Hospitalists target inpatient glycemic control

 

Physicians are trained to manage their patients’ diabetes and often do a meticulous job – one on one. But in order to maximize glycemic control outcomes throughout the hospital, you need a kind of diabetic epidemiology team to focus on the data, said Andjela Drincic, MD, an endocrinologist at Nebraska Medicine, the clinical partner of the University of Nebraska Medical Center in Omaha.

As medical director for diabetes stewardship, Dr. Drincic serves as the epidemiologic lead for her hospital, which has worked systematically to improve inpatient glycemic control since 2012 – with help from the Society of Hospital Medicine.

“You need a team and to set up a system that works, with protocols and some way of knowing if the protocols are succeeding,” Dr. Drincic said. “Quality improvement targets are never static.” She credited SHM’s glycemic control eQUIPS (Electronic Quality Improvement Program), an online quality improvement resource and collaborative of 104 participating hospitals, for providing the support and the data needed to drive glycemic QI efforts at Nebraska Medicine. SHM provided reporting metrics, quarterly benchmarking reports, a library of tools and resources, an implementation guide, educational webinars on demand and, for some participants, mentored implementation with the advice of a leading expert in the field.

One big reason for giving more attention to glycemic control in the hospital is patient safety, said Gregory Maynard, MD, MHM, clinical professor and chief quality officer at the University of California–Davis Medical Center and SHM’s project team leader for eQUIPS.

“Hyperglycemia in hospitalized patients is an extraordinarily common and growing problem, affecting up to 40%-50% of patients in the hospital,” he said. In 2012, 7.7 million hospital stays involved patients with diabetes, the seventh leading cause of death in the United States.¹

Hyperglycemia is linked to elevated rates of medical complications, infections, wound complications, hospital mortality, length of stay, readmissions, and ICU admissions, along with other outcomes not directly related to diabetes. Hyperglycemia in hospitalized patients who have not been given a diagnosis of diabetes is, if anything, more dangerous. Add the related risk for hypoglycemia, and clinicians are challenged to keep their patients controlled within the zone between the extremes of hyper- and hypoglycemia. The American Diabetes Association recently issued recommendations with more relaxed glucose targets between 140 and 180 mg/dL for most patients in non–intensive care settings.²

“To not have a standardized way of managing hyperglycemia for your hospital seems like an enormous missed opportunity,” Dr. Maynard said. “If someone comes into the hospital with a chronic condition of diabetes that you ignore, just maintaining them in the hospital and sending them back out into the world without addressing the underlying condition is not good care. You have missed an important opportunity to alter the course of a serious chronic condition.”

Dr. Maynard said SHM recognized this opportunity when it established eQUIPS. “Hospitalists are often tasked with taking care of patients with glycemic issues because there may not be an endocrinologist readily accessible in the hospital,” he said. “We have seen through our benchmarking in eQUIPS incredible variability – with 10-fold differences in hyperglycemia and hypoglycemia rates between the best- and worst-performing sites. The biggest variable is whether the hospital systematically manages glycemic control. We have also shown that achieving high levels of glycemic control and low hypoglycemia rates concurrently is very possible.”
 

 

Reliable benchmarks

Nebraska Medicine enrolled in eQUIPS in 2012.

“We utilize SHM’s glucometrics (standardized analyses of inpatient glycemic control data).”³ said Dr. Drincic. “I was looking for a reliable glucometric system and some way to make comparisons with other hospitals when I came across the data Dr. Maynard published about SHM via a PubMed search. We needed outcomes that are validated in the literature and comparison groups.”

Nebraska Medicine has also received a certificate of distinction for inpatient diabetes care from the Joint Commission, and Dr. Drincic is active in PRIDE (Planning Research in Inpatient Diabetes), a national consortium of leading investigators in inpatient diabetes care formed to promote collaborative research. The PRIDE group meets yearly at the ADA conference, communicates regularly by email, and publishes articles.

“Once a year I present our glycemic control data to our administration and to the quality and safety committees at the hospital. I have been pleased with the level of support we have received,” Dr. Drincic said. “We needed a mandate to do this, but when I reported the impact on readmissions and other outcomes, I got the full support of administration. This would have been a lot harder without SHM.”

Engagement with hospitalists is another key to the glucose management project’s success, Dr. Drincic said. “We as endocrinologists think we know how to manage diabetes, but hospitalists have the daunting task of dealing with all of the patient’s medical issues. If we don’t have a strong collaboration, how can we change practice hospitalwide?” Rachel Thompson, MD, SFHM, Nebraska Medicine’s chief of hospital medicine, participates in the glucose management project, Dr. Drincic said.

“We occasionally are guests at hospitalist meetings to share new glucose treatment algorithms,” she said. “We’re also looking at collaborating on other quality initiatives, for example, studying how perioperative dexamethasone affects glycemic control. We built this relationship with hospitalists by establishing trust while trying to shed a reputation as ‘sugar police.’ I don’t want hospitalists saying ‘There she goes again’ whenever I come on the unit. We have tried to establish personal relationships and figure out what the hospitalists need, especially relative to EPIC (the hospital’s electronic medical record software).”

Dr. Thompson said her group’s recent growth to nearly 70 clinicians has increased its footprint hospitalwide and given hospitalists a greater opportunity to influence glycemic control. “We see up to a third of the patients in the hospital outside of the ICU. Glycemic control is something you learn as a hospitalist – It’s a very important frontline quality issue. In the patient list on EPIC every morning we have a field highlighting all patients with glycemic control issues,” she said.

“Poor glucose control is associated with poor outcomes for our patients. We need the right systems in place for patient safety. Moreover, if we are ignoring glycemic control when the patient is in the hospital, we’re sending the wrong message and setting a bad example for our patients when they return home.”
 

 

Lack of clear metrics

A significant defect in the infrastructure of many glucose management programs is the lack of clear metrics for outcomes, Dr. Maynard said. Nearly one-third of hospitals in the United States have no standardized metric to track the quality of their inpatient glycemic management, a sobering statistic considering that the first step in any QI initiative is to define and measure the problem at hand.

“I believe the main reason that glycemic control has been left off hospitals’ radar screens is that we still have not adopted national, publicly reported quality measures for glycemic control, although those were proposed recently by a government interagency work group,” Dr. Maynard said. “Until that happens, we’ll continue to see uneven response.”

The first step for frontline hospitalists is to learn and understand the basics of glucose control, for example, basal bolus insulin administration, and to stop writing orders for sliding scale insulin as the sole means of controlling hyperglycemia.

“Develop and adopt standards of practice for insulin administration in your hospital,” Dr. Maynard said. “Be part of the solution, not the problem. Once you get into the weeds – patients on steroids or on total parenteral nutrition – it can get tricky. But it’s important to get the basics right and move beyond inertia on this topic.”

The glycemic team at Nebraska Medicine includes, in addition to Dr. Drincic and Dr. Thompson, an endocrinology fellow, diabetes case managers, resource nurses, nurse leadership, pharmacists, inpatient care transitions coordinators, and representatives from pediatrics and critical care, all working to impact the overall quality of glycemic management in the hospital. Jon Knezevich, PharmD is diabetes stewardship pharmacy coordinator, and Shelly Lautenbaugh, RN, CDE, is diabetes lead care manager and diabetes coordinator for the Joint Commission certificate program. Diabetes stewardship also includes online and live training courses and a class in acute glucose management for the diabetes resource nurses, who bring the knowledge back to their units.

The glucose team’s job is to make sure patients are cared for safely, using appropriate policies and procedures, education, and training, Ms. Lautenbaugh said. “We have a mission as a hospital to transform people’s lives. We try to live our values, and everything follows from the focus on patient safety,” she added. “If our patients can receive extraordinary care and leave better informed about their condition than when they came in, and then we don’t see them again, we’ve achieved our ultimate goal.”

Hyperglycemia is most often not the primary reason why patients are hospitalized, Ms. Lautenbaugh said. “But we need to give them appropriate glucose management regardless. We’ve worked with bedside staff, nurse leadership, and teams to develop plans to raise our outcome scores. We have a lot of different outcomes we examine, and it’s always evolving.”

Quality metrics are incorporated into the electronic medical record, but those reports are not timely enough for day-to-day management, Dr. Knezevich said. “So we created a diabetes dashboard, constantly updated in real time to identify patients who are out of glycemic control.” The measures tracked include a mean patient day glucose score, percentage of readings within recommended limits, mean time between measured low readings and next documented reading or resolution of hypoglycemia, readmission rates, and diabetes nutrition assessments.

For hospitals with diabetes certificates, the Joint Commission also requires that every patient with hyperglycemia receives a clinic visit 30 days after discharge to make sure they are receiving appropriate follow-up care. Other facets of the Nebraska glycemic initiative include utilizing the hospital’s voluntary “Meds to Beds” program, which brings prescribed medications to the patient’s room at discharge. “We offer a diabetes discharge kit for patients who are self-pay, with all of the insulin and medical supplies they will need to get to the 30-day follow-up visit,” Dr. Knezevich said. “We can dream up amazing treatment regimens, but if they can’t afford the medications, what have we accomplished?”

SHM’s external benchmarks have provided an objective format for comparing and improving outcomes, Ms. Lautenbaugh said. “We like to see where we are and use the data to make significant improvements, but we’re also focused on internal assessments. If we make changes for a given metric, how does it affect performance in other areas?” One important metric is percentage of glucose readings within target range hospitalwide. “Our overall goal is 75%. It was 72% in April 2018, and we’ve raised it to 74.4%. It’s a small gain but it shows steady progress. Little steps make small but steady improvement,” she said.

“One area where we were not pleased was the occurrence of hypoglycemia,” Ms. Lautenbaugh said. “We did a root cause analysis of every hypoglycemic event, including several reports for patients who didn’t have diabetes at all. We had to weed out some that weren’t pertinent to our quality questions, but for those that are, the diabetes case manager calls the provider to make sure they were aware of the incident. We were able to identify the outliers in noncritical care, which we’re now able to tackle using a systematic approach.”
 

 

Get on the bus

Hospitalists are also integrally involved in a hospital glycemic improvement initiative at Orange Regional Medical Center (ORMC) in Middletown, N.Y.

The Glycemic Improvement Team (GIT) was formed in 2012 when a new hospital campus opened and EPIC was implemented as the hospital’s EMR. But glycemic control has taken on greater focus since 2015, when ORMC enrolled in eQUIPS, said Lorraine Porcaro, RN, the hospital’s diabetes clinical manager. The glycemic control team includes representatives from medicine, nursing, case management, laboratory, nutrition, pharmacy, wound care, and quality improvement.

Implementing the new EMR offered the opportunity to track a number of medical values in real time, Ms. Porcaro said. ORMC has focused its glycemic quality improvement efforts on hypoglycemia and hyperglycemia, with a recent emphasis on the need for improvements related to glucose reassessment 15 minutes post hypoglycemia treatment. More than a hundred “Diabetes Champions” have completed 16 hours of advanced training in diabetes and provide in-unit mentorship for other staff.

Photo courtesy of Orange Regional Medical Center

The ORMC team’s glycemic improvement “bus” is a rolling cart that goes from unit to unit supplying nurse education, reminders, copies of department-specific policies and protocols, and treats for staff. “It’s what we’re known for,” Ms. Porcaro said. Pens with the motto: “Don’t Miss the Bus! Retest in 15!” summarize the GIT’s current focus on post–hypoglycemia treatment retesting.

Hospitalists were part of the glycemic improvement process at ORMC from the beginning and are still involved, said Adrian Paraschiv, MD, FHM, a hospitalist and assistant director of the medical center, as well as the ORMC director of clinical information technology. ORMC initiated hospitalist coverage in 1998 and now has three HM groups, two of them represented on the glycemic improvement team.

“Like any hospital, we feel we should minimize hypoglycemic events,” Dr. Paraschiv explained. “This became important for other hospital departments, and we recognized we needed a major QI initiative to improve our outcomes hospitalwide. In the process, we noticed what other people were saying: Results from improving glycemic control included reduced length of stay, cost, and infections. That provided motivation for the hospital to support our initiative.”

Glucose management isn’t only about blood sugar, but whether the patient ate or not, their other blood work, the level of education for patient and staff, and a variety of other inputs, Dr. Paraschiv said. “All of these things were in the EMR but all over the place. EPIC had an incipient structure for pulling the data together, and we modified it to show everything that’s going on with the patient’s glycemic control on a single screen. We can build order sets and issue different reports.”

Today at ORMC, hypoglycemia is reassessed within 30 minutes more than 50% of the time. “It will never be at 100%, but we wanted to at least be at the national mean for eQUIPS hospitals. Our stretch goal was to be in the top quartile, and by the end of 2017, we realized that goal,” Ms. Porcaro said. Sometimes, because of changes in patients and staff, the GIT needs to repeat the education and review policies. “Since then, it’s been a matter of continuing staff education; sharing glucose data with stakeholders; talking about goals for ICU and non-ICU units; and, when needed, rolling out the bus.”

Participation in eQUIPS has made it possible to gather this information in one place and present it in a way that makes sense to physicians, Dr. Paraschiv said. “Dr. Maynard and SHM showed us how to put the data together to add value. Using these tools, we started looking at our processes, what needed to change, and what we are able to change. Now we’re examining what happens afterward. Can we use the electronic system to automatically alert physicians to make changes to the treatment regimen in real time? We continue to improve using upgrades to our EMR, such as an alert system with best practice advisories for the clinician. We now think we can actually achieve what we set out to achieve,” he said.

“Our idea was that we needed to market this program throughout the hospital – starting from the kitchen, meal delivery staff, IT, laboratory, medical and nursing staff,” Ms. Porcaro said. “The issue is multifactorial – it’s for the entire hospital. My heart is warmed when I see the woman who delivers the meals asking the patient: ‘Have you gotten your insulin shot?’ ”
 

References

1. Corvino L et al. “Management of diabetes and hyperglycemia in hospitalized patients.” Updated 2017 Oct 1 in De Groot LJ et al. editors. Endotext. South Dartmouth (MA): MDText.com 2000.

2. American Diabetes Association. Glycemic targets. Diabetes Care 2017 Jan;40(Suppl 1):S48-56.

3. Maynard G et al. “Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics.” J Diabetes Sci Technol. 2014 May 12;8(4):630-40.

 

Physicians are trained to manage their patients’ diabetes and often do a meticulous job – one on one. But in order to maximize glycemic control outcomes throughout the hospital, you need a kind of diabetic epidemiology team to focus on the data, said Andjela Drincic, MD, an endocrinologist at Nebraska Medicine, the clinical partner of the University of Nebraska Medical Center in Omaha.

As medical director for diabetes stewardship, Dr. Drincic serves as the epidemiologic lead for her hospital, which has worked systematically to improve inpatient glycemic control since 2012 – with help from the Society of Hospital Medicine.

“You need a team and to set up a system that works, with protocols and some way of knowing if the protocols are succeeding,” Dr. Drincic said. “Quality improvement targets are never static.” She credited SHM’s glycemic control eQUIPS (Electronic Quality Improvement Program), an online quality improvement resource and collaborative of 104 participating hospitals, for providing the support and the data needed to drive glycemic QI efforts at Nebraska Medicine. SHM provided reporting metrics, quarterly benchmarking reports, a library of tools and resources, an implementation guide, educational webinars on demand and, for some participants, mentored implementation with the advice of a leading expert in the field.

One big reason for giving more attention to glycemic control in the hospital is patient safety, said Gregory Maynard, MD, MHM, clinical professor and chief quality officer at the University of California–Davis Medical Center and SHM’s project team leader for eQUIPS.

“Hyperglycemia in hospitalized patients is an extraordinarily common and growing problem, affecting up to 40%-50% of patients in the hospital,” he said. In 2012, 7.7 million hospital stays involved patients with diabetes, the seventh leading cause of death in the United States.¹

Hyperglycemia is linked to elevated rates of medical complications, infections, wound complications, hospital mortality, length of stay, readmissions, and ICU admissions, along with other outcomes not directly related to diabetes. Hyperglycemia in hospitalized patients who have not been given a diagnosis of diabetes is, if anything, more dangerous. Add the related risk for hypoglycemia, and clinicians are challenged to keep their patients controlled within the zone between the extremes of hyper- and hypoglycemia. The American Diabetes Association recently issued recommendations with more relaxed glucose targets between 140 and 180 mg/dL for most patients in non–intensive care settings.²

“To not have a standardized way of managing hyperglycemia for your hospital seems like an enormous missed opportunity,” Dr. Maynard said. “If someone comes into the hospital with a chronic condition of diabetes that you ignore, just maintaining them in the hospital and sending them back out into the world without addressing the underlying condition is not good care. You have missed an important opportunity to alter the course of a serious chronic condition.”

Dr. Maynard said SHM recognized this opportunity when it established eQUIPS. “Hospitalists are often tasked with taking care of patients with glycemic issues because there may not be an endocrinologist readily accessible in the hospital,” he said. “We have seen through our benchmarking in eQUIPS incredible variability – with 10-fold differences in hyperglycemia and hypoglycemia rates between the best- and worst-performing sites. The biggest variable is whether the hospital systematically manages glycemic control. We have also shown that achieving high levels of glycemic control and low hypoglycemia rates concurrently is very possible.”
 

 

Reliable benchmarks

Nebraska Medicine enrolled in eQUIPS in 2012.

“We utilize SHM’s glucometrics (standardized analyses of inpatient glycemic control data).”³ said Dr. Drincic. “I was looking for a reliable glucometric system and some way to make comparisons with other hospitals when I came across the data Dr. Maynard published about SHM via a PubMed search. We needed outcomes that are validated in the literature and comparison groups.”

Nebraska Medicine has also received a certificate of distinction for inpatient diabetes care from the Joint Commission, and Dr. Drincic is active in PRIDE (Planning Research in Inpatient Diabetes), a national consortium of leading investigators in inpatient diabetes care formed to promote collaborative research. The PRIDE group meets yearly at the ADA conference, communicates regularly by email, and publishes articles.

“Once a year I present our glycemic control data to our administration and to the quality and safety committees at the hospital. I have been pleased with the level of support we have received,” Dr. Drincic said. “We needed a mandate to do this, but when I reported the impact on readmissions and other outcomes, I got the full support of administration. This would have been a lot harder without SHM.”

Engagement with hospitalists is another key to the glucose management project’s success, Dr. Drincic said. “We as endocrinologists think we know how to manage diabetes, but hospitalists have the daunting task of dealing with all of the patient’s medical issues. If we don’t have a strong collaboration, how can we change practice hospitalwide?” Rachel Thompson, MD, SFHM, Nebraska Medicine’s chief of hospital medicine, participates in the glucose management project, Dr. Drincic said.

“We occasionally are guests at hospitalist meetings to share new glucose treatment algorithms,” she said. “We’re also looking at collaborating on other quality initiatives, for example, studying how perioperative dexamethasone affects glycemic control. We built this relationship with hospitalists by establishing trust while trying to shed a reputation as ‘sugar police.’ I don’t want hospitalists saying ‘There she goes again’ whenever I come on the unit. We have tried to establish personal relationships and figure out what the hospitalists need, especially relative to EPIC (the hospital’s electronic medical record software).”

Dr. Thompson said her group’s recent growth to nearly 70 clinicians has increased its footprint hospitalwide and given hospitalists a greater opportunity to influence glycemic control. “We see up to a third of the patients in the hospital outside of the ICU. Glycemic control is something you learn as a hospitalist – It’s a very important frontline quality issue. In the patient list on EPIC every morning we have a field highlighting all patients with glycemic control issues,” she said.

“Poor glucose control is associated with poor outcomes for our patients. We need the right systems in place for patient safety. Moreover, if we are ignoring glycemic control when the patient is in the hospital, we’re sending the wrong message and setting a bad example for our patients when they return home.”
 

 

Lack of clear metrics

A significant defect in the infrastructure of many glucose management programs is the lack of clear metrics for outcomes, Dr. Maynard said. Nearly one-third of hospitals in the United States have no standardized metric to track the quality of their inpatient glycemic management, a sobering statistic considering that the first step in any QI initiative is to define and measure the problem at hand.

“I believe the main reason that glycemic control has been left off hospitals’ radar screens is that we still have not adopted national, publicly reported quality measures for glycemic control, although those were proposed recently by a government interagency work group,” Dr. Maynard said. “Until that happens, we’ll continue to see uneven response.”

The first step for frontline hospitalists is to learn and understand the basics of glucose control, for example, basal bolus insulin administration, and to stop writing orders for sliding scale insulin as the sole means of controlling hyperglycemia.

“Develop and adopt standards of practice for insulin administration in your hospital,” Dr. Maynard said. “Be part of the solution, not the problem. Once you get into the weeds – patients on steroids or on total parenteral nutrition – it can get tricky. But it’s important to get the basics right and move beyond inertia on this topic.”

The glycemic team at Nebraska Medicine includes, in addition to Dr. Drincic and Dr. Thompson, an endocrinology fellow, diabetes case managers, resource nurses, nurse leadership, pharmacists, inpatient care transitions coordinators, and representatives from pediatrics and critical care, all working to impact the overall quality of glycemic management in the hospital. Jon Knezevich, PharmD is diabetes stewardship pharmacy coordinator, and Shelly Lautenbaugh, RN, CDE, is diabetes lead care manager and diabetes coordinator for the Joint Commission certificate program. Diabetes stewardship also includes online and live training courses and a class in acute glucose management for the diabetes resource nurses, who bring the knowledge back to their units.

The glucose team’s job is to make sure patients are cared for safely, using appropriate policies and procedures, education, and training, Ms. Lautenbaugh said. “We have a mission as a hospital to transform people’s lives. We try to live our values, and everything follows from the focus on patient safety,” she added. “If our patients can receive extraordinary care and leave better informed about their condition than when they came in, and then we don’t see them again, we’ve achieved our ultimate goal.”

Hyperglycemia is most often not the primary reason why patients are hospitalized, Ms. Lautenbaugh said. “But we need to give them appropriate glucose management regardless. We’ve worked with bedside staff, nurse leadership, and teams to develop plans to raise our outcome scores. We have a lot of different outcomes we examine, and it’s always evolving.”

Quality metrics are incorporated into the electronic medical record, but those reports are not timely enough for day-to-day management, Dr. Knezevich said. “So we created a diabetes dashboard, constantly updated in real time to identify patients who are out of glycemic control.” The measures tracked include a mean patient day glucose score, percentage of readings within recommended limits, mean time between measured low readings and next documented reading or resolution of hypoglycemia, readmission rates, and diabetes nutrition assessments.

For hospitals with diabetes certificates, the Joint Commission also requires that every patient with hyperglycemia receives a clinic visit 30 days after discharge to make sure they are receiving appropriate follow-up care. Other facets of the Nebraska glycemic initiative include utilizing the hospital’s voluntary “Meds to Beds” program, which brings prescribed medications to the patient’s room at discharge. “We offer a diabetes discharge kit for patients who are self-pay, with all of the insulin and medical supplies they will need to get to the 30-day follow-up visit,” Dr. Knezevich said. “We can dream up amazing treatment regimens, but if they can’t afford the medications, what have we accomplished?”

SHM’s external benchmarks have provided an objective format for comparing and improving outcomes, Ms. Lautenbaugh said. “We like to see where we are and use the data to make significant improvements, but we’re also focused on internal assessments. If we make changes for a given metric, how does it affect performance in other areas?” One important metric is percentage of glucose readings within target range hospitalwide. “Our overall goal is 75%. It was 72% in April 2018, and we’ve raised it to 74.4%. It’s a small gain but it shows steady progress. Little steps make small but steady improvement,” she said.

“One area where we were not pleased was the occurrence of hypoglycemia,” Ms. Lautenbaugh said. “We did a root cause analysis of every hypoglycemic event, including several reports for patients who didn’t have diabetes at all. We had to weed out some that weren’t pertinent to our quality questions, but for those that are, the diabetes case manager calls the provider to make sure they were aware of the incident. We were able to identify the outliers in noncritical care, which we’re now able to tackle using a systematic approach.”
 

 

Get on the bus

Hospitalists are also integrally involved in a hospital glycemic improvement initiative at Orange Regional Medical Center (ORMC) in Middletown, N.Y.

The Glycemic Improvement Team (GIT) was formed in 2012 when a new hospital campus opened and EPIC was implemented as the hospital’s EMR. But glycemic control has taken on greater focus since 2015, when ORMC enrolled in eQUIPS, said Lorraine Porcaro, RN, the hospital’s diabetes clinical manager. The glycemic control team includes representatives from medicine, nursing, case management, laboratory, nutrition, pharmacy, wound care, and quality improvement.

Implementing the new EMR offered the opportunity to track a number of medical values in real time, Ms. Porcaro said. ORMC has focused its glycemic quality improvement efforts on hypoglycemia and hyperglycemia, with a recent emphasis on the need for improvements related to glucose reassessment 15 minutes post hypoglycemia treatment. More than a hundred “Diabetes Champions” have completed 16 hours of advanced training in diabetes and provide in-unit mentorship for other staff.

Photo courtesy of Orange Regional Medical Center

The ORMC team’s glycemic improvement “bus” is a rolling cart that goes from unit to unit supplying nurse education, reminders, copies of department-specific policies and protocols, and treats for staff. “It’s what we’re known for,” Ms. Porcaro said. Pens with the motto: “Don’t Miss the Bus! Retest in 15!” summarize the GIT’s current focus on post–hypoglycemia treatment retesting.

Hospitalists were part of the glycemic improvement process at ORMC from the beginning and are still involved, said Adrian Paraschiv, MD, FHM, a hospitalist and assistant director of the medical center, as well as the ORMC director of clinical information technology. ORMC initiated hospitalist coverage in 1998 and now has three HM groups, two of them represented on the glycemic improvement team.

“Like any hospital, we feel we should minimize hypoglycemic events,” Dr. Paraschiv explained. “This became important for other hospital departments, and we recognized we needed a major QI initiative to improve our outcomes hospitalwide. In the process, we noticed what other people were saying: Results from improving glycemic control included reduced length of stay, cost, and infections. That provided motivation for the hospital to support our initiative.”

Glucose management isn’t only about blood sugar, but whether the patient ate or not, their other blood work, the level of education for patient and staff, and a variety of other inputs, Dr. Paraschiv said. “All of these things were in the EMR but all over the place. EPIC had an incipient structure for pulling the data together, and we modified it to show everything that’s going on with the patient’s glycemic control on a single screen. We can build order sets and issue different reports.”

Today at ORMC, hypoglycemia is reassessed within 30 minutes more than 50% of the time. “It will never be at 100%, but we wanted to at least be at the national mean for eQUIPS hospitals. Our stretch goal was to be in the top quartile, and by the end of 2017, we realized that goal,” Ms. Porcaro said. Sometimes, because of changes in patients and staff, the GIT needs to repeat the education and review policies. “Since then, it’s been a matter of continuing staff education; sharing glucose data with stakeholders; talking about goals for ICU and non-ICU units; and, when needed, rolling out the bus.”

Participation in eQUIPS has made it possible to gather this information in one place and present it in a way that makes sense to physicians, Dr. Paraschiv said. “Dr. Maynard and SHM showed us how to put the data together to add value. Using these tools, we started looking at our processes, what needed to change, and what we are able to change. Now we’re examining what happens afterward. Can we use the electronic system to automatically alert physicians to make changes to the treatment regimen in real time? We continue to improve using upgrades to our EMR, such as an alert system with best practice advisories for the clinician. We now think we can actually achieve what we set out to achieve,” he said.

“Our idea was that we needed to market this program throughout the hospital – starting from the kitchen, meal delivery staff, IT, laboratory, medical and nursing staff,” Ms. Porcaro said. “The issue is multifactorial – it’s for the entire hospital. My heart is warmed when I see the woman who delivers the meals asking the patient: ‘Have you gotten your insulin shot?’ ”
 

References

1. Corvino L et al. “Management of diabetes and hyperglycemia in hospitalized patients.” Updated 2017 Oct 1 in De Groot LJ et al. editors. Endotext. South Dartmouth (MA): MDText.com 2000.

2. American Diabetes Association. Glycemic targets. Diabetes Care 2017 Jan;40(Suppl 1):S48-56.

3. Maynard G et al. “Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics.” J Diabetes Sci Technol. 2014 May 12;8(4):630-40.

 

Physicians are trained to manage their patients’ diabetes and often do a meticulous job – one on one. But in order to maximize glycemic control outcomes throughout the hospital, you need a kind of diabetic epidemiology team to focus on the data, said Andjela Drincic, MD, an endocrinologist at Nebraska Medicine, the clinical partner of the University of Nebraska Medical Center in Omaha.

As medical director for diabetes stewardship, Dr. Drincic serves as the epidemiologic lead for her hospital, which has worked systematically to improve inpatient glycemic control since 2012 – with help from the Society of Hospital Medicine.

“You need a team and to set up a system that works, with protocols and some way of knowing if the protocols are succeeding,” Dr. Drincic said. “Quality improvement targets are never static.” She credited SHM’s glycemic control eQUIPS (Electronic Quality Improvement Program), an online quality improvement resource and collaborative of 104 participating hospitals, for providing the support and the data needed to drive glycemic QI efforts at Nebraska Medicine. SHM provided reporting metrics, quarterly benchmarking reports, a library of tools and resources, an implementation guide, educational webinars on demand and, for some participants, mentored implementation with the advice of a leading expert in the field.

One big reason for giving more attention to glycemic control in the hospital is patient safety, said Gregory Maynard, MD, MHM, clinical professor and chief quality officer at the University of California–Davis Medical Center and SHM’s project team leader for eQUIPS.

“Hyperglycemia in hospitalized patients is an extraordinarily common and growing problem, affecting up to 40%-50% of patients in the hospital,” he said. In 2012, 7.7 million hospital stays involved patients with diabetes, the seventh leading cause of death in the United States.¹

Hyperglycemia is linked to elevated rates of medical complications, infections, wound complications, hospital mortality, length of stay, readmissions, and ICU admissions, along with other outcomes not directly related to diabetes. Hyperglycemia in hospitalized patients who have not been given a diagnosis of diabetes is, if anything, more dangerous. Add the related risk for hypoglycemia, and clinicians are challenged to keep their patients controlled within the zone between the extremes of hyper- and hypoglycemia. The American Diabetes Association recently issued recommendations with more relaxed glucose targets between 140 and 180 mg/dL for most patients in non–intensive care settings.²

“To not have a standardized way of managing hyperglycemia for your hospital seems like an enormous missed opportunity,” Dr. Maynard said. “If someone comes into the hospital with a chronic condition of diabetes that you ignore, just maintaining them in the hospital and sending them back out into the world without addressing the underlying condition is not good care. You have missed an important opportunity to alter the course of a serious chronic condition.”

Dr. Maynard said SHM recognized this opportunity when it established eQUIPS. “Hospitalists are often tasked with taking care of patients with glycemic issues because there may not be an endocrinologist readily accessible in the hospital,” he said. “We have seen through our benchmarking in eQUIPS incredible variability – with 10-fold differences in hyperglycemia and hypoglycemia rates between the best- and worst-performing sites. The biggest variable is whether the hospital systematically manages glycemic control. We have also shown that achieving high levels of glycemic control and low hypoglycemia rates concurrently is very possible.”
 

 

Reliable benchmarks

Nebraska Medicine enrolled in eQUIPS in 2012.

“We utilize SHM’s glucometrics (standardized analyses of inpatient glycemic control data).”³ said Dr. Drincic. “I was looking for a reliable glucometric system and some way to make comparisons with other hospitals when I came across the data Dr. Maynard published about SHM via a PubMed search. We needed outcomes that are validated in the literature and comparison groups.”

Nebraska Medicine has also received a certificate of distinction for inpatient diabetes care from the Joint Commission, and Dr. Drincic is active in PRIDE (Planning Research in Inpatient Diabetes), a national consortium of leading investigators in inpatient diabetes care formed to promote collaborative research. The PRIDE group meets yearly at the ADA conference, communicates regularly by email, and publishes articles.

“Once a year I present our glycemic control data to our administration and to the quality and safety committees at the hospital. I have been pleased with the level of support we have received,” Dr. Drincic said. “We needed a mandate to do this, but when I reported the impact on readmissions and other outcomes, I got the full support of administration. This would have been a lot harder without SHM.”

Engagement with hospitalists is another key to the glucose management project’s success, Dr. Drincic said. “We as endocrinologists think we know how to manage diabetes, but hospitalists have the daunting task of dealing with all of the patient’s medical issues. If we don’t have a strong collaboration, how can we change practice hospitalwide?” Rachel Thompson, MD, SFHM, Nebraska Medicine’s chief of hospital medicine, participates in the glucose management project, Dr. Drincic said.

“We occasionally are guests at hospitalist meetings to share new glucose treatment algorithms,” she said. “We’re also looking at collaborating on other quality initiatives, for example, studying how perioperative dexamethasone affects glycemic control. We built this relationship with hospitalists by establishing trust while trying to shed a reputation as ‘sugar police.’ I don’t want hospitalists saying ‘There she goes again’ whenever I come on the unit. We have tried to establish personal relationships and figure out what the hospitalists need, especially relative to EPIC (the hospital’s electronic medical record software).”

Dr. Thompson said her group’s recent growth to nearly 70 clinicians has increased its footprint hospitalwide and given hospitalists a greater opportunity to influence glycemic control. “We see up to a third of the patients in the hospital outside of the ICU. Glycemic control is something you learn as a hospitalist – It’s a very important frontline quality issue. In the patient list on EPIC every morning we have a field highlighting all patients with glycemic control issues,” she said.

“Poor glucose control is associated with poor outcomes for our patients. We need the right systems in place for patient safety. Moreover, if we are ignoring glycemic control when the patient is in the hospital, we’re sending the wrong message and setting a bad example for our patients when they return home.”
 

 

Lack of clear metrics

A significant defect in the infrastructure of many glucose management programs is the lack of clear metrics for outcomes, Dr. Maynard said. Nearly one-third of hospitals in the United States have no standardized metric to track the quality of their inpatient glycemic management, a sobering statistic considering that the first step in any QI initiative is to define and measure the problem at hand.

“I believe the main reason that glycemic control has been left off hospitals’ radar screens is that we still have not adopted national, publicly reported quality measures for glycemic control, although those were proposed recently by a government interagency work group,” Dr. Maynard said. “Until that happens, we’ll continue to see uneven response.”

The first step for frontline hospitalists is to learn and understand the basics of glucose control, for example, basal bolus insulin administration, and to stop writing orders for sliding scale insulin as the sole means of controlling hyperglycemia.

“Develop and adopt standards of practice for insulin administration in your hospital,” Dr. Maynard said. “Be part of the solution, not the problem. Once you get into the weeds – patients on steroids or on total parenteral nutrition – it can get tricky. But it’s important to get the basics right and move beyond inertia on this topic.”

The glycemic team at Nebraska Medicine includes, in addition to Dr. Drincic and Dr. Thompson, an endocrinology fellow, diabetes case managers, resource nurses, nurse leadership, pharmacists, inpatient care transitions coordinators, and representatives from pediatrics and critical care, all working to impact the overall quality of glycemic management in the hospital. Jon Knezevich, PharmD is diabetes stewardship pharmacy coordinator, and Shelly Lautenbaugh, RN, CDE, is diabetes lead care manager and diabetes coordinator for the Joint Commission certificate program. Diabetes stewardship also includes online and live training courses and a class in acute glucose management for the diabetes resource nurses, who bring the knowledge back to their units.

The glucose team’s job is to make sure patients are cared for safely, using appropriate policies and procedures, education, and training, Ms. Lautenbaugh said. “We have a mission as a hospital to transform people’s lives. We try to live our values, and everything follows from the focus on patient safety,” she added. “If our patients can receive extraordinary care and leave better informed about their condition than when they came in, and then we don’t see them again, we’ve achieved our ultimate goal.”

Hyperglycemia is most often not the primary reason why patients are hospitalized, Ms. Lautenbaugh said. “But we need to give them appropriate glucose management regardless. We’ve worked with bedside staff, nurse leadership, and teams to develop plans to raise our outcome scores. We have a lot of different outcomes we examine, and it’s always evolving.”

Quality metrics are incorporated into the electronic medical record, but those reports are not timely enough for day-to-day management, Dr. Knezevich said. “So we created a diabetes dashboard, constantly updated in real time to identify patients who are out of glycemic control.” The measures tracked include a mean patient day glucose score, percentage of readings within recommended limits, mean time between measured low readings and next documented reading or resolution of hypoglycemia, readmission rates, and diabetes nutrition assessments.

For hospitals with diabetes certificates, the Joint Commission also requires that every patient with hyperglycemia receives a clinic visit 30 days after discharge to make sure they are receiving appropriate follow-up care. Other facets of the Nebraska glycemic initiative include utilizing the hospital’s voluntary “Meds to Beds” program, which brings prescribed medications to the patient’s room at discharge. “We offer a diabetes discharge kit for patients who are self-pay, with all of the insulin and medical supplies they will need to get to the 30-day follow-up visit,” Dr. Knezevich said. “We can dream up amazing treatment regimens, but if they can’t afford the medications, what have we accomplished?”

SHM’s external benchmarks have provided an objective format for comparing and improving outcomes, Ms. Lautenbaugh said. “We like to see where we are and use the data to make significant improvements, but we’re also focused on internal assessments. If we make changes for a given metric, how does it affect performance in other areas?” One important metric is percentage of glucose readings within target range hospitalwide. “Our overall goal is 75%. It was 72% in April 2018, and we’ve raised it to 74.4%. It’s a small gain but it shows steady progress. Little steps make small but steady improvement,” she said.

“One area where we were not pleased was the occurrence of hypoglycemia,” Ms. Lautenbaugh said. “We did a root cause analysis of every hypoglycemic event, including several reports for patients who didn’t have diabetes at all. We had to weed out some that weren’t pertinent to our quality questions, but for those that are, the diabetes case manager calls the provider to make sure they were aware of the incident. We were able to identify the outliers in noncritical care, which we’re now able to tackle using a systematic approach.”
 

 

Get on the bus

Hospitalists are also integrally involved in a hospital glycemic improvement initiative at Orange Regional Medical Center (ORMC) in Middletown, N.Y.

The Glycemic Improvement Team (GIT) was formed in 2012 when a new hospital campus opened and EPIC was implemented as the hospital’s EMR. But glycemic control has taken on greater focus since 2015, when ORMC enrolled in eQUIPS, said Lorraine Porcaro, RN, the hospital’s diabetes clinical manager. The glycemic control team includes representatives from medicine, nursing, case management, laboratory, nutrition, pharmacy, wound care, and quality improvement.

Implementing the new EMR offered the opportunity to track a number of medical values in real time, Ms. Porcaro said. ORMC has focused its glycemic quality improvement efforts on hypoglycemia and hyperglycemia, with a recent emphasis on the need for improvements related to glucose reassessment 15 minutes post hypoglycemia treatment. More than a hundred “Diabetes Champions” have completed 16 hours of advanced training in diabetes and provide in-unit mentorship for other staff.

Photo courtesy of Orange Regional Medical Center

The ORMC team’s glycemic improvement “bus” is a rolling cart that goes from unit to unit supplying nurse education, reminders, copies of department-specific policies and protocols, and treats for staff. “It’s what we’re known for,” Ms. Porcaro said. Pens with the motto: “Don’t Miss the Bus! Retest in 15!” summarize the GIT’s current focus on post–hypoglycemia treatment retesting.

Hospitalists were part of the glycemic improvement process at ORMC from the beginning and are still involved, said Adrian Paraschiv, MD, FHM, a hospitalist and assistant director of the medical center, as well as the ORMC director of clinical information technology. ORMC initiated hospitalist coverage in 1998 and now has three HM groups, two of them represented on the glycemic improvement team.

“Like any hospital, we feel we should minimize hypoglycemic events,” Dr. Paraschiv explained. “This became important for other hospital departments, and we recognized we needed a major QI initiative to improve our outcomes hospitalwide. In the process, we noticed what other people were saying: Results from improving glycemic control included reduced length of stay, cost, and infections. That provided motivation for the hospital to support our initiative.”

Glucose management isn’t only about blood sugar, but whether the patient ate or not, their other blood work, the level of education for patient and staff, and a variety of other inputs, Dr. Paraschiv said. “All of these things were in the EMR but all over the place. EPIC had an incipient structure for pulling the data together, and we modified it to show everything that’s going on with the patient’s glycemic control on a single screen. We can build order sets and issue different reports.”

Today at ORMC, hypoglycemia is reassessed within 30 minutes more than 50% of the time. “It will never be at 100%, but we wanted to at least be at the national mean for eQUIPS hospitals. Our stretch goal was to be in the top quartile, and by the end of 2017, we realized that goal,” Ms. Porcaro said. Sometimes, because of changes in patients and staff, the GIT needs to repeat the education and review policies. “Since then, it’s been a matter of continuing staff education; sharing glucose data with stakeholders; talking about goals for ICU and non-ICU units; and, when needed, rolling out the bus.”

Participation in eQUIPS has made it possible to gather this information in one place and present it in a way that makes sense to physicians, Dr. Paraschiv said. “Dr. Maynard and SHM showed us how to put the data together to add value. Using these tools, we started looking at our processes, what needed to change, and what we are able to change. Now we’re examining what happens afterward. Can we use the electronic system to automatically alert physicians to make changes to the treatment regimen in real time? We continue to improve using upgrades to our EMR, such as an alert system with best practice advisories for the clinician. We now think we can actually achieve what we set out to achieve,” he said.

“Our idea was that we needed to market this program throughout the hospital – starting from the kitchen, meal delivery staff, IT, laboratory, medical and nursing staff,” Ms. Porcaro said. “The issue is multifactorial – it’s for the entire hospital. My heart is warmed when I see the woman who delivers the meals asking the patient: ‘Have you gotten your insulin shot?’ ”
 

References

1. Corvino L et al. “Management of diabetes and hyperglycemia in hospitalized patients.” Updated 2017 Oct 1 in De Groot LJ et al. editors. Endotext. South Dartmouth (MA): MDText.com 2000.

2. American Diabetes Association. Glycemic targets. Diabetes Care 2017 Jan;40(Suppl 1):S48-56.

3. Maynard G et al. “Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics.” J Diabetes Sci Technol. 2014 May 12;8(4):630-40.