Published in the February 2004 issue of Today’s Hospitalist
For years, efforts to control hyperglycemia in hospitalized patients have been patchwork at best. While some hospitals have enacted aggressive control measures, national guidelines didn’t exist, and research hadn’t convinced physicians that managing patients’ glucose levels in hospitals was a top priority.
All that has changed. Late last year, the American Association of Clinical Endocrinologists (AACE) hosted a conference that brought together representatives from a wide range of professional and specialist societies, including the Society of Critical Care Medicine and the Society of Hospital Medicine.
Presenters at the conference offered startling evidence that poor glucose control is wreaking havoc with both patients’ health and hospitals’ bottom line. The failure to control inpatient hyperglycemia, they said, is taking a grim toll not only in terms of increased mortality rates and serious complications, but in longer lengths of stay.
The conference produced the first-ever standards for monitoring blood sugar levels in hospitalized patients. The meeting also finalized guidelines for target glucose levels that are expected to be published early this year.
The bottom line? Hospitalists now have a roadmap to standardize glucose control efforts in hospitals around the country.
“This is going to pay for itself,” says endocrinologist Alan J. Garber, MD, PhD, conference co-chair and chief of the endocrinology, diabetes and metabolism service at Houston’s Methodist Hospital. “This actually saves money for hospitals “but it also changes the way people have to approach blood sugar control.”
While diabetes affects more than 18 million Americans, up to one-third of them will never be diagnosed with the condition. At the same time, hyperglycemia is common, even among hospitalized patients who aren’t diabetic. Blood sugar levels become elevated due to stress, infection and the use of therapies such as steroids and IV nutrition.
According to a position statement released at the AACE conference and online at www.aace.com, the cost of not controlling glucose among diabetic and hyperglycemic patients in hospitals is steep. Randomized trials have established, for instance, that poorly controlled hyperglycemia in critically ill patients leads to a higher risk of sepsis, kidney failure and mortality.
Meta-analyses have also linked elevated glucose levels to higher rates of mortality and congestive heart failure in heart attack patients, and to more severe cerebrovascular events and impaired recovery in stroke patients. And depending on patients’ diagnoses, poorly managed blood sugar can increase length of stay by up to several days.
At the same time, appropriately managing hyperglycemia in hospitalized patients can produce dramatic results.
Studies have shown, for instance, that maintaining glucose levels below 110 mg/dL in ICU patients reduced mortality by more than 30 percent. And the risk of deep-wound infections in hyperglycemic cardiac surgery patients fell 66 percent with proper control, while intensive insulin therapy in hyperglycemic ICU patients reduced sepsis rates by 46 percent.
According to the AACE position statement, hospitals’ savings from fewer patient complications “more than offset” the costs of intravenous insulin, resulting in a net savings of nearly $700 per patient.
Obstacles to improvement
Why hasn’t inpatient glucose management improved? For one, research findings pointing to gains in both patient health and hospital finances from aggressively controlling glucose levels have reached “a critical mass” only within the last three years, Dr. Garber says.
Other barriers may be more entrenched. According to Dr. Garber, many physicians and medical staff members mistakenly believe that they don’t need to focus on blood sugar for patients who come to the hospital for other conditions.
“In hospitals, the admitting diagnosis “myocardial infarction or kidney failure “becomes the primary concern,” Dr. Garber says. “Physicians don’t perceive that the attending elevated glucose levels might potentially complicate or prolong the admission.”
And hospital systems themselves are not designed to successfully control glucose. “Fasting sugars in the morning are often done at a time and in a manner for the convenience of hospital staff,” Dr. Garber explains, “instead of to meet the needs of the patient.”
As a result, many hospitals rely on sliding scale insulin therapy to manage blood sugar spikes, an approach the new position paper strongly discourages.
“We’re treating elevated blood sugars retrospectively,” Dr. Garber points out. “A much better approach is to prevent such an elevation with anticipatory doses of insulin.”
IV and subcutaneous therapy
To prevent blood sugar spikes, the AACE position paper includes another first: indications for using intravenous insulin before converting patients to subcutaneous therapy.
The position paper says that intravenous therapy is indicated in several situations: critically ill or transplant patients; stroke patients or those in labor and delivery; perioperatively; and as a dose-finding strategy before converting to subcutaneous therapy.
“When patients leave the ICU to go to a step-down unit, their blood sugar may still be very high for the first two days or so,” says endocrinologist Etie Moghissi, MD, conference co-chair and AACE board member. “We prefer to continue IV insulin until their blood sugar is stable.”
Patients can then be switched to subcutaneous insulin, she says, acknowledging that some hospitals with nursing shortages may need to switch patients to less labor-intensive subcutaneous insulin once they’re out of the ICU.
A consensus approach to change
The first step to successful control should be crafting a set of written protocols, Dr. Moghissi says.
At Centinela Hospital in Inglewood, Calif., where she works, Dr. Moghissi helped convene a committee of every professional who had a stake in managing patient glucose. The groups included hospitalists, intensivists, internists, surgeons, anesthesiologists and nurses.
“We created protocols for a blueprint to achieve good control,” says Dr. Moghissi. She then sent those protocols through every hospital committee “including groups that weren’t part of the initial protocol-drafting team “asking for recommendations.
“If you don’t create protocols as a team and get buy-in from everyone, the protocols won’t work,” she says. Or worse, different members of the care team may take different approaches to glucose control. The nurses who have to implement the protocols end up confused and frustrated.
Protocols should include therapeutic guidelines, such as how to adjust the insulin dose and how often glucose should be tested. At Centinela, for instance, patients in the ICU are tested every hour, Dr. Moghissi says, “although if there has been a rapid change, we may have to go to every 15 minutes.”
Once ICU patients are stable, glucose testing can be done every two hours, she adds. And when patients have been moved to floors and are on subcutaneous insulin, testing before each meal and at bedtime should be sufficient.
Protocols also need to address another critical step in successful glucose management: systems changes and educational needs within the hospital.
For instance, meal tray deliveries, particularly for diabetic patients, have to be timed and standardized. Specific hospital routines must also be scrutinized, and some may need to be changed.
“Patients often get their ‘bedtime’ snack at 7:30 in the evening, a convenient time for the dietary department,” Dr. Garber says. “For diabetics, that’s too close to their evening meal.”
Opportunity for hospitalists
Successful glucose control in hospitalized patients requires another mandate for hospitalists: communicating patients’ insulin needs during hospitalization to outpatient physicians upon discharge. That should include strong recommendations for follow-up.
“Maybe these patients have undiagnosed diabetes and we’re picking it up for the first time when they’re sick,” Dr. Moghissi says. “It’s important to not write it off as stress-induced hyperglycemia.” After discharge, she adds, patients will need to be monitored and get fasting blood sugars taken or glucose tolerance tests.
According to Dr. Garber, successfully managing glucose is just one more way hospitalists can help lead hospital teams to better outcomes and lower costs.
“Hospitalists have to join together with endocrinologists and demand that hospital systems be changed,” he says. “These patients will have to be treated with a great deal more care.”