values were found in non‐ICU data but not in ICU data. During the time these data were collected, recommendations about glucose targets in the critically ill were in a state of flux.[22, 23, 24, 25, 26, 27] Thus, the lack of hyperglycemia improvement in the ICU data between 2007 and 2009 may reflect the reluctance of providers to aggressively manage hyperglycemia because of recent reports linking increased mortality to tight glucose control.[25, 28, 29, 30] The differences in patient‐day‐weighted mean glucose values detected in the non‐ICU data between the 2 analytic periods were statistically significant, but were otherwise small and may not have clinical implications as far as an association with improved patient outcomes. Ongoing longitudinal analysis is required to establish whether these improvements in non‐ICU glucose control will persist over time.

Changes in glycemic control between the 2 periods were also noted when data were stratified according to hospital characteristics. Differences in glucose control in ICU data were not consistently better or worse, but varied by category of hospital characteristics (hospital size, hospital type, and geographic region). Other than academic hospitals and hospitals in the West, changes in the ICU data were small and likely do not have clinical importance. Analysis of non‐ICU data, however, showed consistent improvement within all 3 categories. Some hospital characteristics did change between the 2 study periods: there were fewer hospitals with <200 beds, more hospitals with 200 to 299 beds, a decrease in hospitals identified as rural, and an increase in hospitals designated as urban. Our previous analyses have indicated that hospital characteristics should be considered when examining national inpatient glucose data.[18, 19] In this analysis there was a statistically significant interaction between the year for which data were analyzed and each category of hospital characteristics. It is unclear how these evolving characteristics could have impacted inpatient glucose control. A change in hospital characteristics may in fact represent a change in resources to manage inpatient hyperglycemia. Future studies with nationally aggregated inpatient glucose data that assess longitudinal changes in glucose data may also have to account for variations in hospital characteristics over time in addition to the characteristics of the hospitals themselves.

Differences in hypoglycemia frequency, as calculated as the proportion of patient hospital days, were also detected. In the ICU data, the percentage of days with at least 1 value <70 mg/dL was similar between 2007 and 2009, but the proportion of days with at least 1 value <40 mg/dL was less in 2009, suggesting that institutions as a whole in this analysis may have been more focused on reducing the frequency of severe hypoglycemia. However, in the non‐ICU, there were more days in 2009 with a value <70 mg/dL, but fewer with a value <40 mg/dL. In noncritically ill patients, institutions likely continue to attempt to find the best balance between optimizing glycemic control while minimizing the risk of hypoglycemia. It should be pointed out, however, that overall, the frequency of hypoglycemia, particularly severe hypoglycemia, was quite low in this analysis, as it has been in our previous reports.[18, 19] An examination of hypoglycemia frequency by hospital characteristic to evaluate differences in this metric would be of interest in a future analysis.

The limitations of these data have been previously outlined,[18, 19] and they include the lack of patient‐level data such as demographics and the lack of information on diagnoses that allow adjustment of comparisons by the severity of illness. Moreover, without detailed treatment‐specific information (such as type of insulin protocol), one cannot establish the basis for longitudinal differences in glucose control. Volunteer‐dependent hospital involvement that creates selection bias may skew data toward those who are aware that they are witnessing a successful reduction in hyperglycemia. Finally, POC‐BG may not be the optimal method for assessing glycemic control. The limitations of current methods of evaluating inpatient glycemic control were recently reviewed.[31] Nonetheless, POC‐BG measurements remain the richest source of data on hospital hyperglycemia because of their widespread use and large sample size. A data warehouse of nearly 600 hospitals now exists,[18] which will permit future longitudinal analyses of glucose control in even larger samples.

Despite such limitations, our findings do represent the first analysis of trends in glucose control in a large cross‐section of US hospitals. Over 2 years, non‐ICU hyperglycemia improved among hospitals of all sizes and types and in all regions, whereas similar improvement did not occur in ICU hyperglycemia. Continued analysis will determine whether these trends continue. For those hospitals that are achieving better glucose control in non‐ICU patients, more information is needed on how they are accomplishing this so that protocols can be standardized and disseminated.

The prevalence of diabetes mellitus continues to increase, now affecting almost 26 million people in the United States alone.[1] Hospitalizations associated with diabetes also continue to rise,[2] and nearly 50% of the $174 billion annual costs related to diabetes care in the United States are for inpatient hospital stays.[3] In recent years, inpatient glucose control has received considerable attention, and consensus statements for glucose targets have been published.[4, 5, 6]

A number of developments support the rationale for tracking and reporting inpatient glucose control. For instance, there are clinical scenarios where treatment of hyperglycemia has been shown to lead to better patient outcomes.[6, 7, 8, 9] Second, several organizations have recognized the value of better inpatient glucose management and have developed educational resources to assist practitioners and their institutions toward achieving that goal.[10, 11, 12, 13, 14] Finally, pay‐for‐performance requirements are emerging that are relevant to inpatient diabetes management.[15, 16]

Reports on the status of inpatient glucose control in large samples of US hospitals are now becoming available, and their findings suggest differences on the basis of hospital size, hospital type, and geographic location.[17, 18] However, these reports represent cross‐sectional studies, and little is known about trends in hospital glucose control over time. To determine whether changes were occurring, we obtained inpatient point‐of‐care blood glucose (POC‐BG) data from 126 hospitals for January to December 2009 and compared these with glycemic control data collected from the same hospitals for January to December 2007,[19] separately analyzing measurements from the intensive care unit (ICU) and the non‐intensive care unit (non‐ICU).

METHODS

RESULTS

Changes in Glycemic Control

For 2007, we analyzed a total of 12,541,929 POC‐BG measurements for 1,010,705 patients, and for 2009, we analyzed a total of 10,659,418 measurements for 656,206 patients. For ICU patients, a mean of 4.6 POC‐BG measurements per day was obtained in 2009 compared to a mean of 4.7 POC‐BG measurements per day in 2007. For non‐ICU patients, the POC‐BG mean was 3.1 per day in 2009 vs 2.9 per day in 2007.

For non‐ICU data, the patient‐day‐weighted mean POC‐BG values decreased in 2009 by 5 mg/dL compared with the 2007 values (154 mg/dL vs 159 mg/dL, respectively; P < 0.001), and were clinically unchanged in the ICU data (167 mg/dL vs 166 mg/dL, respectively; P < 0.001). For non‐ICU data, the proportion of patient‐day‐weighted mean POC‐BG values in any hyperglycemia category decreased in 2009 compared with those in 2007 among all patients (all P < 0.001) (Figure 1). For the ICU data, there was no significant difference (all P > 0.20; not shown) from 2007 to 2009.

Figure 1

In the ICU data, 2.9% of patient days on average had at least 1 POC‐BG value <70 mg/dL in both 2007 and 2009 (P = 0.67). There were fewer patient days with values <40 mg/dL in 2009 (1.1%) compared to 2007 (1.4%) in the ICU (P < 0.001). In the non‐ICU data, the mean percentage of patient days with a value <70 mg/dL was higher in 2009 (5.1%) than in 2007 (4.7%) (P < 0.001); however, there were actually fewer patient days in 2009 on average with a value <40 mg/dL (0.84% vs 1.1% for 2009 vs 2007; P < 0.001).

DISCUSSION

Optimal management of hospital hyperglycemia is now advocated by a number of professional societies and organizations.[10, 11, 12, 13] One of the next major tasks in the area of inpatient diabetes management will be how to identify and evaluate changes in glycemic control among US hospitals over time. Respondents to a recent survey of hospitals indicated that most institutions are now attempting to initiate quality improvement programs for the management of inpatients with diabetes.[21] These initiatives may translate into objective changes that could be monitored on a national level. However, few data exist on trends in glucose control in US hospitals. In our analysis, POC‐BG data from 126 hospitals collected in 2009 were compared to data obtained from the same hospitals in 2007. Our findings, and the methods of data collection and analysis described previously,[18, 19] demonstrate how such data can be used as a national benchmarking process for inpatient glucose control.

At all levels of hyperglycemia, significant decreases in patient‐day‐weighted mean values were found in non‐ICU data but not in ICU data. During the time these data were collected, recommendations about glucose targets in the critically ill were in a state of flux.[22, 23, 24, 25, 26, 27] Thus, the lack of hyperglycemia improvement in the ICU data between 2007 and 2009 may reflect the reluctance of providers to aggressively manage hyperglycemia because of recent reports linking increased mortality to tight glucose control.[25, 28, 29, 30] The differences in patient‐day‐weighted mean glucose values detected in the non‐ICU data between the 2 analytic periods were statistically significant, but were otherwise small and may not have clinical implications as far as an association with improved patient outcomes. Ongoing longitudinal analysis is required to establish whether these improvements in non‐ICU glucose control will persist over time.

Changes in glycemic control between the 2 periods were also noted when data were stratified according to hospital characteristics. Differences in glucose control in ICU data were not consistently better or worse, but varied by category of hospital characteristics (hospital size, hospital type, and geographic region). Other than academic hospitals and hospitals in the West, changes in the ICU data were small and likely do not have clinical importance. Analysis of non‐ICU data, however, showed consistent improvement within all 3 categories. Some hospital characteristics did change between the 2 study periods: there were fewer hospitals with <200 beds, more hospitals with 200 to 299 beds, a decrease in hospitals identified as rural, and an increase in hospitals designated as urban. Our previous analyses have indicated that hospital characteristics should be considered when examining national inpatient glucose data.[18, 19] In this analysis there was a statistically significant interaction between the year for which data were analyzed and each category of hospital characteristics. It is unclear how these evolving characteristics could have impacted inpatient glucose control. A change in hospital characteristics may in fact represent a change in resources to manage inpatient hyperglycemia. Future studies with nationally aggregated inpatient glucose data that assess longitudinal changes in glucose data may also have to account for variations in hospital characteristics over time in addition to the characteristics of the hospitals themselves.

Differences in hypoglycemia frequency, as calculated as the proportion of patient hospital days, were also detected. In the ICU data, the percentage of days with at least 1 value <70 mg/dL was similar between 2007 and 2009, but the proportion of days with at least 1 value <40 mg/dL was less in 2009, suggesting that institutions as a whole in this analysis may have been more focused on reducing the frequency of severe hypoglycemia. However, in the non‐ICU, there were more days in 2009 with a value <70 mg/dL, but fewer with a value <40 mg/dL. In noncritically ill patients, institutions likely continue to attempt to find the best balance between optimizing glycemic control while minimizing the risk of hypoglycemia. It should be pointed out, however, that overall, the frequency of hypoglycemia, particularly severe hypoglycemia, was quite low in this analysis, as it has been in our previous reports.[18, 19] An examination of hypoglycemia frequency by hospital characteristic to evaluate differences in this metric would be of interest in a future analysis.

The limitations of these data have been previously outlined,[18, 19] and they include the lack of patient‐level data such as demographics and the lack of information on diagnoses that allow adjustment of comparisons by the severity of illness. Moreover, without detailed treatment‐specific information (such as type of insulin protocol), one cannot establish the basis for longitudinal differences in glucose control. Volunteer‐dependent hospital involvement that creates selection bias may skew data toward those who are aware that they are witnessing a successful reduction in hyperglycemia. Finally, POC‐BG may not be the optimal method for assessing glycemic control. The limitations of current methods of evaluating inpatient glycemic control were recently reviewed.[31] Nonetheless, POC‐BG measurements remain the richest source of data on hospital hyperglycemia because of their widespread use and large sample size. A data warehouse of nearly 600 hospitals now exists,[18] which will permit future longitudinal analyses of glucose control in even larger samples.

Despite such limitations, our findings do represent the first analysis of trends in glucose control in a large cross‐section of US hospitals. Over 2 years, non‐ICU hyperglycemia improved among hospitals of all sizes and types and in all regions, whereas similar improvement did not occur in ICU hyperglycemia. Continued analysis will determine whether these trends continue. For those hospitals that are achieving better glucose control in non‐ICU patients, more information is needed on how they are accomplishing this so that protocols can be standardized and disseminated.

The prevalence of diabetes mellitus continues to increase, now affecting almost 26 million people in the United States alone.[1] Hospitalizations associated with diabetes also continue to rise,[2] and nearly 50% of the $174 billion annual costs related to diabetes care in the United States are for inpatient hospital stays.[3] In recent years, inpatient glucose control has received considerable attention, and consensus statements for glucose targets have been published.[4, 5, 6]

A number of developments support the rationale for tracking and reporting inpatient glucose control. For instance, there are clinical scenarios where treatment of hyperglycemia has been shown to lead to better patient outcomes.[6, 7, 8, 9] Second, several organizations have recognized the value of better inpatient glucose management and have developed educational resources to assist practitioners and their institutions toward achieving that goal.[10, 11, 12, 13, 14] Finally, pay‐for‐performance requirements are emerging that are relevant to inpatient diabetes management.[15, 16]

Reports on the status of inpatient glucose control in large samples of US hospitals are now becoming available, and their findings suggest differences on the basis of hospital size, hospital type, and geographic location.[17, 18] However, these reports represent cross‐sectional studies, and little is known about trends in hospital glucose control over time. To determine whether changes were occurring, we obtained inpatient point‐of‐care blood glucose (POC‐BG) data from 126 hospitals for January to December 2009 and compared these with glycemic control data collected from the same hospitals for January to December 2007,[19] separately analyzing measurements from the intensive care unit (ICU) and the non‐intensive care unit (non‐ICU).

METHODS

RESULTS

Changes in Glycemic Control

For 2007, we analyzed a total of 12,541,929 POC‐BG measurements for 1,010,705 patients, and for 2009, we analyzed a total of 10,659,418 measurements for 656,206 patients. For ICU patients, a mean of 4.6 POC‐BG measurements per day was obtained in 2009 compared to a mean of 4.7 POC‐BG measurements per day in 2007. For non‐ICU patients, the POC‐BG mean was 3.1 per day in 2009 vs 2.9 per day in 2007.

For non‐ICU data, the patient‐day‐weighted mean POC‐BG values decreased in 2009 by 5 mg/dL compared with the 2007 values (154 mg/dL vs 159 mg/dL, respectively; P < 0.001), and were clinically unchanged in the ICU data (167 mg/dL vs 166 mg/dL, respectively; P < 0.001). For non‐ICU data, the proportion of patient‐day‐weighted mean POC‐BG values in any hyperglycemia category decreased in 2009 compared with those in 2007 among all patients (all P < 0.001) (Figure 1). For the ICU data, there was no significant difference (all P > 0.20; not shown) from 2007 to 2009.

Figure 1

In the ICU data, 2.9% of patient days on average had at least 1 POC‐BG value <70 mg/dL in both 2007 and 2009 (P = 0.67). There were fewer patient days with values <40 mg/dL in 2009 (1.1%) compared to 2007 (1.4%) in the ICU (P < 0.001). In the non‐ICU data, the mean percentage of patient days with a value <70 mg/dL was higher in 2009 (5.1%) than in 2007 (4.7%) (P < 0.001); however, there were actually fewer patient days in 2009 on average with a value <40 mg/dL (0.84% vs 1.1% for 2009 vs 2007; P < 0.001).

DISCUSSION

Optimal management of hospital hyperglycemia is now advocated by a number of professional societies and organizations.[10, 11, 12, 13] One of the next major tasks in the area of inpatient diabetes management will be how to identify and evaluate changes in glycemic control among US hospitals over time. Respondents to a recent survey of hospitals indicated that most institutions are now attempting to initiate quality improvement programs for the management of inpatients with diabetes.[21] These initiatives may translate into objective changes that could be monitored on a national level. However, few data exist on trends in glucose control in US hospitals. In our analysis, POC‐BG data from 126 hospitals collected in 2009 were compared to data obtained from the same hospitals in 2007. Our findings, and the methods of data collection and analysis described previously,[18, 19] demonstrate how such data can be used as a national benchmarking process for inpatient glucose control.

At all levels of hyperglycemia, significant decreases in patient‐day‐weighted mean values were found in non‐ICU data but not in ICU data. During the time these data were collected, recommendations about glucose targets in the critically ill were in a state of flux.[22, 23, 24, 25, 26, 27] Thus, the lack of hyperglycemia improvement in the ICU data between 2007 and 2009 may reflect the reluctance of providers to aggressively manage hyperglycemia because of recent reports linking increased mortality to tight glucose control.[25, 28, 29, 30] The differences in patient‐day‐weighted mean glucose values detected in the non‐ICU data between the 2 analytic periods were statistically significant, but were otherwise small and may not have clinical implications as far as an association with improved patient outcomes. Ongoing longitudinal analysis is required to establish whether these improvements in non‐ICU glucose control will persist over time.

Changes in glycemic control between the 2 periods were also noted when data were stratified according to hospital characteristics. Differences in glucose control in ICU data were not consistently better or worse, but varied by category of hospital characteristics (hospital size, hospital type, and geographic region). Other than academic hospitals and hospitals in the West, changes in the ICU data were small and likely do not have clinical importance. Analysis of non‐ICU data, however, showed consistent improvement within all 3 categories. Some hospital characteristics did change between the 2 study periods: there were fewer hospitals with <200 beds, more hospitals with 200 to 299 beds, a decrease in hospitals identified as rural, and an increase in hospitals designated as urban. Our previous analyses have indicated that hospital characteristics should be considered when examining national inpatient glucose data.[18, 19] In this analysis there was a statistically significant interaction between the year for which data were analyzed and each category of hospital characteristics. It is unclear how these evolving characteristics could have impacted inpatient glucose control. A change in hospital characteristics may in fact represent a change in resources to manage inpatient hyperglycemia. Future studies with nationally aggregated inpatient glucose data that assess longitudinal changes in glucose data may also have to account for variations in hospital characteristics over time in addition to the characteristics of the hospitals themselves.

Differences in hypoglycemia frequency, as calculated as the proportion of patient hospital days, were also detected. In the ICU data, the percentage of days with at least 1 value <70 mg/dL was similar between 2007 and 2009, but the proportion of days with at least 1 value <40 mg/dL was less in 2009, suggesting that institutions as a whole in this analysis may have been more focused on reducing the frequency of severe hypoglycemia. However, in the non‐ICU, there were more days in 2009 with a value <70 mg/dL, but fewer with a value <40 mg/dL. In noncritically ill patients, institutions likely continue to attempt to find the best balance between optimizing glycemic control while minimizing the risk of hypoglycemia. It should be pointed out, however, that overall, the frequency of hypoglycemia, particularly severe hypoglycemia, was quite low in this analysis, as it has been in our previous reports.[18, 19] An examination of hypoglycemia frequency by hospital characteristic to evaluate differences in this metric would be of interest in a future analysis.

The limitations of these data have been previously outlined,[18, 19] and they include the lack of patient‐level data such as demographics and the lack of information on diagnoses that allow adjustment of comparisons by the severity of illness. Moreover, without detailed treatment‐specific information (such as type of insulin protocol), one cannot establish the basis for longitudinal differences in glucose control. Volunteer‐dependent hospital involvement that creates selection bias may skew data toward those who are aware that they are witnessing a successful reduction in hyperglycemia. Finally, POC‐BG may not be the optimal method for assessing glycemic control. The limitations of current methods of evaluating inpatient glycemic control were recently reviewed.[31] Nonetheless, POC‐BG measurements remain the richest source of data on hospital hyperglycemia because of their widespread use and large sample size. A data warehouse of nearly 600 hospitals now exists,[18] which will permit future longitudinal analyses of glucose control in even larger samples.

Despite such limitations, our findings do represent the first analysis of trends in glucose control in a large cross‐section of US hospitals. Over 2 years, non‐ICU hyperglycemia improved among hospitals of all sizes and types and in all regions, whereas similar improvement did not occur in ICU hyperglycemia. Continued analysis will determine whether these trends continue. For those hospitals that are achieving better glucose control in non‐ICU patients, more information is needed on how they are accomplishing this so that protocols can be standardized and disseminated.

Ongoing surveillance indicates that the number of hospitalizations involving patients with a diagnosis of diabetes mellitus is increasing in the United States.1, 2 Hospitalized patients with hyperglycemia have worse outcomes (eg, greater mortality, longer length of stay, and more infections) than those without high glucose levels.3, 4 The rate of adverse outcomes associated with hyperglycemia can be decreased with improved management.3, 4 Consequently, the American Diabetes Association and the American College of Endocrinology advocate lower glucose targets for all hospitalized patients regardless of whether they have a known diagnosis of diabetes.3, 4

Practitioners continue to debate the exact glucose targets that should be attained for inpatients;5, 6 however, there is more to inpatient hyperglycemia management than just trying to achieve a specific glucose range. Caring for patients with diabetes in the hospital is complex and must also encompass patient safety, but many practitioners perceive a state of glycemic chaos in the hospital.7 Because many physicians frequently overlook diabetes and glucose control in the hospital, appropriate therapeutic responses to hyperglycemia do not occur.810 National,11, 12 state,13 and specialty societies3, 4, 14 are working toimprove care for hospitalized patients with hyperglycemia. A recent consensus conference emphasized the need to develop broad‐based educational programs to increase awareness about the importance of inpatient glycemic control and to develop a standardized set of tools for hospitals to use to improve care.4 However, there is ongoing concern about the slow pace at which hospitals are implementing recommendations about glycemic control.4

Intensive and prolonged educational efforts about the importance of glycemic control will be essential ingredients of any quality improvement effort designed to create glycemic order out of glycemic chaos in the hospital.15 Before educational interventions and policies directed at improving the management of hyperglycemia in hospitalized patients can be developed, institutions need to gain a better understanding of how clinicians view the importance of inpatient glucose control and which barriers they perceive as constraints to their ability to care for inpatients with hyperglycemia.

At Atlanta Medical Center (AMC), the large urban teaching hospital where this study was conducted, the glucose control team detected resistance to changes that were implemented to improve the hospital's quality of glycemic control;16 this observation led to a desire to gain more information about practitioner attitudes regarding inpatient glucose control management. Data on practitioner attitudes and beliefs about inpatient hyperglycemia are only now emerging and are limited to studies from a single institution.17, 18 Thus, additional studies are needed to determine whether findings from these first studies are applicable to other types of hospital settings that have different inpatient populations. To gain additional insight into clinician beliefs about inpatient glucose control, we adapted a previously published questionnaire17, 18 and used it to survey resident physicians training at AMC.

METHODS

RESULTS

Beliefs About Glucose Targets and Hypoglycemia

When asked to indicate the target glucose levels that they would like to achieve, most resident physicians indicated that good glycemic control meant a target range of 80 to 110 mg/dL for critically‐ill patients and for perioperative patients. For non‐critically‐ill patients, targets were split between a target range of 80 to 110 mg/dL and 111 to 180 mg/dL. Trainees rarely suggested targets greater than 180 mg/dL (Table 1).

Most respondents believed that they were achieving their glycemic goals in 41% to 60% of their patients (Fig. 1A). More than half (56%) perceived that they were achieving their glucose targets in more than 40% of their diabetes patients. When asked at what glucose level they first considered the patient to be hypoglycemic, half of the respondents chose <60 mg/dL (Fig. 1B), although some had even lower cutoffs before they considered someone to have a diagnosis of hypoglycemia.

Figure 1

DISCUSSION

In recent years national and regional organizations have focused greater attention on the management of hyperglycemia among inpatient populations by introducing and promoting guidelines for better care.3, 4, 1114 A consensus conference in 2006 urged hospitals to move rapidly to make euglycemia a goal for all inpatients and to make patient safety in glycemic control a reality. 20 AMC has already taken some steps toward understanding and improving its hospital‐based care of hyperglycemia, including understanding the mortality associated with hyperglycemia within the institution and implementing a novel insulin infusion algorithm.16, 19

Before hospitals can develop high‐quality improvement and educational programs focused on inpatient hyperglycemia, they will need more insight into their clinicians' views on inpatient glycemic control and the perceived barriers to successful treatment of hyperglycemia. However, the only data that have been published about practitioner attitudes on inpatient diabetes and glycemic control are from a single institution.17, 18 Thus, analyses should be broadened to include different types of hospital settings to determine common beliefs on the topic.

AMC is very different from the hospital facility where earlier studies on physician attitudes about inpatient glucose management were conducted. Whereas the site of the earlier studies is located in the Southwest and has a diabetes inpatient population that is primarily white, AMC is an urban hospital in the Southeast whose diabetes inpatient population is primarily minority.21 Despite the institutional, geographic, and patient population differences, however, results of the current survey suggest that there may be similar beliefs among practitioners about inpatient glucose management as well as common knowledge deficits that can be targeted for educational interventions.

Similar to the resident physicians surveyed in previous studies,17, 18 AMC resident physicians considered diabetes to be a substantial part of their inpatient practices: 56% of respondents believed that more than 40% of their inpatients had a diagnosis of diabetes. Historically, the prevalence at AMC of hyperglycemia has been about 38% and the prevalence of diabetes about 26%.19 The increasing number of hospital dismissals attributable to diabetes likely has increased the inpatient prevalence of the disease at AMC as well, but very high rates perceived by some residents (eg, 81%‐100%) are likely not accurate. Nonetheless, this perception of such a large burden of diabetes clearly substantiates the need to provide pertinent information and essential tools to clinicians for successful management of hyperglycemia in hospital patients. We also established that most AMC resident physicians who were surveyed believed that good glucose control was very important in situations relating to critical illness or noncritical illness. For most respondents, good glucose control was also very important in the perioperative period. This finding suggests that the trainees understand the importance of good glucose control in such situations.

In keeping with findings from previous studies,17, 18 respondents to this survey indicated glucose targets that would be well within currently existing guidelines.3, 4 Glucose management training might be improved by conveying whether actual glucose outcomes match residents' perceived achievement of glycemic control.

Insulin is the recommended treatment for inpatient hyperglycemia,3, 4 yet residents' responses reflected concern about insulin use. The most commonly noted issues, cited with equal frequency, were related to insulin use: knowing what insulin type or regimen works best and fluctuating insulin demands related to stress/concomitantly used medications. Our survey did not evaluate whether residents had different degrees of comfort with different subcutaneous insulin programs (eg, sliding scale versus basal‐bolus). Future surveys could be modified to better hone in on evaluating self‐perceived competencies in these areas.

Given the increasing complexity of insulin therapy, resident physicians' perception of insulin administration as the top barrier to inpatient glucose management may not be surprising.17, 18 The number of insulin analogs has increased in recent years. Moreover, numerous intravenous insulin algorithms are available.22, 23 Errors in insulin administration are among the most frequently occurring medication errors in hospitals.24 To address patient safety and medical system errors in the fields of diabetes and endocrinology, the American College of Endocrinology published a position statement on the topic in 2005.25 Guidelines about when to initiate insulin therapy, how to choose from numerous insulin treatment options, and how to adjust therapy in response to rapidly changing clinical situations will have to be integrated into any effort to improve inpatient glucose management. One study indicated that an educational process focused on teaching residents about insulin therapy can be successful.26

Clinician fear of hypoglycemia is often perceived as the primary obstacle to successful control of inpatient glucose levels;3, 27 however, this was not the chief concern expressed by either AMC resident physicians or by practitioners surveyed in prior studies.17, 18 Emerging data suggest that hypoglycemia in the hospital is actually uncommon.21, 28 As hospitals intensify hyperglycemia management efforts, hypoglycemia and concerns about its frequency of occurrence will most likely increase. No consensus exists regarding the number of hypoglycemic events that are acceptable in a hospitalized patient. The American Diabetes Association Workgroup on Hypoglycemia has defined hypoglycemia as an (arterialized venous) plasma glucose concentration of less than or equal to 70 mg/dL.29 As a group, residents surveyed for the current study were not consistent in their definition of hypoglycemia.

The residents at AMC also reported potential obstacles to care besides insulin management that suggest system‐based problems. Unpredictable timing of patient procedures and unpredictable changes in patient diet and mealtimes were among the 5 most frequently cited concerns. Other concerns included patient not in hospital long enough to adequately control glucose and shift changes and cross‐coverage lead to inconsistent management. These findings are identical to those of prior studies17, 18 and suggest system‐based problems as common barriers to inpatient glucose management. Some of these obstacles, such as length of hospital stay and timing of procedures, would be difficult to reengineer. However, other aspects, such as adjusting therapy to mealtimes and ensuring standardization of treatment across shifts, could be addressed through institution‐wide education and changes in policies.

As in previous studies, another major finding that emerged from this survey was the lack of resident physician familiarity with existing policies and procedures related to inpatient glucose management. AMC has a longstanding policy on hypoglycemia management and has preprinted order sets for subcutaneous insulin. AMC has implemented a revised insulin infusion algorithm16 in addition to a policy and an order set for the use of insulin pumps.30 There are no specific data on how many patients receiving insulin pump therapy are hospitalized, but these patients are likely to be encountered only rarely in the hospital setting. Hence, it may not be surprising that residents are unfamiliar with policies pertaining to inpatient insulin pump use, but they should at least be aware that guidance is available. One of the first steps to enhancing and standardizing hospital glucose management may simply be to make certain that clinicians are familiar with policies that are already in place within the institution.

A limitation of this study is the small sample size. The results of the present study should not be extrapolated to nonresident medical staff such as attending physicians, but the questionnaire could be adapted, with minor modifications, to investigate how other health care professionals view inpatient glucose management. In addition, the questionnaire could be used to assess changes in beliefs over time. Future studies should be designed to correlate resident perceptions about their inpatient diabetes care and actual practice patterns.

More surveys such as the one reported on here need to be conducted in additional institutions in order to expand our understanding of practitioner attitudes regarding inpatient diabetes care. Data from the current study and previous ones suggest that practitioners share beliefs, knowledge deficits, and perceived barriers about inpatient glucose management. Most AMC resident physicians recognized the importance of good glucose control and set target glucose ranges consistent with existing guidelines. Knowledge deficits may be addressed by developing training programs that specifically spotlight insulin use in the hospital. As a first step to quality improvement, training programs should focus on familiarizing staff with existing institutional policies and procedures pertaining to hospital hyperglycemia. In addition, hospitals need to design strategies to overcome perceived and actual barriers to care so that they can realize the desired improvement in the management of hyperglycemia in their patients. We have already begun the development and implementation of educational modules directed at addressing many of these important issues.

Ongoing surveillance indicates that the number of hospitalizations involving patients with a diagnosis of diabetes mellitus is increasing in the United States.1, 2 Hospitalized patients with hyperglycemia have worse outcomes (eg, greater mortality, longer length of stay, and more infections) than those without high glucose levels.3, 4 The rate of adverse outcomes associated with hyperglycemia can be decreased with improved management.3, 4 Consequently, the American Diabetes Association and the American College of Endocrinology advocate lower glucose targets for all hospitalized patients regardless of whether they have a known diagnosis of diabetes.3, 4

Practitioners continue to debate the exact glucose targets that should be attained for inpatients;5, 6 however, there is more to inpatient hyperglycemia management than just trying to achieve a specific glucose range. Caring for patients with diabetes in the hospital is complex and must also encompass patient safety, but many practitioners perceive a state of glycemic chaos in the hospital.7 Because many physicians frequently overlook diabetes and glucose control in the hospital, appropriate therapeutic responses to hyperglycemia do not occur.810 National,11, 12 state,13 and specialty societies3, 4, 14 are working toimprove care for hospitalized patients with hyperglycemia. A recent consensus conference emphasized the need to develop broad‐based educational programs to increase awareness about the importance of inpatient glycemic control and to develop a standardized set of tools for hospitals to use to improve care.4 However, there is ongoing concern about the slow pace at which hospitals are implementing recommendations about glycemic control.4

Intensive and prolonged educational efforts about the importance of glycemic control will be essential ingredients of any quality improvement effort designed to create glycemic order out of glycemic chaos in the hospital.15 Before educational interventions and policies directed at improving the management of hyperglycemia in hospitalized patients can be developed, institutions need to gain a better understanding of how clinicians view the importance of inpatient glucose control and which barriers they perceive as constraints to their ability to care for inpatients with hyperglycemia.

At Atlanta Medical Center (AMC), the large urban teaching hospital where this study was conducted, the glucose control team detected resistance to changes that were implemented to improve the hospital's quality of glycemic control;16 this observation led to a desire to gain more information about practitioner attitudes regarding inpatient glucose control management. Data on practitioner attitudes and beliefs about inpatient hyperglycemia are only now emerging and are limited to studies from a single institution.17, 18 Thus, additional studies are needed to determine whether findings from these first studies are applicable to other types of hospital settings that have different inpatient populations. To gain additional insight into clinician beliefs about inpatient glucose control, we adapted a previously published questionnaire17, 18 and used it to survey resident physicians training at AMC.

METHODS

RESULTS

Beliefs About Glucose Targets and Hypoglycemia

When asked to indicate the target glucose levels that they would like to achieve, most resident physicians indicated that good glycemic control meant a target range of 80 to 110 mg/dL for critically‐ill patients and for perioperative patients. For non‐critically‐ill patients, targets were split between a target range of 80 to 110 mg/dL and 111 to 180 mg/dL. Trainees rarely suggested targets greater than 180 mg/dL (Table 1).

Most respondents believed that they were achieving their glycemic goals in 41% to 60% of their patients (Fig. 1A). More than half (56%) perceived that they were achieving their glucose targets in more than 40% of their diabetes patients. When asked at what glucose level they first considered the patient to be hypoglycemic, half of the respondents chose <60 mg/dL (Fig. 1B), although some had even lower cutoffs before they considered someone to have a diagnosis of hypoglycemia.

Figure 1

DISCUSSION

In recent years national and regional organizations have focused greater attention on the management of hyperglycemia among inpatient populations by introducing and promoting guidelines for better care.3, 4, 1114 A consensus conference in 2006 urged hospitals to move rapidly to make euglycemia a goal for all inpatients and to make patient safety in glycemic control a reality. 20 AMC has already taken some steps toward understanding and improving its hospital‐based care of hyperglycemia, including understanding the mortality associated with hyperglycemia within the institution and implementing a novel insulin infusion algorithm.16, 19

Before hospitals can develop high‐quality improvement and educational programs focused on inpatient hyperglycemia, they will need more insight into their clinicians' views on inpatient glycemic control and the perceived barriers to successful treatment of hyperglycemia. However, the only data that have been published about practitioner attitudes on inpatient diabetes and glycemic control are from a single institution.17, 18 Thus, analyses should be broadened to include different types of hospital settings to determine common beliefs on the topic.

AMC is very different from the hospital facility where earlier studies on physician attitudes about inpatient glucose management were conducted. Whereas the site of the earlier studies is located in the Southwest and has a diabetes inpatient population that is primarily white, AMC is an urban hospital in the Southeast whose diabetes inpatient population is primarily minority.21 Despite the institutional, geographic, and patient population differences, however, results of the current survey suggest that there may be similar beliefs among practitioners about inpatient glucose management as well as common knowledge deficits that can be targeted for educational interventions.

Similar to the resident physicians surveyed in previous studies,17, 18 AMC resident physicians considered diabetes to be a substantial part of their inpatient practices: 56% of respondents believed that more than 40% of their inpatients had a diagnosis of diabetes. Historically, the prevalence at AMC of hyperglycemia has been about 38% and the prevalence of diabetes about 26%.19 The increasing number of hospital dismissals attributable to diabetes likely has increased the inpatient prevalence of the disease at AMC as well, but very high rates perceived by some residents (eg, 81%‐100%) are likely not accurate. Nonetheless, this perception of such a large burden of diabetes clearly substantiates the need to provide pertinent information and essential tools to clinicians for successful management of hyperglycemia in hospital patients. We also established that most AMC resident physicians who were surveyed believed that good glucose control was very important in situations relating to critical illness or noncritical illness. For most respondents, good glucose control was also very important in the perioperative period. This finding suggests that the trainees understand the importance of good glucose control in such situations.

In keeping with findings from previous studies,17, 18 respondents to this survey indicated glucose targets that would be well within currently existing guidelines.3, 4 Glucose management training might be improved by conveying whether actual glucose outcomes match residents' perceived achievement of glycemic control.

Insulin is the recommended treatment for inpatient hyperglycemia,3, 4 yet residents' responses reflected concern about insulin use. The most commonly noted issues, cited with equal frequency, were related to insulin use: knowing what insulin type or regimen works best and fluctuating insulin demands related to stress/concomitantly used medications. Our survey did not evaluate whether residents had different degrees of comfort with different subcutaneous insulin programs (eg, sliding scale versus basal‐bolus). Future surveys could be modified to better hone in on evaluating self‐perceived competencies in these areas.

Given the increasing complexity of insulin therapy, resident physicians' perception of insulin administration as the top barrier to inpatient glucose management may not be surprising.17, 18 The number of insulin analogs has increased in recent years. Moreover, numerous intravenous insulin algorithms are available.22, 23 Errors in insulin administration are among the most frequently occurring medication errors in hospitals.24 To address patient safety and medical system errors in the fields of diabetes and endocrinology, the American College of Endocrinology published a position statement on the topic in 2005.25 Guidelines about when to initiate insulin therapy, how to choose from numerous insulin treatment options, and how to adjust therapy in response to rapidly changing clinical situations will have to be integrated into any effort to improve inpatient glucose management. One study indicated that an educational process focused on teaching residents about insulin therapy can be successful.26

Clinician fear of hypoglycemia is often perceived as the primary obstacle to successful control of inpatient glucose levels;3, 27 however, this was not the chief concern expressed by either AMC resident physicians or by practitioners surveyed in prior studies.17, 18 Emerging data suggest that hypoglycemia in the hospital is actually uncommon.21, 28 As hospitals intensify hyperglycemia management efforts, hypoglycemia and concerns about its frequency of occurrence will most likely increase. No consensus exists regarding the number of hypoglycemic events that are acceptable in a hospitalized patient. The American Diabetes Association Workgroup on Hypoglycemia has defined hypoglycemia as an (arterialized venous) plasma glucose concentration of less than or equal to 70 mg/dL.29 As a group, residents surveyed for the current study were not consistent in their definition of hypoglycemia.

The residents at AMC also reported potential obstacles to care besides insulin management that suggest system‐based problems. Unpredictable timing of patient procedures and unpredictable changes in patient diet and mealtimes were among the 5 most frequently cited concerns. Other concerns included patient not in hospital long enough to adequately control glucose and shift changes and cross‐coverage lead to inconsistent management. These findings are identical to those of prior studies17, 18 and suggest system‐based problems as common barriers to inpatient glucose management. Some of these obstacles, such as length of hospital stay and timing of procedures, would be difficult to reengineer. However, other aspects, such as adjusting therapy to mealtimes and ensuring standardization of treatment across shifts, could be addressed through institution‐wide education and changes in policies.

As in previous studies, another major finding that emerged from this survey was the lack of resident physician familiarity with existing policies and procedures related to inpatient glucose management. AMC has a longstanding policy on hypoglycemia management and has preprinted order sets for subcutaneous insulin. AMC has implemented a revised insulin infusion algorithm16 in addition to a policy and an order set for the use of insulin pumps.30 There are no specific data on how many patients receiving insulin pump therapy are hospitalized, but these patients are likely to be encountered only rarely in the hospital setting. Hence, it may not be surprising that residents are unfamiliar with policies pertaining to inpatient insulin pump use, but they should at least be aware that guidance is available. One of the first steps to enhancing and standardizing hospital glucose management may simply be to make certain that clinicians are familiar with policies that are already in place within the institution.

A limitation of this study is the small sample size. The results of the present study should not be extrapolated to nonresident medical staff such as attending physicians, but the questionnaire could be adapted, with minor modifications, to investigate how other health care professionals view inpatient glucose management. In addition, the questionnaire could be used to assess changes in beliefs over time. Future studies should be designed to correlate resident perceptions about their inpatient diabetes care and actual practice patterns.

More surveys such as the one reported on here need to be conducted in additional institutions in order to expand our understanding of practitioner attitudes regarding inpatient diabetes care. Data from the current study and previous ones suggest that practitioners share beliefs, knowledge deficits, and perceived barriers about inpatient glucose management. Most AMC resident physicians recognized the importance of good glucose control and set target glucose ranges consistent with existing guidelines. Knowledge deficits may be addressed by developing training programs that specifically spotlight insulin use in the hospital. As a first step to quality improvement, training programs should focus on familiarizing staff with existing institutional policies and procedures pertaining to hospital hyperglycemia. In addition, hospitals need to design strategies to overcome perceived and actual barriers to care so that they can realize the desired improvement in the management of hyperglycemia in their patients. We have already begun the development and implementation of educational modules directed at addressing many of these important issues.

Ongoing surveillance indicates that the number of hospitalizations involving patients with a diagnosis of diabetes mellitus is increasing in the United States.1, 2 Hospitalized patients with hyperglycemia have worse outcomes (eg, greater mortality, longer length of stay, and more infections) than those without high glucose levels.3, 4 The rate of adverse outcomes associated with hyperglycemia can be decreased with improved management.3, 4 Consequently, the American Diabetes Association and the American College of Endocrinology advocate lower glucose targets for all hospitalized patients regardless of whether they have a known diagnosis of diabetes.3, 4

Practitioners continue to debate the exact glucose targets that should be attained for inpatients;5, 6 however, there is more to inpatient hyperglycemia management than just trying to achieve a specific glucose range. Caring for patients with diabetes in the hospital is complex and must also encompass patient safety, but many practitioners perceive a state of glycemic chaos in the hospital.7 Because many physicians frequently overlook diabetes and glucose control in the hospital, appropriate therapeutic responses to hyperglycemia do not occur.810 National,11, 12 state,13 and specialty societies3, 4, 14 are working toimprove care for hospitalized patients with hyperglycemia. A recent consensus conference emphasized the need to develop broad‐based educational programs to increase awareness about the importance of inpatient glycemic control and to develop a standardized set of tools for hospitals to use to improve care.4 However, there is ongoing concern about the slow pace at which hospitals are implementing recommendations about glycemic control.4

Intensive and prolonged educational efforts about the importance of glycemic control will be essential ingredients of any quality improvement effort designed to create glycemic order out of glycemic chaos in the hospital.15 Before educational interventions and policies directed at improving the management of hyperglycemia in hospitalized patients can be developed, institutions need to gain a better understanding of how clinicians view the importance of inpatient glucose control and which barriers they perceive as constraints to their ability to care for inpatients with hyperglycemia.

At Atlanta Medical Center (AMC), the large urban teaching hospital where this study was conducted, the glucose control team detected resistance to changes that were implemented to improve the hospital's quality of glycemic control;16 this observation led to a desire to gain more information about practitioner attitudes regarding inpatient glucose control management. Data on practitioner attitudes and beliefs about inpatient hyperglycemia are only now emerging and are limited to studies from a single institution.17, 18 Thus, additional studies are needed to determine whether findings from these first studies are applicable to other types of hospital settings that have different inpatient populations. To gain additional insight into clinician beliefs about inpatient glucose control, we adapted a previously published questionnaire17, 18 and used it to survey resident physicians training at AMC.

METHODS

RESULTS

Beliefs About Glucose Targets and Hypoglycemia

When asked to indicate the target glucose levels that they would like to achieve, most resident physicians indicated that good glycemic control meant a target range of 80 to 110 mg/dL for critically‐ill patients and for perioperative patients. For non‐critically‐ill patients, targets were split between a target range of 80 to 110 mg/dL and 111 to 180 mg/dL. Trainees rarely suggested targets greater than 180 mg/dL (Table 1).

Most respondents believed that they were achieving their glycemic goals in 41% to 60% of their patients (Fig. 1A). More than half (56%) perceived that they were achieving their glucose targets in more than 40% of their diabetes patients. When asked at what glucose level they first considered the patient to be hypoglycemic, half of the respondents chose <60 mg/dL (Fig. 1B), although some had even lower cutoffs before they considered someone to have a diagnosis of hypoglycemia.

Figure 1

DISCUSSION

In recent years national and regional organizations have focused greater attention on the management of hyperglycemia among inpatient populations by introducing and promoting guidelines for better care.3, 4, 1114 A consensus conference in 2006 urged hospitals to move rapidly to make euglycemia a goal for all inpatients and to make patient safety in glycemic control a reality. 20 AMC has already taken some steps toward understanding and improving its hospital‐based care of hyperglycemia, including understanding the mortality associated with hyperglycemia within the institution and implementing a novel insulin infusion algorithm.16, 19

Before hospitals can develop high‐quality improvement and educational programs focused on inpatient hyperglycemia, they will need more insight into their clinicians' views on inpatient glycemic control and the perceived barriers to successful treatment of hyperglycemia. However, the only data that have been published about practitioner attitudes on inpatient diabetes and glycemic control are from a single institution.17, 18 Thus, analyses should be broadened to include different types of hospital settings to determine common beliefs on the topic.

AMC is very different from the hospital facility where earlier studies on physician attitudes about inpatient glucose management were conducted. Whereas the site of the earlier studies is located in the Southwest and has a diabetes inpatient population that is primarily white, AMC is an urban hospital in the Southeast whose diabetes inpatient population is primarily minority.21 Despite the institutional, geographic, and patient population differences, however, results of the current survey suggest that there may be similar beliefs among practitioners about inpatient glucose management as well as common knowledge deficits that can be targeted for educational interventions.

Similar to the resident physicians surveyed in previous studies,17, 18 AMC resident physicians considered diabetes to be a substantial part of their inpatient practices: 56% of respondents believed that more than 40% of their inpatients had a diagnosis of diabetes. Historically, the prevalence at AMC of hyperglycemia has been about 38% and the prevalence of diabetes about 26%.19 The increasing number of hospital dismissals attributable to diabetes likely has increased the inpatient prevalence of the disease at AMC as well, but very high rates perceived by some residents (eg, 81%‐100%) are likely not accurate. Nonetheless, this perception of such a large burden of diabetes clearly substantiates the need to provide pertinent information and essential tools to clinicians for successful management of hyperglycemia in hospital patients. We also established that most AMC resident physicians who were surveyed believed that good glucose control was very important in situations relating to critical illness or noncritical illness. For most respondents, good glucose control was also very important in the perioperative period. This finding suggests that the trainees understand the importance of good glucose control in such situations.

In keeping with findings from previous studies,17, 18 respondents to this survey indicated glucose targets that would be well within currently existing guidelines.3, 4 Glucose management training might be improved by conveying whether actual glucose outcomes match residents' perceived achievement of glycemic control.

Insulin is the recommended treatment for inpatient hyperglycemia,3, 4 yet residents' responses reflected concern about insulin use. The most commonly noted issues, cited with equal frequency, were related to insulin use: knowing what insulin type or regimen works best and fluctuating insulin demands related to stress/concomitantly used medications. Our survey did not evaluate whether residents had different degrees of comfort with different subcutaneous insulin programs (eg, sliding scale versus basal‐bolus). Future surveys could be modified to better hone in on evaluating self‐perceived competencies in these areas.

Given the increasing complexity of insulin therapy, resident physicians' perception of insulin administration as the top barrier to inpatient glucose management may not be surprising.17, 18 The number of insulin analogs has increased in recent years. Moreover, numerous intravenous insulin algorithms are available.22, 23 Errors in insulin administration are among the most frequently occurring medication errors in hospitals.24 To address patient safety and medical system errors in the fields of diabetes and endocrinology, the American College of Endocrinology published a position statement on the topic in 2005.25 Guidelines about when to initiate insulin therapy, how to choose from numerous insulin treatment options, and how to adjust therapy in response to rapidly changing clinical situations will have to be integrated into any effort to improve inpatient glucose management. One study indicated that an educational process focused on teaching residents about insulin therapy can be successful.26

Clinician fear of hypoglycemia is often perceived as the primary obstacle to successful control of inpatient glucose levels;3, 27 however, this was not the chief concern expressed by either AMC resident physicians or by practitioners surveyed in prior studies.17, 18 Emerging data suggest that hypoglycemia in the hospital is actually uncommon.21, 28 As hospitals intensify hyperglycemia management efforts, hypoglycemia and concerns about its frequency of occurrence will most likely increase. No consensus exists regarding the number of hypoglycemic events that are acceptable in a hospitalized patient. The American Diabetes Association Workgroup on Hypoglycemia has defined hypoglycemia as an (arterialized venous) plasma glucose concentration of less than or equal to 70 mg/dL.29 As a group, residents surveyed for the current study were not consistent in their definition of hypoglycemia.

The residents at AMC also reported potential obstacles to care besides insulin management that suggest system‐based problems. Unpredictable timing of patient procedures and unpredictable changes in patient diet and mealtimes were among the 5 most frequently cited concerns. Other concerns included patient not in hospital long enough to adequately control glucose and shift changes and cross‐coverage lead to inconsistent management. These findings are identical to those of prior studies17, 18 and suggest system‐based problems as common barriers to inpatient glucose management. Some of these obstacles, such as length of hospital stay and timing of procedures, would be difficult to reengineer. However, other aspects, such as adjusting therapy to mealtimes and ensuring standardization of treatment across shifts, could be addressed through institution‐wide education and changes in policies.

As in previous studies, another major finding that emerged from this survey was the lack of resident physician familiarity with existing policies and procedures related to inpatient glucose management. AMC has a longstanding policy on hypoglycemia management and has preprinted order sets for subcutaneous insulin. AMC has implemented a revised insulin infusion algorithm16 in addition to a policy and an order set for the use of insulin pumps.30 There are no specific data on how many patients receiving insulin pump therapy are hospitalized, but these patients are likely to be encountered only rarely in the hospital setting. Hence, it may not be surprising that residents are unfamiliar with policies pertaining to inpatient insulin pump use, but they should at least be aware that guidance is available. One of the first steps to enhancing and standardizing hospital glucose management may simply be to make certain that clinicians are familiar with policies that are already in place within the institution.

A limitation of this study is the small sample size. The results of the present study should not be extrapolated to nonresident medical staff such as attending physicians, but the questionnaire could be adapted, with minor modifications, to investigate how other health care professionals view inpatient glucose management. In addition, the questionnaire could be used to assess changes in beliefs over time. Future studies should be designed to correlate resident perceptions about their inpatient diabetes care and actual practice patterns.

More surveys such as the one reported on here need to be conducted in additional institutions in order to expand our understanding of practitioner attitudes regarding inpatient diabetes care. Data from the current study and previous ones suggest that practitioners share beliefs, knowledge deficits, and perceived barriers about inpatient glucose management. Most AMC resident physicians recognized the importance of good glucose control and set target glucose ranges consistent with existing guidelines. Knowledge deficits may be addressed by developing training programs that specifically spotlight insulin use in the hospital. As a first step to quality improvement, training programs should focus on familiarizing staff with existing institutional policies and procedures pertaining to hospital hyperglycemia. In addition, hospitals need to design strategies to overcome perceived and actual barriers to care so that they can realize the desired improvement in the management of hyperglycemia in their patients. We have already begun the development and implementation of educational modules directed at addressing many of these important issues.

Diabetes confers a substantial burden on the hospital system. Diabetes is the fourth‐leading comorbid condition associated with any hospital discharge in the United States1. During 2001, for more than 500,000 patients discharged from U.S. hospitals diabetes was listed as the principal diagnosis and for more than 4 million it was listed as a codiagnosis.2, 3 Nearly one‐third of diabetes patients require at least 2 hospitalizations annually,4 and inpatient stays account for the largest proportion of direct medical expenses incurred by persons with the disease.5

Numerous studies have demonstrated that hyperglycemia is associated with adverse outcomes of hospitalized patients.68 However, studies have also confirmed that attention to lowering glucose levels in the hospital improves patient outcomes.7, 8 Although inpatients with known diabetes will likely constitute the largest and most visible percentage of those who will require treatment for high glucose, the recommendation to control glucose applies to all inpatients regardless of whether they have been diagnosed with diabetes prior to hospitalization or have manifested hyperglycemia only during the hospital stay.79

Now that the relationship between hyperglycemia and hospital outcomes is well established, the task of organizations that deliver care and set policy is to translate current recommendations of good glucose control into real‐world hospital settings. Quality improvement organizations are currently working toward developing and disseminating performance measures for control of inpatient hyperglycemia.10, 11 Although management of hospital hyperglycemia is often perceived as suboptimal,12 actual data are limited and are based on review of small numbers of charts,1315 and information is even sparser on the pharmacologic strategies being used to treat inpatient hyperglycemia. Before educational programs and policies can be developed, individual hospital systems need to gain more insight into how hyperglycemia is being managed in the hospital.

We reported previously the results of a review of a small number of charts (n = 90) of patients hospitalized with diabetes. The findings from this review suggested there was clinical inertia in glycemia management in the hospital.15 Clinical inertia was originally described in relationship to diabetes care in the outpatient setting and was defined as a failure to perform a needed service or make a change in treatment when indicated.16, 17 Since the original description, additional reports have documented the problem of clinical inertia, but these have all been based on experiences in the outpatient setting.1822 To our knowledge, our previous report was the first to question whether clinical inertia occurred in the hospital environment. In addition, we described the negative therapeutic momentuma deintensification of treatment despite ongoing hyperglycemia15. However, our prior study examined only a small number of cases and did not include detailed data on pharmacologic treatment for hyperglycemia. Therefore, we expanded our analysis using an information systems rather than a chart reviewbased methodology to assess the status of hyperglycemia management in our hospital.

METHODS

RESULTS

Glycemic Control

The median duration between admission and time of first bedside glucose measurement was 3.0 hours. Patients had an average of 19 bedside glucose measurements; the overall mean number of bedside measurements was 3.4 per day, 3.7 during the first 24‐hour period, and 3.4 during the last 24 hours of hospitalization. Nearly 25% of patients were hyperglycemic (bedside glucose > 200 mg/dL) during the first 24 hours of hospitalization (Fig. 1A), 20% had persistent hyperglycemia throughout the entire hospitalization (Fig. 1B), and 21% were hyperglycemic during the 24 hours before discharge (Fig. 1C), with some patients discharged with an average bedside glucose of at least 300 mg/dL during the 24 hours before discharge.

Figure 1

The incidence of hypoglycemic episodes was lower than that of hyperglycemic episodes: 21% of patients had at least 1 bedside glucose value less than 70 mg/dL, but 68% had at least 1 value greater than 200 mg/dL. The frequency of hypoglycemic measurements was low (Fig. 2A) compared with the frequency of hyperglycemic episodes (Fig. 2B).

Figure 2

Hyperglycemia Therapy

Most patients (72%) received subcutaneous insulin at some point during their hospital stay; 19% had no therapy, 9% had oral agents only, 26% had oral agents plus insulin, and 46% had insulin only. The proportion receiving no therapy decreased from 32% among patients whose BedGluc_avg was in the first tertile to 2% in the third tertile; the percentage of patients taking oral agents only decreased from 18% to 1%; the proportion taking oral agents plus insulin was 17% in the first tertile and 30% in the third; and the proportion of those taking insulin only was 32% in the first tertile and 66% in the third (Fig. 3). Thus, nearly all patients whose BedGluc_avg value was in the third tertile received insulin, either as monotherapy or in combination with oral agents.

Figure 3

Among insulin users, 58% received bolus‐only, 42% received basal‐bolus, and 1% received basal‐only injections. Because of the small proportion of basal‐only patients, we conducted analyses only of patients whose insulin treatment fell into 1 of the first 2 categories. The use of a basal‐bolus insulin program increased from 34% in patients whose BedGluc_avg was in the first tertile to 54% for those who had BedGluc_avg in the third tertile (P < .001; Fig. 4, left). Thus, although there was a greater transition to a more intensive insulin regimen with worsening hyperglycemia, a substantial number of patients (46%) whose BedGluc_avg was in the third tertile still did not have their insulin regimen intensified to a basal‐bolus program.

Figure 4

Fifty‐four percent of subcutaneous insulin users (N = 1680) had an increase in the amount of insulin administered between the first and last 24 hours of hospitalization (average increase, 17 U), 39% had a decrease (average decrease, 12 U), and 7% had no change. With rising hyperglycemia, more patients had their insulin increased by the time of discharge; 41% of persons who had BedGluc_avg values in the first tertile were on more insulin by the time of discharge, whereas 65% of those who had average glucose values in the third tertile had insulin increased (Fig. 4, right). However, the pattern of changes in the amount of administered insulin was heterogeneous, with increases, decreases, and no change occurring in all tertiles of BedGluc_avg (Fig. 3, right). Nearly 31% of patients whose BedGluc_avg values were in the third tertile actually had a decrease in insulin. This decrease occurred despite evidence of a low frequency of hypoglycemia (only 1.2 values < 70 mg/dL per 100 measurements per person) and a high frequency of hyperglycemia (55.4 values > 200 mg/dL per person per 100 measurements).

DISCUSSION

The number of diabetes‐associated hospital discharges has been climbing2, 3; our own data indicate an increase in the number of patients with diabetes as a proportion of the total number of discharged patients. A recent consensus advocates good glucose control in the hospital to optimize outcomes,79 and institutions need to begin the process of assessing their quality of inpatient hyperglycemia management as a first step to enhancing care.

There are no guidelines about which method of glucose measurement (ie, blood glucose or bedside glucose) should be used as the quality measure to evaluate glycemic control in hospital patients. Both blood and bedside glucose measurements have been used in outcomes studies.23, 24 We analyzed capillary bedside values measured by a method subjected to ongoing quality control oversight and stored in the electronic laboratory database. Bedside glucose measurements are typically obtained with far greater frequency than blood glucose measurements and therefore provide better insight into daily changes in glycemic control; in practice, clinicians rely on bedside values when assessing hyperglycemia and making therapeutic decisions.

There is also no consensus about what glucose metric should be used to assess the status of glycemic control in the hospital. Some studies have used single glucose values to examine the relationship between hyperglycemia and outcomes,25, 26 whereas others have used values averaged over various lengths of time.24, 27 To evaluate glucose control, we averaged capillary measurements in the first 24 hours of hospitalization (F24BedGluc_avg), the last 24 hours of hospitalization (L24BedGluc_avg), and for the entire LOS (BedGluc_avg), and we calculated the number of documented hyper‐ and hypoglycemic events. The measures we used to examine hyperglycemia would serve as useful benchmarks for following the progress of future institutional interventions directed at glucose control in hospitalized patients at our hospital.

A substantial number of our patients selected for analysis (ie, noncritically ill with LOS 3 days) were found to have sustained hyperglycemia at the beginning, during, and at the end of their hospital stay. We found very few instances of severe hypoglycemia (values < 50 or < 40 mg/dL), and the low frequency of hypoglycemia compared to that of hyperglycemia could encourage practitioners to be more aggressive in treating hyperglycemia. The high frequency of recorded bedside glucose compared with blood glucose measurements ( 3 per day), the ongoing patient surveillance by medical, nursing, and other staff members, and our institution's written hypoglycemia policy most likely minimize the number of unobserved, undocumented, or untreated hypoglycemic episodes. There are no data or recommendations about what would be an acceptable number of hypoglycemic episodes in the hospital.

Very little is known about the therapeutic strategies being applied to hyperglycemia in the hospital. Our data show that subcutaneous insulin (either alone or in combination with oral agents) was used at some point during hospitalization for nearly three‐fourths of noncritically patients who were in the hospital for 3 days or longer. Moreover, as hyperglycemia worsened, use of oral hypoglycemic agents declined, there was a shift toward greater use of a scheduled basal‐bolus insulin program, and a greater proportion of patients had more insulin administered.

Although these latter findings are encouraging and suggest that practitioners are responding to the severity of hyperglycemia, further examination of the data suggests that a substantial number of patients in the highest glucose tertile did not have insulin therapy intensified. Nearly half our patients whose glucose values were in the highest tertile were treated with short‐acting insulin aloneprobably an ineffective regimen23, 28or did not have more insulin administered. The higher doses administered were not likely solely a result of using more sliding‐scale insulin, as previous investigators actually found no correlation between intensity of the sliding scale and total daily insulin dose.14 Although evidence here is circumstantial (we did not examine changes in provider orders in response to glucose levels), these findings, together with those in our previous study15 and in another study,14 provide indirect evidence of clinical inertia in the hospital.

Beyond clinical inertia, however, there was evidence of negative therapeutic momentum: nearly one‐third of patients whose glucose was in the highest tertile had insulin decreased rather than increased, despite the low frequency of hypoglycemia and the high frequency of hyperglycemia. It is likely that even a single episode of hypoglycemia concerned practitioners, but the clinical response in these situations should be to investigate and correct the circumstances leading to the hypoglycemia, rather than to necessarily deintensify therapy in the face of continued hyperglycemia. The analysis of this larger data set corroborated our observations of clinical inertia and negative therapeutic momentum from an earlier study of chart reviews of a smaller patient sample.15

The variable application of insulin therapy to the treatment of hyperglycemia may be an indication of the level of comfort practitioners have about using this pharmacologic agent. A recently completed survey of resident physicians at our institution indicated that understanding how to use insulin was the most common barrier to successful management of inpatient hyperglycemia.29 These observations reinforce the need for institutions to develop standardized insulin order sets and develop programs to educate the staff on the use of insulin.

This study differs from our original analysis based on chart review in 4 ways. First, the sample size in our first study (n = 90) was small and derived from discharges from a single year (2003), whereas the sample in the present study spanned several years and included several thousand cases. Second, in our prior study we did not have detailed pharmacologic data on glucose management and how treatment approaches varied relative to severity of hyperglycemia. In general, there is very limited data on what therapeutic strategies are being applied to inpatient hyperglycemia, and this analysis of a large sample of cases provides more insight into how practitioners are managing glucose.

Third, we wanted to corroborate observations made in our previous report using a different methodologyin this instance, adapting existing information systems to assessment of inpatient diabetes care. For example, our last study was based on a limited number of glucose observations but suggested that the prevalence of hypoglycemia in our hospital was low compared with that of hyperglycemia; the present analysis of a very large number of glucose values confirmed these initial findings. In addition, use of information systems versus a chart review approach to assessing inpatient diabetes care corroborates our earlier suspicions about the presence of clinical inertia and negative therapeutic momentum in glucose management.

Fourth and finally, this study gave us experience with use of electronic records as a means to assess the status of inpatient diabetes care. Electronic data sources will likely be common tools to monitor quality of inpatient diabetes care and will likely figure prominently in future accreditation processes.10, 11 Unlike chart abstraction, which would require extensive man‐hours to extract data on few patients, use of electronic records allows examination of large numbers of hospital cases. Queries of information systems could be automated, and report cards potentially generated and feedback given to providers on the status of inpatient glycemic control. The industry is actively pursuing software development to assist hospitals in assessing the quality of inpatient glycemic control (eg, RALS‐TGCM, available at http:\\www.medicalautomation.com/RALS‐TGCM.html).

However, there are also limitations to using electronic records as the sole method of assessing inpatient diabetes care. For instance, retrospective review of electronic records does not allow assessment of reasons underlying decision‐making behavior of clinicians (eg, why they did or did not change therapy). Diabetes and hyperglycemia associated hospitalizations must be identified by discharge diagnosis codes, so some cases of diabetes and hyperglycemia were likely missed.30, 31 Recent guidelines propose preprandial targets for glucose in the hospital.8 It is not easy to determine from an electronic data source which is a preprandial bedside glucose and which is a postprandial bedside glucose. Pre‐ and postpyramidal glucose categories would be difficult to define even during prospective studies, given the varying nature of nutritional support (ie, enteral, parenteral) used in the hospital and the administration of continuous dextrose infusions. Some type of quality control, such as conducting reviews of small samples of randomly selected charts to see how they compare with the electronic data, will need to be conducted.

From electronic discharge data, we cannot establish who had preexisting diabetes, who was admitted with new‐onset diabetes, and who developed hyperglycemia as a result of the hospital stay. Our previous random chart review15 indicated it is likely that most (more than 90%) had an established diagnosis of diabetes before admission. However, the recommendation to treat hyperglycemia should apply to all patients regardless of whether they had diagnosed diabetes prior to hospitalization or manifested hyperglycemia only during the hospital stay.79

As hospitals move toward making efforts to improve performance related to treating inpatient hyperglycemia, they must be cognizant of the heterogeneity of the inpatient population and the challenges to managing hospital hyperglycemia before drawing conclusions about their management. Inpatients with hyperglycemia are a diverse group, comprising patients with preexisting diabetes, with previously undiagnosed diabetes, and stress‐caused hyperglycemia. The unpredictable timing of procedures, various and changing forms of nutritional support, and different levels of staff expertise all contribute to the challenges of managing inpatient hyperglycemia. Inpatient practitioners may be forced to attempt glycemic control catch‐up for hospitalized persons who had poor outpatient glucose control. Patients who have required a stay in the intensive care unit may have very different glycemic outcomes than those who have not. Patients whose LOS was short (< 3days) may have different glycemic outcomes than persons whose LOS was longer ( 3 days as defined here) because of the length of time practitioners have to work to control their hyperglycemia. These and other variables may have to be taken into account when developing and assessing the impact of interventions.

Despite these limitations, our analysis was helpful in providing direction for enhancing the care of hospitalized patients with hyperglycemia in our facility. For instance, our generalists and surgeons are the principal caretakers of noncritically ill patients with diabetes, and these practitioners could be targeted for the first continuing educational programs about inpatient care of hyperglycemia. In addition, institutional guidelines on when and how to initiate and change therapyparticularly insulincan be designed so that hyperglycemia in noncritically ill hospital patients can be managed more effectively. These and other ongoing educational initiatives are necessary to ensure delivery of the highest quality of inpatient glucose care.

Diabetes confers a substantial burden on the hospital system. Diabetes is the fourth‐leading comorbid condition associated with any hospital discharge in the United States1. During 2001, for more than 500,000 patients discharged from U.S. hospitals diabetes was listed as the principal diagnosis and for more than 4 million it was listed as a codiagnosis.2, 3 Nearly one‐third of diabetes patients require at least 2 hospitalizations annually,4 and inpatient stays account for the largest proportion of direct medical expenses incurred by persons with the disease.5

Numerous studies have demonstrated that hyperglycemia is associated with adverse outcomes of hospitalized patients.68 However, studies have also confirmed that attention to lowering glucose levels in the hospital improves patient outcomes.7, 8 Although inpatients with known diabetes will likely constitute the largest and most visible percentage of those who will require treatment for high glucose, the recommendation to control glucose applies to all inpatients regardless of whether they have been diagnosed with diabetes prior to hospitalization or have manifested hyperglycemia only during the hospital stay.79

Now that the relationship between hyperglycemia and hospital outcomes is well established, the task of organizations that deliver care and set policy is to translate current recommendations of good glucose control into real‐world hospital settings. Quality improvement organizations are currently working toward developing and disseminating performance measures for control of inpatient hyperglycemia.10, 11 Although management of hospital hyperglycemia is often perceived as suboptimal,12 actual data are limited and are based on review of small numbers of charts,1315 and information is even sparser on the pharmacologic strategies being used to treat inpatient hyperglycemia. Before educational programs and policies can be developed, individual hospital systems need to gain more insight into how hyperglycemia is being managed in the hospital.

We reported previously the results of a review of a small number of charts (n = 90) of patients hospitalized with diabetes. The findings from this review suggested there was clinical inertia in glycemia management in the hospital.15 Clinical inertia was originally described in relationship to diabetes care in the outpatient setting and was defined as a failure to perform a needed service or make a change in treatment when indicated.16, 17 Since the original description, additional reports have documented the problem of clinical inertia, but these have all been based on experiences in the outpatient setting.1822 To our knowledge, our previous report was the first to question whether clinical inertia occurred in the hospital environment. In addition, we described the negative therapeutic momentuma deintensification of treatment despite ongoing hyperglycemia15. However, our prior study examined only a small number of cases and did not include detailed data on pharmacologic treatment for hyperglycemia. Therefore, we expanded our analysis using an information systems rather than a chart reviewbased methodology to assess the status of hyperglycemia management in our hospital.

METHODS

RESULTS

Glycemic Control

The median duration between admission and time of first bedside glucose measurement was 3.0 hours. Patients had an average of 19 bedside glucose measurements; the overall mean number of bedside measurements was 3.4 per day, 3.7 during the first 24‐hour period, and 3.4 during the last 24 hours of hospitalization. Nearly 25% of patients were hyperglycemic (bedside glucose > 200 mg/dL) during the first 24 hours of hospitalization (Fig. 1A), 20% had persistent hyperglycemia throughout the entire hospitalization (Fig. 1B), and 21% were hyperglycemic during the 24 hours before discharge (Fig. 1C), with some patients discharged with an average bedside glucose of at least 300 mg/dL during the 24 hours before discharge.

Figure 1

The incidence of hypoglycemic episodes was lower than that of hyperglycemic episodes: 21% of patients had at least 1 bedside glucose value less than 70 mg/dL, but 68% had at least 1 value greater than 200 mg/dL. The frequency of hypoglycemic measurements was low (Fig. 2A) compared with the frequency of hyperglycemic episodes (Fig. 2B).

Figure 2

Hyperglycemia Therapy

Most patients (72%) received subcutaneous insulin at some point during their hospital stay; 19% had no therapy, 9% had oral agents only, 26% had oral agents plus insulin, and 46% had insulin only. The proportion receiving no therapy decreased from 32% among patients whose BedGluc_avg was in the first tertile to 2% in the third tertile; the percentage of patients taking oral agents only decreased from 18% to 1%; the proportion taking oral agents plus insulin was 17% in the first tertile and 30% in the third; and the proportion of those taking insulin only was 32% in the first tertile and 66% in the third (Fig. 3). Thus, nearly all patients whose BedGluc_avg value was in the third tertile received insulin, either as monotherapy or in combination with oral agents.

Figure 3

Among insulin users, 58% received bolus‐only, 42% received basal‐bolus, and 1% received basal‐only injections. Because of the small proportion of basal‐only patients, we conducted analyses only of patients whose insulin treatment fell into 1 of the first 2 categories. The use of a basal‐bolus insulin program increased from 34% in patients whose BedGluc_avg was in the first tertile to 54% for those who had BedGluc_avg in the third tertile (P < .001; Fig. 4, left). Thus, although there was a greater transition to a more intensive insulin regimen with worsening hyperglycemia, a substantial number of patients (46%) whose BedGluc_avg was in the third tertile still did not have their insulin regimen intensified to a basal‐bolus program.

Figure 4

Fifty‐four percent of subcutaneous insulin users (N = 1680) had an increase in the amount of insulin administered between the first and last 24 hours of hospitalization (average increase, 17 U), 39% had a decrease (average decrease, 12 U), and 7% had no change. With rising hyperglycemia, more patients had their insulin increased by the time of discharge; 41% of persons who had BedGluc_avg values in the first tertile were on more insulin by the time of discharge, whereas 65% of those who had average glucose values in the third tertile had insulin increased (Fig. 4, right). However, the pattern of changes in the amount of administered insulin was heterogeneous, with increases, decreases, and no change occurring in all tertiles of BedGluc_avg (Fig. 3, right). Nearly 31% of patients whose BedGluc_avg values were in the third tertile actually had a decrease in insulin. This decrease occurred despite evidence of a low frequency of hypoglycemia (only 1.2 values < 70 mg/dL per 100 measurements per person) and a high frequency of hyperglycemia (55.4 values > 200 mg/dL per person per 100 measurements).

DISCUSSION

The number of diabetes‐associated hospital discharges has been climbing2, 3; our own data indicate an increase in the number of patients with diabetes as a proportion of the total number of discharged patients. A recent consensus advocates good glucose control in the hospital to optimize outcomes,79 and institutions need to begin the process of assessing their quality of inpatient hyperglycemia management as a first step to enhancing care.

There are no guidelines about which method of glucose measurement (ie, blood glucose or bedside glucose) should be used as the quality measure to evaluate glycemic control in hospital patients. Both blood and bedside glucose measurements have been used in outcomes studies.23, 24 We analyzed capillary bedside values measured by a method subjected to ongoing quality control oversight and stored in the electronic laboratory database. Bedside glucose measurements are typically obtained with far greater frequency than blood glucose measurements and therefore provide better insight into daily changes in glycemic control; in practice, clinicians rely on bedside values when assessing hyperglycemia and making therapeutic decisions.

There is also no consensus about what glucose metric should be used to assess the status of glycemic control in the hospital. Some studies have used single glucose values to examine the relationship between hyperglycemia and outcomes,25, 26 whereas others have used values averaged over various lengths of time.24, 27 To evaluate glucose control, we averaged capillary measurements in the first 24 hours of hospitalization (F24BedGluc_avg), the last 24 hours of hospitalization (L24BedGluc_avg), and for the entire LOS (BedGluc_avg), and we calculated the number of documented hyper‐ and hypoglycemic events. The measures we used to examine hyperglycemia would serve as useful benchmarks for following the progress of future institutional interventions directed at glucose control in hospitalized patients at our hospital.

A substantial number of our patients selected for analysis (ie, noncritically ill with LOS 3 days) were found to have sustained hyperglycemia at the beginning, during, and at the end of their hospital stay. We found very few instances of severe hypoglycemia (values < 50 or < 40 mg/dL), and the low frequency of hypoglycemia compared to that of hyperglycemia could encourage practitioners to be more aggressive in treating hyperglycemia. The high frequency of recorded bedside glucose compared with blood glucose measurements ( 3 per day), the ongoing patient surveillance by medical, nursing, and other staff members, and our institution's written hypoglycemia policy most likely minimize the number of unobserved, undocumented, or untreated hypoglycemic episodes. There are no data or recommendations about what would be an acceptable number of hypoglycemic episodes in the hospital.

Very little is known about the therapeutic strategies being applied to hyperglycemia in the hospital. Our data show that subcutaneous insulin (either alone or in combination with oral agents) was used at some point during hospitalization for nearly three‐fourths of noncritically patients who were in the hospital for 3 days or longer. Moreover, as hyperglycemia worsened, use of oral hypoglycemic agents declined, there was a shift toward greater use of a scheduled basal‐bolus insulin program, and a greater proportion of patients had more insulin administered.

Although these latter findings are encouraging and suggest that practitioners are responding to the severity of hyperglycemia, further examination of the data suggests that a substantial number of patients in the highest glucose tertile did not have insulin therapy intensified. Nearly half our patients whose glucose values were in the highest tertile were treated with short‐acting insulin aloneprobably an ineffective regimen23, 28or did not have more insulin administered. The higher doses administered were not likely solely a result of using more sliding‐scale insulin, as previous investigators actually found no correlation between intensity of the sliding scale and total daily insulin dose.14 Although evidence here is circumstantial (we did not examine changes in provider orders in response to glucose levels), these findings, together with those in our previous study15 and in another study,14 provide indirect evidence of clinical inertia in the hospital.

Beyond clinical inertia, however, there was evidence of negative therapeutic momentum: nearly one‐third of patients whose glucose was in the highest tertile had insulin decreased rather than increased, despite the low frequency of hypoglycemia and the high frequency of hyperglycemia. It is likely that even a single episode of hypoglycemia concerned practitioners, but the clinical response in these situations should be to investigate and correct the circumstances leading to the hypoglycemia, rather than to necessarily deintensify therapy in the face of continued hyperglycemia. The analysis of this larger data set corroborated our observations of clinical inertia and negative therapeutic momentum from an earlier study of chart reviews of a smaller patient sample.15

The variable application of insulin therapy to the treatment of hyperglycemia may be an indication of the level of comfort practitioners have about using this pharmacologic agent. A recently completed survey of resident physicians at our institution indicated that understanding how to use insulin was the most common barrier to successful management of inpatient hyperglycemia.29 These observations reinforce the need for institutions to develop standardized insulin order sets and develop programs to educate the staff on the use of insulin.

This study differs from our original analysis based on chart review in 4 ways. First, the sample size in our first study (n = 90) was small and derived from discharges from a single year (2003), whereas the sample in the present study spanned several years and included several thousand cases. Second, in our prior study we did not have detailed pharmacologic data on glucose management and how treatment approaches varied relative to severity of hyperglycemia. In general, there is very limited data on what therapeutic strategies are being applied to inpatient hyperglycemia, and this analysis of a large sample of cases provides more insight into how practitioners are managing glucose.

Third, we wanted to corroborate observations made in our previous report using a different methodologyin this instance, adapting existing information systems to assessment of inpatient diabetes care. For example, our last study was based on a limited number of glucose observations but suggested that the prevalence of hypoglycemia in our hospital was low compared with that of hyperglycemia; the present analysis of a very large number of glucose values confirmed these initial findings. In addition, use of information systems versus a chart review approach to assessing inpatient diabetes care corroborates our earlier suspicions about the presence of clinical inertia and negative therapeutic momentum in glucose management.

Fourth and finally, this study gave us experience with use of electronic records as a means to assess the status of inpatient diabetes care. Electronic data sources will likely be common tools to monitor quality of inpatient diabetes care and will likely figure prominently in future accreditation processes.10, 11 Unlike chart abstraction, which would require extensive man‐hours to extract data on few patients, use of electronic records allows examination of large numbers of hospital cases. Queries of information systems could be automated, and report cards potentially generated and feedback given to providers on the status of inpatient glycemic control. The industry is actively pursuing software development to assist hospitals in assessing the quality of inpatient glycemic control (eg, RALS‐TGCM, available at http:\\www.medicalautomation.com/RALS‐TGCM.html).

However, there are also limitations to using electronic records as the sole method of assessing inpatient diabetes care. For instance, retrospective review of electronic records does not allow assessment of reasons underlying decision‐making behavior of clinicians (eg, why they did or did not change therapy). Diabetes and hyperglycemia associated hospitalizations must be identified by discharge diagnosis codes, so some cases of diabetes and hyperglycemia were likely missed.30, 31 Recent guidelines propose preprandial targets for glucose in the hospital.8 It is not easy to determine from an electronic data source which is a preprandial bedside glucose and which is a postprandial bedside glucose. Pre‐ and postpyramidal glucose categories would be difficult to define even during prospective studies, given the varying nature of nutritional support (ie, enteral, parenteral) used in the hospital and the administration of continuous dextrose infusions. Some type of quality control, such as conducting reviews of small samples of randomly selected charts to see how they compare with the electronic data, will need to be conducted.

From electronic discharge data, we cannot establish who had preexisting diabetes, who was admitted with new‐onset diabetes, and who developed hyperglycemia as a result of the hospital stay. Our previous random chart review15 indicated it is likely that most (more than 90%) had an established diagnosis of diabetes before admission. However, the recommendation to treat hyperglycemia should apply to all patients regardless of whether they had diagnosed diabetes prior to hospitalization or manifested hyperglycemia only during the hospital stay.79

As hospitals move toward making efforts to improve performance related to treating inpatient hyperglycemia, they must be cognizant of the heterogeneity of the inpatient population and the challenges to managing hospital hyperglycemia before drawing conclusions about their management. Inpatients with hyperglycemia are a diverse group, comprising patients with preexisting diabetes, with previously undiagnosed diabetes, and stress‐caused hyperglycemia. The unpredictable timing of procedures, various and changing forms of nutritional support, and different levels of staff expertise all contribute to the challenges of managing inpatient hyperglycemia. Inpatient practitioners may be forced to attempt glycemic control catch‐up for hospitalized persons who had poor outpatient glucose control. Patients who have required a stay in the intensive care unit may have very different glycemic outcomes than those who have not. Patients whose LOS was short (< 3days) may have different glycemic outcomes than persons whose LOS was longer ( 3 days as defined here) because of the length of time practitioners have to work to control their hyperglycemia. These and other variables may have to be taken into account when developing and assessing the impact of interventions.

Despite these limitations, our analysis was helpful in providing direction for enhancing the care of hospitalized patients with hyperglycemia in our facility. For instance, our generalists and surgeons are the principal caretakers of noncritically ill patients with diabetes, and these practitioners could be targeted for the first continuing educational programs about inpatient care of hyperglycemia. In addition, institutional guidelines on when and how to initiate and change therapyparticularly insulincan be designed so that hyperglycemia in noncritically ill hospital patients can be managed more effectively. These and other ongoing educational initiatives are necessary to ensure delivery of the highest quality of inpatient glucose care.

Diabetes confers a substantial burden on the hospital system. Diabetes is the fourth‐leading comorbid condition associated with any hospital discharge in the United States1. During 2001, for more than 500,000 patients discharged from U.S. hospitals diabetes was listed as the principal diagnosis and for more than 4 million it was listed as a codiagnosis.2, 3 Nearly one‐third of diabetes patients require at least 2 hospitalizations annually,4 and inpatient stays account for the largest proportion of direct medical expenses incurred by persons with the disease.5

Numerous studies have demonstrated that hyperglycemia is associated with adverse outcomes of hospitalized patients.68 However, studies have also confirmed that attention to lowering glucose levels in the hospital improves patient outcomes.7, 8 Although inpatients with known diabetes will likely constitute the largest and most visible percentage of those who will require treatment for high glucose, the recommendation to control glucose applies to all inpatients regardless of whether they have been diagnosed with diabetes prior to hospitalization or have manifested hyperglycemia only during the hospital stay.79

Now that the relationship between hyperglycemia and hospital outcomes is well established, the task of organizations that deliver care and set policy is to translate current recommendations of good glucose control into real‐world hospital settings. Quality improvement organizations are currently working toward developing and disseminating performance measures for control of inpatient hyperglycemia.10, 11 Although management of hospital hyperglycemia is often perceived as suboptimal,12 actual data are limited and are based on review of small numbers of charts,1315 and information is even sparser on the pharmacologic strategies being used to treat inpatient hyperglycemia. Before educational programs and policies can be developed, individual hospital systems need to gain more insight into how hyperglycemia is being managed in the hospital.

We reported previously the results of a review of a small number of charts (n = 90) of patients hospitalized with diabetes. The findings from this review suggested there was clinical inertia in glycemia management in the hospital.15 Clinical inertia was originally described in relationship to diabetes care in the outpatient setting and was defined as a failure to perform a needed service or make a change in treatment when indicated.16, 17 Since the original description, additional reports have documented the problem of clinical inertia, but these have all been based on experiences in the outpatient setting.1822 To our knowledge, our previous report was the first to question whether clinical inertia occurred in the hospital environment. In addition, we described the negative therapeutic momentuma deintensification of treatment despite ongoing hyperglycemia15. However, our prior study examined only a small number of cases and did not include detailed data on pharmacologic treatment for hyperglycemia. Therefore, we expanded our analysis using an information systems rather than a chart reviewbased methodology to assess the status of hyperglycemia management in our hospital.

METHODS

RESULTS

Glycemic Control

The median duration between admission and time of first bedside glucose measurement was 3.0 hours. Patients had an average of 19 bedside glucose measurements; the overall mean number of bedside measurements was 3.4 per day, 3.7 during the first 24‐hour period, and 3.4 during the last 24 hours of hospitalization. Nearly 25% of patients were hyperglycemic (bedside glucose > 200 mg/dL) during the first 24 hours of hospitalization (Fig. 1A), 20% had persistent hyperglycemia throughout the entire hospitalization (Fig. 1B), and 21% were hyperglycemic during the 24 hours before discharge (Fig. 1C), with some patients discharged with an average bedside glucose of at least 300 mg/dL during the 24 hours before discharge.

Figure 1

The incidence of hypoglycemic episodes was lower than that of hyperglycemic episodes: 21% of patients had at least 1 bedside glucose value less than 70 mg/dL, but 68% had at least 1 value greater than 200 mg/dL. The frequency of hypoglycemic measurements was low (Fig. 2A) compared with the frequency of hyperglycemic episodes (Fig. 2B).

Figure 2

Hyperglycemia Therapy

Most patients (72%) received subcutaneous insulin at some point during their hospital stay; 19% had no therapy, 9% had oral agents only, 26% had oral agents plus insulin, and 46% had insulin only. The proportion receiving no therapy decreased from 32% among patients whose BedGluc_avg was in the first tertile to 2% in the third tertile; the percentage of patients taking oral agents only decreased from 18% to 1%; the proportion taking oral agents plus insulin was 17% in the first tertile and 30% in the third; and the proportion of those taking insulin only was 32% in the first tertile and 66% in the third (Fig. 3). Thus, nearly all patients whose BedGluc_avg value was in the third tertile received insulin, either as monotherapy or in combination with oral agents.

Figure 3

Among insulin users, 58% received bolus‐only, 42% received basal‐bolus, and 1% received basal‐only injections. Because of the small proportion of basal‐only patients, we conducted analyses only of patients whose insulin treatment fell into 1 of the first 2 categories. The use of a basal‐bolus insulin program increased from 34% in patients whose BedGluc_avg was in the first tertile to 54% for those who had BedGluc_avg in the third tertile (P < .001; Fig. 4, left). Thus, although there was a greater transition to a more intensive insulin regimen with worsening hyperglycemia, a substantial number of patients (46%) whose BedGluc_avg was in the third tertile still did not have their insulin regimen intensified to a basal‐bolus program.

Figure 4

Fifty‐four percent of subcutaneous insulin users (N = 1680) had an increase in the amount of insulin administered between the first and last 24 hours of hospitalization (average increase, 17 U), 39% had a decrease (average decrease, 12 U), and 7% had no change. With rising hyperglycemia, more patients had their insulin increased by the time of discharge; 41% of persons who had BedGluc_avg values in the first tertile were on more insulin by the time of discharge, whereas 65% of those who had average glucose values in the third tertile had insulin increased (Fig. 4, right). However, the pattern of changes in the amount of administered insulin was heterogeneous, with increases, decreases, and no change occurring in all tertiles of BedGluc_avg (Fig. 3, right). Nearly 31% of patients whose BedGluc_avg values were in the third tertile actually had a decrease in insulin. This decrease occurred despite evidence of a low frequency of hypoglycemia (only 1.2 values < 70 mg/dL per 100 measurements per person) and a high frequency of hyperglycemia (55.4 values > 200 mg/dL per person per 100 measurements).

DISCUSSION

The number of diabetes‐associated hospital discharges has been climbing2, 3; our own data indicate an increase in the number of patients with diabetes as a proportion of the total number of discharged patients. A recent consensus advocates good glucose control in the hospital to optimize outcomes,79 and institutions need to begin the process of assessing their quality of inpatient hyperglycemia management as a first step to enhancing care.

There are no guidelines about which method of glucose measurement (ie, blood glucose or bedside glucose) should be used as the quality measure to evaluate glycemic control in hospital patients. Both blood and bedside glucose measurements have been used in outcomes studies.23, 24 We analyzed capillary bedside values measured by a method subjected to ongoing quality control oversight and stored in the electronic laboratory database. Bedside glucose measurements are typically obtained with far greater frequency than blood glucose measurements and therefore provide better insight into daily changes in glycemic control; in practice, clinicians rely on bedside values when assessing hyperglycemia and making therapeutic decisions.

There is also no consensus about what glucose metric should be used to assess the status of glycemic control in the hospital. Some studies have used single glucose values to examine the relationship between hyperglycemia and outcomes,25, 26 whereas others have used values averaged over various lengths of time.24, 27 To evaluate glucose control, we averaged capillary measurements in the first 24 hours of hospitalization (F24BedGluc_avg), the last 24 hours of hospitalization (L24BedGluc_avg), and for the entire LOS (BedGluc_avg), and we calculated the number of documented hyper‐ and hypoglycemic events. The measures we used to examine hyperglycemia would serve as useful benchmarks for following the progress of future institutional interventions directed at glucose control in hospitalized patients at our hospital.

A substantial number of our patients selected for analysis (ie, noncritically ill with LOS 3 days) were found to have sustained hyperglycemia at the beginning, during, and at the end of their hospital stay. We found very few instances of severe hypoglycemia (values < 50 or < 40 mg/dL), and the low frequency of hypoglycemia compared to that of hyperglycemia could encourage practitioners to be more aggressive in treating hyperglycemia. The high frequency of recorded bedside glucose compared with blood glucose measurements ( 3 per day), the ongoing patient surveillance by medical, nursing, and other staff members, and our institution's written hypoglycemia policy most likely minimize the number of unobserved, undocumented, or untreated hypoglycemic episodes. There are no data or recommendations about what would be an acceptable number of hypoglycemic episodes in the hospital.

Very little is known about the therapeutic strategies being applied to hyperglycemia in the hospital. Our data show that subcutaneous insulin (either alone or in combination with oral agents) was used at some point during hospitalization for nearly three‐fourths of noncritically patients who were in the hospital for 3 days or longer. Moreover, as hyperglycemia worsened, use of oral hypoglycemic agents declined, there was a shift toward greater use of a scheduled basal‐bolus insulin program, and a greater proportion of patients had more insulin administered.

Although these latter findings are encouraging and suggest that practitioners are responding to the severity of hyperglycemia, further examination of the data suggests that a substantial number of patients in the highest glucose tertile did not have insulin therapy intensified. Nearly half our patients whose glucose values were in the highest tertile were treated with short‐acting insulin aloneprobably an ineffective regimen23, 28or did not have more insulin administered. The higher doses administered were not likely solely a result of using more sliding‐scale insulin, as previous investigators actually found no correlation between intensity of the sliding scale and total daily insulin dose.14 Although evidence here is circumstantial (we did not examine changes in provider orders in response to glucose levels), these findings, together with those in our previous study15 and in another study,14 provide indirect evidence of clinical inertia in the hospital.

Beyond clinical inertia, however, there was evidence of negative therapeutic momentum: nearly one‐third of patients whose glucose was in the highest tertile had insulin decreased rather than increased, despite the low frequency of hypoglycemia and the high frequency of hyperglycemia. It is likely that even a single episode of hypoglycemia concerned practitioners, but the clinical response in these situations should be to investigate and correct the circumstances leading to the hypoglycemia, rather than to necessarily deintensify therapy in the face of continued hyperglycemia. The analysis of this larger data set corroborated our observations of clinical inertia and negative therapeutic momentum from an earlier study of chart reviews of a smaller patient sample.15

The variable application of insulin therapy to the treatment of hyperglycemia may be an indication of the level of comfort practitioners have about using this pharmacologic agent. A recently completed survey of resident physicians at our institution indicated that understanding how to use insulin was the most common barrier to successful management of inpatient hyperglycemia.29 These observations reinforce the need for institutions to develop standardized insulin order sets and develop programs to educate the staff on the use of insulin.

This study differs from our original analysis based on chart review in 4 ways. First, the sample size in our first study (n = 90) was small and derived from discharges from a single year (2003), whereas the sample in the present study spanned several years and included several thousand cases. Second, in our prior study we did not have detailed pharmacologic data on glucose management and how treatment approaches varied relative to severity of hyperglycemia. In general, there is very limited data on what therapeutic strategies are being applied to inpatient hyperglycemia, and this analysis of a large sample of cases provides more insight into how practitioners are managing glucose.

Third, we wanted to corroborate observations made in our previous report using a different methodologyin this instance, adapting existing information systems to assessment of inpatient diabetes care. For example, our last study was based on a limited number of glucose observations but suggested that the prevalence of hypoglycemia in our hospital was low compared with that of hyperglycemia; the present analysis of a very large number of glucose values confirmed these initial findings. In addition, use of information systems versus a chart review approach to assessing inpatient diabetes care corroborates our earlier suspicions about the presence of clinical inertia and negative therapeutic momentum in glucose management.

Fourth and finally, this study gave us experience with use of electronic records as a means to assess the status of inpatient diabetes care. Electronic data sources will likely be common tools to monitor quality of inpatient diabetes care and will likely figure prominently in future accreditation processes.10, 11 Unlike chart abstraction, which would require extensive man‐hours to extract data on few patients, use of electronic records allows examination of large numbers of hospital cases. Queries of information systems could be automated, and report cards potentially generated and feedback given to providers on the status of inpatient glycemic control. The industry is actively pursuing software development to assist hospitals in assessing the quality of inpatient glycemic control (eg, RALS‐TGCM, available at http:\\www.medicalautomation.com/RALS‐TGCM.html).

However, there are also limitations to using electronic records as the sole method of assessing inpatient diabetes care. For instance, retrospective review of electronic records does not allow assessment of reasons underlying decision‐making behavior of clinicians (eg, why they did or did not change therapy). Diabetes and hyperglycemia associated hospitalizations must be identified by discharge diagnosis codes, so some cases of diabetes and hyperglycemia were likely missed.30, 31 Recent guidelines propose preprandial targets for glucose in the hospital.8 It is not easy to determine from an electronic data source which is a preprandial bedside glucose and which is a postprandial bedside glucose. Pre‐ and postpyramidal glucose categories would be difficult to define even during prospective studies, given the varying nature of nutritional support (ie, enteral, parenteral) used in the hospital and the administration of continuous dextrose infusions. Some type of quality control, such as conducting reviews of small samples of randomly selected charts to see how they compare with the electronic data, will need to be conducted.

From electronic discharge data, we cannot establish who had preexisting diabetes, who was admitted with new‐onset diabetes, and who developed hyperglycemia as a result of the hospital stay. Our previous random chart review15 indicated it is likely that most (more than 90%) had an established diagnosis of diabetes before admission. However, the recommendation to treat hyperglycemia should apply to all patients regardless of whether they had diagnosed diabetes prior to hospitalization or manifested hyperglycemia only during the hospital stay.79

As hospitals move toward making efforts to improve performance related to treating inpatient hyperglycemia, they must be cognizant of the heterogeneity of the inpatient population and the challenges to managing hospital hyperglycemia before drawing conclusions about their management. Inpatients with hyperglycemia are a diverse group, comprising patients with preexisting diabetes, with previously undiagnosed diabetes, and stress‐caused hyperglycemia. The unpredictable timing of procedures, various and changing forms of nutritional support, and different levels of staff expertise all contribute to the challenges of managing inpatient hyperglycemia. Inpatient practitioners may be forced to attempt glycemic control catch‐up for hospitalized persons who had poor outpatient glucose control. Patients who have required a stay in the intensive care unit may have very different glycemic outcomes than those who have not. Patients whose LOS was short (< 3days) may have different glycemic outcomes than persons whose LOS was longer ( 3 days as defined here) because of the length of time practitioners have to work to control their hyperglycemia. These and other variables may have to be taken into account when developing and assessing the impact of interventions.

Despite these limitations, our analysis was helpful in providing direction for enhancing the care of hospitalized patients with hyperglycemia in our facility. For instance, our generalists and surgeons are the principal caretakers of noncritically ill patients with diabetes, and these practitioners could be targeted for the first continuing educational programs about inpatient care of hyperglycemia. In addition, institutional guidelines on when and how to initiate and change therapyparticularly insulincan be designed so that hyperglycemia in noncritically ill hospital patients can be managed more effectively. These and other ongoing educational initiatives are necessary to ensure delivery of the highest quality of inpatient glucose care.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.