Ronald E. Schmidt

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.