Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.

Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.

Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.

Professional and patient safety organizations have recognized the importance of safe transitions as patients move through the health care system, and such attention is even more critical when attempting to achieve glycemic control.14 Since the publication of the Diabetes Control and Complications Trial (DCCT)5 and the United Kingdom Prospective Diabetes Study (UKPDS),6 we have known that intensive glycemic control in the ambulatory setting prevents complications in both type 1 and type 2 diabetes mellitus (DM). Despite the increased risk of hypoglycemia, these trials changed practice patterns in the outpatient settings in favor of intensification of diabetes therapy. In the same way, randomized, prospective trials using intravenous (IV) insulin therapy have revolutionized our thinking about inpatient care by showing that tight glycemic control in the critically ill7 and patients with acute myocardial infarction8 reduces mortality and morbidity. These, as well as additional observational studies associating hyperglycemia with poor outcomes in a variety of medical and surgical patients,915 have led to increased attention on glycemic control in all venues of care.16, 17 Concerns over excessive hypoglycemia and a nonsignificant increase in mortality in certain populations of medical intensive care unit (ICU) patients have raised questions over whether the initial studies can be reproduced or generalized to other groups of inpatients.18, 19 Additional studies are underway to clarify these questions but consensus exists that blood glucose values should at least be less than 180 mg/dL and that the traditional practice of ignoring hyperglycemia is no longer acceptable.

While a uniform focus on glycemic control will allow our patients to receive a consistent message about diabetes, the unique limitations inherent to each practice setting requires different therapeutic regimens and intentional focus on the risks as patients transition from one care area to another. This work addresses several areas of care transition that are particularly important in safely achieving glycemic control including: transition into the hospital for patients on a variety of home regimens, transitions within the hospital (related to changes in dietary intake, change from IV to subcutaneous [SC] therapy, and the perioperative setting), and the transition from the hospital to home or another healthcare facility.

TRANSITION INTO THE HOSPITAL

Until recently, most patients with diabetes admitted to the hospital were managed with sliding‐scale‐only regimens.20, 21 Unfortunately, this led to a variety of complications, including hyperglycemia, hypoglycemia, iatrogenic ketoacidosis, and an inconsistent message to patients on the importance of glycemic control.22 Some outpatient clinicians and patients combated this tradition by creating in‐hospital glucose control plans with orders, which patients would bring with them to the hospital.23 This practice continues to be a helpful way to guide inpatient therapy and is encouraged when available. Glycemic‐controlrelated documents from outpatient clinicians should include the most recent glycosylated hemoglobin (HbA1c) value, diagnosis and known complications, current names and doses of medications, and other patient‐specific preferences or needs (eg, compliance, financial, fear of needles). If the last HbA1c was performed more than 30 days before admission or is not available, one should be obtained upon hospital admission to help guide discharge therapy.24 By knowing the HbA1c, one can determine the level of diabetic control achieved with the current regimen and can help the inpatient team (clinician and patient) determine if a more aggressive glycemic control regimen is necessary at the time of discharge. It is important to note that if the patient has received a transfusion of red blood cells prior to HbA1c measurement or has a hemoglobinopathy, the HbA1c value may not be accurate.25, 26

In general, the outpatient regimen will need to be modified at admission to achieve the appropriate flexibility needed for the changing nutritional intake and insulin requirements that invariably accompany hospitalization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors (DPP4), such as sitagliptin, have most of their effect immediately, but the other oral antihyperglycemic agents have a relatively long delay between treatment and effect, thus they are not a flexible enough method to achieve glycemic control in the hospital. Additionally, inpatients may have transient contraindications to their prior oral antihyperglycemic medications. Metformin is almost always on hold in the hospital setting, at least initially, due to concerns about lactic acidosis. Sulfonylureas can cause hypoglycemia in the setting of worsening renal function or reduced oral intake. Thiazoladinediones (TZDs) are often withheld due to concerns about fluid retention and should be avoided in patients admitted with heart failure. There is little experience in the hospital with the use of newer agents like exenatide, pramlintide, glinides, and DPP4 inhibitors.

Overall, it is generally recommended that oral antihyperglycemic agents be discontinued upon hospital admission and replaced with insulin infusions or scheduled SC insulin. An estimate of 0.4 to 0.5 units/kg of body weight provides a conservative starting point for the total daily dose of insulin (TDD) for most patients. This TDD should then be divided into basal and nutritional components to match the patients' caloric intake. Additional correction doses of insulin should be prescribed to cover episodes of hyperglycemia that develop despite the provision of anticipatory‐physiologic insulin. Further discussion of insulin dosing and SC regimens is available in detail elsewhere.27, 28 The recommendation for these insulin‐only regimens is made regardless of the glycemic control in the outpatient setting and is not meant to imply that they should be continued at discharge. In fact, most patients will return to their home regimen or to one that is intensified but less labor intensive than the basal‐nutritional‐correction insulin used in the hospital. The antihyperglycemic regimen planned for discharge should be anticipated as early as possible and clearly communicated to the patient and/or caregivers to allow for optimal education.

Outpatient insulin regimens that have a high percentage of basal insulin need to be modified during hospital admission to avoid hypoglycemia that may occur from variable nutritional intake. While hospitalized, the basal portion of the estimated TDD generally should not be more than 50% to 60%. The total number of units of all types of insulin used daily as an outpatient can be used as a starting point for determining the inpatient TDD by a 1:1 conversion. Adjustments up or down based on glycemic control, nutritional intake, and other factors are then necessary. If patients are on regimens with insulin plus oral agents at home, the inpatient TDD should either be the home insulin dose or the dose calculated based on their weight, whichever is greater. Patients who use carbohydrate counting to determine nutritional insulin doses as an outpatient might be continued on this regimen if they have a strong understanding of the methods, they are coherent enough to determine their doses, nursing staff are well educated, and dietary services provides the carbohydrate content for the hospital menu. If patients are on insulin pumps at home, these should be managed according to a uniform hospital policy to assure safety. If conversion to multiple daily injections is needed, the same 1:1 conversion is safe.29

TRANSITIONING FROM THE HOSPITAL

The final but perhaps most important transition is the one from the hospital. With much attention on glycemic control in the hospital, it will become clear to many clinicians that the outpatient regimen needs to be modified. However, any changes in medications increase the chances of hypoglycemia and the possibility of error. The postdischarge time frame has been poorly studied and was specifically identified by the Association for Clinical Endocrinologists (ACE) and American Diabetes Association (ADA) as an area in need of future research.36

Patients may be discharged to a nursing home, hospice, or home, and numerous factors need to be considered to determine the optimal discharge regimen. Important considerations are the HbA1c at admission, home medications, medication interactions, current medical problems, nutritional status, physical disabilities, frequency of self‐monitoring, hypoglycemic risk factors, contraindications to oral medications, goals of care/life expectancy, and financial and other resources. If there are temporary physical or self‐care limitations, then a visiting nurse may need to be arranged to assure a safe transition home with the optimal therapy. If patients are going to a skilled nursing facility or other acute care hospital, the formulary, processes, and staffing issues of that facility will be additional important considerations in determining whether therapy is the same as in the hospital or more like what it will be at home.

An algorithm for outpatient therapy for type 2 DM was recommended in a consensus statement from the ADA and European Association for the Study of Diabetes.42, 43 This has been modified using additional recommendations from the AACE44 and is depicted in Figure 1. While the delineation of these steps is helpful, it must be emphasized that both the choice of regimen and dose will need to be individualized. Prescribing the ideal frequently falls short if there is no way for the patient to implement the recommendations. Intensive insulin therapy requires training in food intake/emnsulin matching, motivation of the patient and outpatient clinician, 4 times daily self‐monitoring of blood glucose, and considerable expense. Some patients may be temporarily continued on basal‐nutritional‐correction regimens as their insulin requirements are rapidly changing and later converted to regimens that involve less frequent insulin doses, (ie, twice daily premixed insulin or basal insulin with oral agents or oral agents alone).45, 46 Other patients who may be medically appropriate for intensive insulin therapy may first need to gain confidence with more simple insulin regimens. There are numerous additional resources on initiating insulin that the reader is referred to for more detail.4448

Figure 1

Oral antihyperglycemic drugs are usually held while a patient is admitted to the hospital but once medical conditions are improved, oral intake is established, and renal function stabilized, these drugs can be restarted. If a patient has a new contraindication to metformin or sulfonylureas but does not need insulin, a TZD or DPP4 inhibitor should be considered. Elderly patients and those with renal or liver disease are at increased risk for developing hypoglycemia.49, 50 Glyburide should be avoided, and doses of other sulfonylureas may need to be adjusted. Other options that may be considered in this situation include sitagliptin and exenatide.51 When patients will be discharged on oral diabetic medications alone, discontinue the basal insulin 12 to 24 hours before and the scheduled nutritional insulin at the same time oral agents are restarted. Sulfonylureas, metformin, DPP4 inhibitors, and exenatide will have most of their effect in the first day, but TZDs have a delayed onset and may not be a good bridge for immediate control at discharge.

If patients are going to be discharged on basal insulin in addition to oral agents, several options exist for determining the dose. Because of the risk of hypoglycemia after discharge, it is advised to either reduce the doses of oral agents or choose more conservative insulin starting doses.52 One possibility is to discontinue the nutritional and correction doses, continue the hospital dose of basal insulin, and restart the oral antidiabetes medications. If the dose of basal insulin was more than 50% of the TDD of insulin, it may need to be reduced. A more conservative option for patients at a higher risk of hypoglycemia is to start 0.2 units/kg or 10 units of NPH, glargine, or detemir at bedtime (Figure 2). Once discharged, blood glucose should be measured 1 to 4 times a day and the basal dose titrated by several different validated methods.53, 54 Appropriate orders for necessary supplies for insulin therapy include a meter with test strips, lancets, syringes, needles, and glucagon kit.55

Figure 2

With a large number of patients with diabetes remaining undiagnosed, it is important to use the information available during hospitalization to identify previously unrecognized diabetes or prediabetes.24 Because there are no unique criteria for the diagnosis of DM in the stressed state, patients may have a presumptive diagnosis made in the hospital and/or follow‐up testing with fasting glucose or an oral glucose tolerance test. No ADA diagnostic thresholds for the HbA1c currently exist, but it can be a useful marker in making this distinction.56 Among patients with new hyperglycemia, an HbA1c of 6% or greater was 100% specific for predicting a future diagnosis of diabetes in the small prospective cohort study by Greci et al.,57 but many endocrinologists use a cutoff of 7%. For all hyperglycemic patients, lifestyle interventions that promote weight loss and increased activity levels should be encouraged. New hyperglycemia should be clearly identified as a diagnosis in discharge communication.

There are many barriers to diabetes self‐management education in the inpatient setting but there are also numerous resources and opportunities. New information will be available regarding patients' understanding of their disease and glycemic control and there may be plans for changes in the home medication regimen. Most of the focus of inpatient education sessions is on survival skills such as taking medications, performing blood glucose monitoring, basic meal planning, identification and treatment of hypoglycemia, sick‐day management, how to access further diabetes education as an outpatient, and when to call the healthcare team.58 The most effective way to accomplish all of this is to identify the discharge regimen early and include nurses and staff in a plan to educate all patients. An inpatient diabetes educator can provide additional help with newly‐diagnosed or uncontrolled patients. Dividing the material over the hospitalization makes it less overwhelming for patients, reinforces previously taught concepts, spreads the responsibility to more providers, and offers it in conjunction with the correlating clinical care. Throughout their hospital stay, patients can begin to practice new skills, including blood glucose monitoring and logbook use, drawing up and administering insulin, sharps disposal, basic diabetic diet information, and sick‐day management. The specific topics addressed in each session can be tracked as part of an interdisciplinary education record that allows coordination among the individuals involved in teaching.59 It is important to give patients the basics, support them with minimal written information, and provide them appropriate follow‐up diabetes education.60 Furthermore, the inpatient team should view the patient's glycemic control education as something that needs to continue across the continuum of care and develop communication strategies that connect with the follow‐up clinical team.

At the time of discharge, it is essential that written documentation and communication with outpatient care providers be completed.61, 62 The more standardized the inpatient insulin regimens are, the more likely the patient is to be on a much different glycemic control regimen than the one on admission; therefore, it is even more important to assure that the admission medication list is accurate and reconciled completely with the modified list at discharge. Discharge check lists and tools for assessing patient acceptance of the discharge plan help with this process.63 Follow‐up with the primary care physician should occur within 7 to 14 days if patients are new to insulin, had medication changes, or are elderly. An increased likelihood of keeping posthospitalization appointments with a diabetes specialty clinic has been associated with being discharged on insulin, a new diagnosis of diabetes, and direct referral.64 Additional attention should be paid to barriers to follow‐up, including lack of health insurance, prior difficulty with follow‐up, and transportation problems.65

SUMMARY

A variety of factors have contributed to difficulty in achieving inpatient and outpatient glucose control. These include care complexity, the lack of standardized protocols, limited knowledge about glucose control, and clinical inertia. Inpatient clinicians have a tendency toward keeping patients on their home regimen in hopes that they might test its effectiveness. Furthermore, there has been the notion of why optimize the glycemic regimen of inpatients because their diabetic needs will change in the outpatient setting. However, because the insulin requirements during acute illness are different and nutritional intake is variable, nearly all inpatients should be placed on multiple daily doses of scheduled insulin or IV insulin to allow the necessary flexibility for rapid titration and abrupt changes in nutrition. This intensive regimen is only appropriate for a minority of outpatients. This difference illustrates that a regimen that works perfectly in one clinical setting will not necessarily be optimal in the next. The patient's outpatient treatment regimen should be reassessed based on HbA1c, self‐monitoring prior to admission, and new contraindications based on medical issues. If a change is indicated and the inpatient physician is motivated, there are numerous helpful resources to aid in addressing all the necessary factors surrounding intensification of therapy.

Despite requiring different glycemic control regimens, the information gained from the needs in each setting guide the next, making communication and planning paramount. Important transitions that must be given attention are: (1) admission to the hospital; (2) in‐hospital transitions, including the perioperative period and IV‐to‐SC insulin; and (3) the hospital to outpatient transition. The complexity of such frequent transitions requires planning, education, and clear communication that are best handled with a systems approach and the development of standardized protocols and order sets. Hospitalists, endocrinologists, and other members of the healthcare team should take an aggressive role in developing systems and facilitating optimal transitions to maximize glycemic control. Further studies are needed to determine the best practices among the variety of options discussed in this article.

Professional and patient safety organizations have recognized the importance of safe transitions as patients move through the health care system, and such attention is even more critical when attempting to achieve glycemic control.14 Since the publication of the Diabetes Control and Complications Trial (DCCT)5 and the United Kingdom Prospective Diabetes Study (UKPDS),6 we have known that intensive glycemic control in the ambulatory setting prevents complications in both type 1 and type 2 diabetes mellitus (DM). Despite the increased risk of hypoglycemia, these trials changed practice patterns in the outpatient settings in favor of intensification of diabetes therapy. In the same way, randomized, prospective trials using intravenous (IV) insulin therapy have revolutionized our thinking about inpatient care by showing that tight glycemic control in the critically ill7 and patients with acute myocardial infarction8 reduces mortality and morbidity. These, as well as additional observational studies associating hyperglycemia with poor outcomes in a variety of medical and surgical patients,915 have led to increased attention on glycemic control in all venues of care.16, 17 Concerns over excessive hypoglycemia and a nonsignificant increase in mortality in certain populations of medical intensive care unit (ICU) patients have raised questions over whether the initial studies can be reproduced or generalized to other groups of inpatients.18, 19 Additional studies are underway to clarify these questions but consensus exists that blood glucose values should at least be less than 180 mg/dL and that the traditional practice of ignoring hyperglycemia is no longer acceptable.

While a uniform focus on glycemic control will allow our patients to receive a consistent message about diabetes, the unique limitations inherent to each practice setting requires different therapeutic regimens and intentional focus on the risks as patients transition from one care area to another. This work addresses several areas of care transition that are particularly important in safely achieving glycemic control including: transition into the hospital for patients on a variety of home regimens, transitions within the hospital (related to changes in dietary intake, change from IV to subcutaneous [SC] therapy, and the perioperative setting), and the transition from the hospital to home or another healthcare facility.

TRANSITION INTO THE HOSPITAL

Until recently, most patients with diabetes admitted to the hospital were managed with sliding‐scale‐only regimens.20, 21 Unfortunately, this led to a variety of complications, including hyperglycemia, hypoglycemia, iatrogenic ketoacidosis, and an inconsistent message to patients on the importance of glycemic control.22 Some outpatient clinicians and patients combated this tradition by creating in‐hospital glucose control plans with orders, which patients would bring with them to the hospital.23 This practice continues to be a helpful way to guide inpatient therapy and is encouraged when available. Glycemic‐controlrelated documents from outpatient clinicians should include the most recent glycosylated hemoglobin (HbA1c) value, diagnosis and known complications, current names and doses of medications, and other patient‐specific preferences or needs (eg, compliance, financial, fear of needles). If the last HbA1c was performed more than 30 days before admission or is not available, one should be obtained upon hospital admission to help guide discharge therapy.24 By knowing the HbA1c, one can determine the level of diabetic control achieved with the current regimen and can help the inpatient team (clinician and patient) determine if a more aggressive glycemic control regimen is necessary at the time of discharge. It is important to note that if the patient has received a transfusion of red blood cells prior to HbA1c measurement or has a hemoglobinopathy, the HbA1c value may not be accurate.25, 26

In general, the outpatient regimen will need to be modified at admission to achieve the appropriate flexibility needed for the changing nutritional intake and insulin requirements that invariably accompany hospitalization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors (DPP4), such as sitagliptin, have most of their effect immediately, but the other oral antihyperglycemic agents have a relatively long delay between treatment and effect, thus they are not a flexible enough method to achieve glycemic control in the hospital. Additionally, inpatients may have transient contraindications to their prior oral antihyperglycemic medications. Metformin is almost always on hold in the hospital setting, at least initially, due to concerns about lactic acidosis. Sulfonylureas can cause hypoglycemia in the setting of worsening renal function or reduced oral intake. Thiazoladinediones (TZDs) are often withheld due to concerns about fluid retention and should be avoided in patients admitted with heart failure. There is little experience in the hospital with the use of newer agents like exenatide, pramlintide, glinides, and DPP4 inhibitors.

Overall, it is generally recommended that oral antihyperglycemic agents be discontinued upon hospital admission and replaced with insulin infusions or scheduled SC insulin. An estimate of 0.4 to 0.5 units/kg of body weight provides a conservative starting point for the total daily dose of insulin (TDD) for most patients. This TDD should then be divided into basal and nutritional components to match the patients' caloric intake. Additional correction doses of insulin should be prescribed to cover episodes of hyperglycemia that develop despite the provision of anticipatory‐physiologic insulin. Further discussion of insulin dosing and SC regimens is available in detail elsewhere.27, 28 The recommendation for these insulin‐only regimens is made regardless of the glycemic control in the outpatient setting and is not meant to imply that they should be continued at discharge. In fact, most patients will return to their home regimen or to one that is intensified but less labor intensive than the basal‐nutritional‐correction insulin used in the hospital. The antihyperglycemic regimen planned for discharge should be anticipated as early as possible and clearly communicated to the patient and/or caregivers to allow for optimal education.

Outpatient insulin regimens that have a high percentage of basal insulin need to be modified during hospital admission to avoid hypoglycemia that may occur from variable nutritional intake. While hospitalized, the basal portion of the estimated TDD generally should not be more than 50% to 60%. The total number of units of all types of insulin used daily as an outpatient can be used as a starting point for determining the inpatient TDD by a 1:1 conversion. Adjustments up or down based on glycemic control, nutritional intake, and other factors are then necessary. If patients are on regimens with insulin plus oral agents at home, the inpatient TDD should either be the home insulin dose or the dose calculated based on their weight, whichever is greater. Patients who use carbohydrate counting to determine nutritional insulin doses as an outpatient might be continued on this regimen if they have a strong understanding of the methods, they are coherent enough to determine their doses, nursing staff are well educated, and dietary services provides the carbohydrate content for the hospital menu. If patients are on insulin pumps at home, these should be managed according to a uniform hospital policy to assure safety. If conversion to multiple daily injections is needed, the same 1:1 conversion is safe.29

TRANSITIONING FROM THE HOSPITAL

The final but perhaps most important transition is the one from the hospital. With much attention on glycemic control in the hospital, it will become clear to many clinicians that the outpatient regimen needs to be modified. However, any changes in medications increase the chances of hypoglycemia and the possibility of error. The postdischarge time frame has been poorly studied and was specifically identified by the Association for Clinical Endocrinologists (ACE) and American Diabetes Association (ADA) as an area in need of future research.36

Patients may be discharged to a nursing home, hospice, or home, and numerous factors need to be considered to determine the optimal discharge regimen. Important considerations are the HbA1c at admission, home medications, medication interactions, current medical problems, nutritional status, physical disabilities, frequency of self‐monitoring, hypoglycemic risk factors, contraindications to oral medications, goals of care/life expectancy, and financial and other resources. If there are temporary physical or self‐care limitations, then a visiting nurse may need to be arranged to assure a safe transition home with the optimal therapy. If patients are going to a skilled nursing facility or other acute care hospital, the formulary, processes, and staffing issues of that facility will be additional important considerations in determining whether therapy is the same as in the hospital or more like what it will be at home.

An algorithm for outpatient therapy for type 2 DM was recommended in a consensus statement from the ADA and European Association for the Study of Diabetes.42, 43 This has been modified using additional recommendations from the AACE44 and is depicted in Figure 1. While the delineation of these steps is helpful, it must be emphasized that both the choice of regimen and dose will need to be individualized. Prescribing the ideal frequently falls short if there is no way for the patient to implement the recommendations. Intensive insulin therapy requires training in food intake/emnsulin matching, motivation of the patient and outpatient clinician, 4 times daily self‐monitoring of blood glucose, and considerable expense. Some patients may be temporarily continued on basal‐nutritional‐correction regimens as their insulin requirements are rapidly changing and later converted to regimens that involve less frequent insulin doses, (ie, twice daily premixed insulin or basal insulin with oral agents or oral agents alone).45, 46 Other patients who may be medically appropriate for intensive insulin therapy may first need to gain confidence with more simple insulin regimens. There are numerous additional resources on initiating insulin that the reader is referred to for more detail.4448

Figure 1

Oral antihyperglycemic drugs are usually held while a patient is admitted to the hospital but once medical conditions are improved, oral intake is established, and renal function stabilized, these drugs can be restarted. If a patient has a new contraindication to metformin or sulfonylureas but does not need insulin, a TZD or DPP4 inhibitor should be considered. Elderly patients and those with renal or liver disease are at increased risk for developing hypoglycemia.49, 50 Glyburide should be avoided, and doses of other sulfonylureas may need to be adjusted. Other options that may be considered in this situation include sitagliptin and exenatide.51 When patients will be discharged on oral diabetic medications alone, discontinue the basal insulin 12 to 24 hours before and the scheduled nutritional insulin at the same time oral agents are restarted. Sulfonylureas, metformin, DPP4 inhibitors, and exenatide will have most of their effect in the first day, but TZDs have a delayed onset and may not be a good bridge for immediate control at discharge.

If patients are going to be discharged on basal insulin in addition to oral agents, several options exist for determining the dose. Because of the risk of hypoglycemia after discharge, it is advised to either reduce the doses of oral agents or choose more conservative insulin starting doses.52 One possibility is to discontinue the nutritional and correction doses, continue the hospital dose of basal insulin, and restart the oral antidiabetes medications. If the dose of basal insulin was more than 50% of the TDD of insulin, it may need to be reduced. A more conservative option for patients at a higher risk of hypoglycemia is to start 0.2 units/kg or 10 units of NPH, glargine, or detemir at bedtime (Figure 2). Once discharged, blood glucose should be measured 1 to 4 times a day and the basal dose titrated by several different validated methods.53, 54 Appropriate orders for necessary supplies for insulin therapy include a meter with test strips, lancets, syringes, needles, and glucagon kit.55

Figure 2

With a large number of patients with diabetes remaining undiagnosed, it is important to use the information available during hospitalization to identify previously unrecognized diabetes or prediabetes.24 Because there are no unique criteria for the diagnosis of DM in the stressed state, patients may have a presumptive diagnosis made in the hospital and/or follow‐up testing with fasting glucose or an oral glucose tolerance test. No ADA diagnostic thresholds for the HbA1c currently exist, but it can be a useful marker in making this distinction.56 Among patients with new hyperglycemia, an HbA1c of 6% or greater was 100% specific for predicting a future diagnosis of diabetes in the small prospective cohort study by Greci et al.,57 but many endocrinologists use a cutoff of 7%. For all hyperglycemic patients, lifestyle interventions that promote weight loss and increased activity levels should be encouraged. New hyperglycemia should be clearly identified as a diagnosis in discharge communication.

There are many barriers to diabetes self‐management education in the inpatient setting but there are also numerous resources and opportunities. New information will be available regarding patients' understanding of their disease and glycemic control and there may be plans for changes in the home medication regimen. Most of the focus of inpatient education sessions is on survival skills such as taking medications, performing blood glucose monitoring, basic meal planning, identification and treatment of hypoglycemia, sick‐day management, how to access further diabetes education as an outpatient, and when to call the healthcare team.58 The most effective way to accomplish all of this is to identify the discharge regimen early and include nurses and staff in a plan to educate all patients. An inpatient diabetes educator can provide additional help with newly‐diagnosed or uncontrolled patients. Dividing the material over the hospitalization makes it less overwhelming for patients, reinforces previously taught concepts, spreads the responsibility to more providers, and offers it in conjunction with the correlating clinical care. Throughout their hospital stay, patients can begin to practice new skills, including blood glucose monitoring and logbook use, drawing up and administering insulin, sharps disposal, basic diabetic diet information, and sick‐day management. The specific topics addressed in each session can be tracked as part of an interdisciplinary education record that allows coordination among the individuals involved in teaching.59 It is important to give patients the basics, support them with minimal written information, and provide them appropriate follow‐up diabetes education.60 Furthermore, the inpatient team should view the patient's glycemic control education as something that needs to continue across the continuum of care and develop communication strategies that connect with the follow‐up clinical team.

At the time of discharge, it is essential that written documentation and communication with outpatient care providers be completed.61, 62 The more standardized the inpatient insulin regimens are, the more likely the patient is to be on a much different glycemic control regimen than the one on admission; therefore, it is even more important to assure that the admission medication list is accurate and reconciled completely with the modified list at discharge. Discharge check lists and tools for assessing patient acceptance of the discharge plan help with this process.63 Follow‐up with the primary care physician should occur within 7 to 14 days if patients are new to insulin, had medication changes, or are elderly. An increased likelihood of keeping posthospitalization appointments with a diabetes specialty clinic has been associated with being discharged on insulin, a new diagnosis of diabetes, and direct referral.64 Additional attention should be paid to barriers to follow‐up, including lack of health insurance, prior difficulty with follow‐up, and transportation problems.65

SUMMARY

A variety of factors have contributed to difficulty in achieving inpatient and outpatient glucose control. These include care complexity, the lack of standardized protocols, limited knowledge about glucose control, and clinical inertia. Inpatient clinicians have a tendency toward keeping patients on their home regimen in hopes that they might test its effectiveness. Furthermore, there has been the notion of why optimize the glycemic regimen of inpatients because their diabetic needs will change in the outpatient setting. However, because the insulin requirements during acute illness are different and nutritional intake is variable, nearly all inpatients should be placed on multiple daily doses of scheduled insulin or IV insulin to allow the necessary flexibility for rapid titration and abrupt changes in nutrition. This intensive regimen is only appropriate for a minority of outpatients. This difference illustrates that a regimen that works perfectly in one clinical setting will not necessarily be optimal in the next. The patient's outpatient treatment regimen should be reassessed based on HbA1c, self‐monitoring prior to admission, and new contraindications based on medical issues. If a change is indicated and the inpatient physician is motivated, there are numerous helpful resources to aid in addressing all the necessary factors surrounding intensification of therapy.

Despite requiring different glycemic control regimens, the information gained from the needs in each setting guide the next, making communication and planning paramount. Important transitions that must be given attention are: (1) admission to the hospital; (2) in‐hospital transitions, including the perioperative period and IV‐to‐SC insulin; and (3) the hospital to outpatient transition. The complexity of such frequent transitions requires planning, education, and clear communication that are best handled with a systems approach and the development of standardized protocols and order sets. Hospitalists, endocrinologists, and other members of the healthcare team should take an aggressive role in developing systems and facilitating optimal transitions to maximize glycemic control. Further studies are needed to determine the best practices among the variety of options discussed in this article.

Professional and patient safety organizations have recognized the importance of safe transitions as patients move through the health care system, and such attention is even more critical when attempting to achieve glycemic control.14 Since the publication of the Diabetes Control and Complications Trial (DCCT)5 and the United Kingdom Prospective Diabetes Study (UKPDS),6 we have known that intensive glycemic control in the ambulatory setting prevents complications in both type 1 and type 2 diabetes mellitus (DM). Despite the increased risk of hypoglycemia, these trials changed practice patterns in the outpatient settings in favor of intensification of diabetes therapy. In the same way, randomized, prospective trials using intravenous (IV) insulin therapy have revolutionized our thinking about inpatient care by showing that tight glycemic control in the critically ill7 and patients with acute myocardial infarction8 reduces mortality and morbidity. These, as well as additional observational studies associating hyperglycemia with poor outcomes in a variety of medical and surgical patients,915 have led to increased attention on glycemic control in all venues of care.16, 17 Concerns over excessive hypoglycemia and a nonsignificant increase in mortality in certain populations of medical intensive care unit (ICU) patients have raised questions over whether the initial studies can be reproduced or generalized to other groups of inpatients.18, 19 Additional studies are underway to clarify these questions but consensus exists that blood glucose values should at least be less than 180 mg/dL and that the traditional practice of ignoring hyperglycemia is no longer acceptable.

While a uniform focus on glycemic control will allow our patients to receive a consistent message about diabetes, the unique limitations inherent to each practice setting requires different therapeutic regimens and intentional focus on the risks as patients transition from one care area to another. This work addresses several areas of care transition that are particularly important in safely achieving glycemic control including: transition into the hospital for patients on a variety of home regimens, transitions within the hospital (related to changes in dietary intake, change from IV to subcutaneous [SC] therapy, and the perioperative setting), and the transition from the hospital to home or another healthcare facility.

TRANSITION INTO THE HOSPITAL

Until recently, most patients with diabetes admitted to the hospital were managed with sliding‐scale‐only regimens.20, 21 Unfortunately, this led to a variety of complications, including hyperglycemia, hypoglycemia, iatrogenic ketoacidosis, and an inconsistent message to patients on the importance of glycemic control.22 Some outpatient clinicians and patients combated this tradition by creating in‐hospital glucose control plans with orders, which patients would bring with them to the hospital.23 This practice continues to be a helpful way to guide inpatient therapy and is encouraged when available. Glycemic‐controlrelated documents from outpatient clinicians should include the most recent glycosylated hemoglobin (HbA1c) value, diagnosis and known complications, current names and doses of medications, and other patient‐specific preferences or needs (eg, compliance, financial, fear of needles). If the last HbA1c was performed more than 30 days before admission or is not available, one should be obtained upon hospital admission to help guide discharge therapy.24 By knowing the HbA1c, one can determine the level of diabetic control achieved with the current regimen and can help the inpatient team (clinician and patient) determine if a more aggressive glycemic control regimen is necessary at the time of discharge. It is important to note that if the patient has received a transfusion of red blood cells prior to HbA1c measurement or has a hemoglobinopathy, the HbA1c value may not be accurate.25, 26

In general, the outpatient regimen will need to be modified at admission to achieve the appropriate flexibility needed for the changing nutritional intake and insulin requirements that invariably accompany hospitalization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors (DPP4), such as sitagliptin, have most of their effect immediately, but the other oral antihyperglycemic agents have a relatively long delay between treatment and effect, thus they are not a flexible enough method to achieve glycemic control in the hospital. Additionally, inpatients may have transient contraindications to their prior oral antihyperglycemic medications. Metformin is almost always on hold in the hospital setting, at least initially, due to concerns about lactic acidosis. Sulfonylureas can cause hypoglycemia in the setting of worsening renal function or reduced oral intake. Thiazoladinediones (TZDs) are often withheld due to concerns about fluid retention and should be avoided in patients admitted with heart failure. There is little experience in the hospital with the use of newer agents like exenatide, pramlintide, glinides, and DPP4 inhibitors.

Overall, it is generally recommended that oral antihyperglycemic agents be discontinued upon hospital admission and replaced with insulin infusions or scheduled SC insulin. An estimate of 0.4 to 0.5 units/kg of body weight provides a conservative starting point for the total daily dose of insulin (TDD) for most patients. This TDD should then be divided into basal and nutritional components to match the patients' caloric intake. Additional correction doses of insulin should be prescribed to cover episodes of hyperglycemia that develop despite the provision of anticipatory‐physiologic insulin. Further discussion of insulin dosing and SC regimens is available in detail elsewhere.27, 28 The recommendation for these insulin‐only regimens is made regardless of the glycemic control in the outpatient setting and is not meant to imply that they should be continued at discharge. In fact, most patients will return to their home regimen or to one that is intensified but less labor intensive than the basal‐nutritional‐correction insulin used in the hospital. The antihyperglycemic regimen planned for discharge should be anticipated as early as possible and clearly communicated to the patient and/or caregivers to allow for optimal education.

Outpatient insulin regimens that have a high percentage of basal insulin need to be modified during hospital admission to avoid hypoglycemia that may occur from variable nutritional intake. While hospitalized, the basal portion of the estimated TDD generally should not be more than 50% to 60%. The total number of units of all types of insulin used daily as an outpatient can be used as a starting point for determining the inpatient TDD by a 1:1 conversion. Adjustments up or down based on glycemic control, nutritional intake, and other factors are then necessary. If patients are on regimens with insulin plus oral agents at home, the inpatient TDD should either be the home insulin dose or the dose calculated based on their weight, whichever is greater. Patients who use carbohydrate counting to determine nutritional insulin doses as an outpatient might be continued on this regimen if they have a strong understanding of the methods, they are coherent enough to determine their doses, nursing staff are well educated, and dietary services provides the carbohydrate content for the hospital menu. If patients are on insulin pumps at home, these should be managed according to a uniform hospital policy to assure safety. If conversion to multiple daily injections is needed, the same 1:1 conversion is safe.29

TRANSITIONING FROM THE HOSPITAL

The final but perhaps most important transition is the one from the hospital. With much attention on glycemic control in the hospital, it will become clear to many clinicians that the outpatient regimen needs to be modified. However, any changes in medications increase the chances of hypoglycemia and the possibility of error. The postdischarge time frame has been poorly studied and was specifically identified by the Association for Clinical Endocrinologists (ACE) and American Diabetes Association (ADA) as an area in need of future research.36

Patients may be discharged to a nursing home, hospice, or home, and numerous factors need to be considered to determine the optimal discharge regimen. Important considerations are the HbA1c at admission, home medications, medication interactions, current medical problems, nutritional status, physical disabilities, frequency of self‐monitoring, hypoglycemic risk factors, contraindications to oral medications, goals of care/life expectancy, and financial and other resources. If there are temporary physical or self‐care limitations, then a visiting nurse may need to be arranged to assure a safe transition home with the optimal therapy. If patients are going to a skilled nursing facility or other acute care hospital, the formulary, processes, and staffing issues of that facility will be additional important considerations in determining whether therapy is the same as in the hospital or more like what it will be at home.

An algorithm for outpatient therapy for type 2 DM was recommended in a consensus statement from the ADA and European Association for the Study of Diabetes.42, 43 This has been modified using additional recommendations from the AACE44 and is depicted in Figure 1. While the delineation of these steps is helpful, it must be emphasized that both the choice of regimen and dose will need to be individualized. Prescribing the ideal frequently falls short if there is no way for the patient to implement the recommendations. Intensive insulin therapy requires training in food intake/emnsulin matching, motivation of the patient and outpatient clinician, 4 times daily self‐monitoring of blood glucose, and considerable expense. Some patients may be temporarily continued on basal‐nutritional‐correction regimens as their insulin requirements are rapidly changing and later converted to regimens that involve less frequent insulin doses, (ie, twice daily premixed insulin or basal insulin with oral agents or oral agents alone).45, 46 Other patients who may be medically appropriate for intensive insulin therapy may first need to gain confidence with more simple insulin regimens. There are numerous additional resources on initiating insulin that the reader is referred to for more detail.4448

Figure 1

Oral antihyperglycemic drugs are usually held while a patient is admitted to the hospital but once medical conditions are improved, oral intake is established, and renal function stabilized, these drugs can be restarted. If a patient has a new contraindication to metformin or sulfonylureas but does not need insulin, a TZD or DPP4 inhibitor should be considered. Elderly patients and those with renal or liver disease are at increased risk for developing hypoglycemia.49, 50 Glyburide should be avoided, and doses of other sulfonylureas may need to be adjusted. Other options that may be considered in this situation include sitagliptin and exenatide.51 When patients will be discharged on oral diabetic medications alone, discontinue the basal insulin 12 to 24 hours before and the scheduled nutritional insulin at the same time oral agents are restarted. Sulfonylureas, metformin, DPP4 inhibitors, and exenatide will have most of their effect in the first day, but TZDs have a delayed onset and may not be a good bridge for immediate control at discharge.

If patients are going to be discharged on basal insulin in addition to oral agents, several options exist for determining the dose. Because of the risk of hypoglycemia after discharge, it is advised to either reduce the doses of oral agents or choose more conservative insulin starting doses.52 One possibility is to discontinue the nutritional and correction doses, continue the hospital dose of basal insulin, and restart the oral antidiabetes medications. If the dose of basal insulin was more than 50% of the TDD of insulin, it may need to be reduced. A more conservative option for patients at a higher risk of hypoglycemia is to start 0.2 units/kg or 10 units of NPH, glargine, or detemir at bedtime (Figure 2). Once discharged, blood glucose should be measured 1 to 4 times a day and the basal dose titrated by several different validated methods.53, 54 Appropriate orders for necessary supplies for insulin therapy include a meter with test strips, lancets, syringes, needles, and glucagon kit.55

Figure 2

With a large number of patients with diabetes remaining undiagnosed, it is important to use the information available during hospitalization to identify previously unrecognized diabetes or prediabetes.24 Because there are no unique criteria for the diagnosis of DM in the stressed state, patients may have a presumptive diagnosis made in the hospital and/or follow‐up testing with fasting glucose or an oral glucose tolerance test. No ADA diagnostic thresholds for the HbA1c currently exist, but it can be a useful marker in making this distinction.56 Among patients with new hyperglycemia, an HbA1c of 6% or greater was 100% specific for predicting a future diagnosis of diabetes in the small prospective cohort study by Greci et al.,57 but many endocrinologists use a cutoff of 7%. For all hyperglycemic patients, lifestyle interventions that promote weight loss and increased activity levels should be encouraged. New hyperglycemia should be clearly identified as a diagnosis in discharge communication.

There are many barriers to diabetes self‐management education in the inpatient setting but there are also numerous resources and opportunities. New information will be available regarding patients' understanding of their disease and glycemic control and there may be plans for changes in the home medication regimen. Most of the focus of inpatient education sessions is on survival skills such as taking medications, performing blood glucose monitoring, basic meal planning, identification and treatment of hypoglycemia, sick‐day management, how to access further diabetes education as an outpatient, and when to call the healthcare team.58 The most effective way to accomplish all of this is to identify the discharge regimen early and include nurses and staff in a plan to educate all patients. An inpatient diabetes educator can provide additional help with newly‐diagnosed or uncontrolled patients. Dividing the material over the hospitalization makes it less overwhelming for patients, reinforces previously taught concepts, spreads the responsibility to more providers, and offers it in conjunction with the correlating clinical care. Throughout their hospital stay, patients can begin to practice new skills, including blood glucose monitoring and logbook use, drawing up and administering insulin, sharps disposal, basic diabetic diet information, and sick‐day management. The specific topics addressed in each session can be tracked as part of an interdisciplinary education record that allows coordination among the individuals involved in teaching.59 It is important to give patients the basics, support them with minimal written information, and provide them appropriate follow‐up diabetes education.60 Furthermore, the inpatient team should view the patient's glycemic control education as something that needs to continue across the continuum of care and develop communication strategies that connect with the follow‐up clinical team.

At the time of discharge, it is essential that written documentation and communication with outpatient care providers be completed.61, 62 The more standardized the inpatient insulin regimens are, the more likely the patient is to be on a much different glycemic control regimen than the one on admission; therefore, it is even more important to assure that the admission medication list is accurate and reconciled completely with the modified list at discharge. Discharge check lists and tools for assessing patient acceptance of the discharge plan help with this process.63 Follow‐up with the primary care physician should occur within 7 to 14 days if patients are new to insulin, had medication changes, or are elderly. An increased likelihood of keeping posthospitalization appointments with a diabetes specialty clinic has been associated with being discharged on insulin, a new diagnosis of diabetes, and direct referral.64 Additional attention should be paid to barriers to follow‐up, including lack of health insurance, prior difficulty with follow‐up, and transportation problems.65

SUMMARY

A variety of factors have contributed to difficulty in achieving inpatient and outpatient glucose control. These include care complexity, the lack of standardized protocols, limited knowledge about glucose control, and clinical inertia. Inpatient clinicians have a tendency toward keeping patients on their home regimen in hopes that they might test its effectiveness. Furthermore, there has been the notion of why optimize the glycemic regimen of inpatients because their diabetic needs will change in the outpatient setting. However, because the insulin requirements during acute illness are different and nutritional intake is variable, nearly all inpatients should be placed on multiple daily doses of scheduled insulin or IV insulin to allow the necessary flexibility for rapid titration and abrupt changes in nutrition. This intensive regimen is only appropriate for a minority of outpatients. This difference illustrates that a regimen that works perfectly in one clinical setting will not necessarily be optimal in the next. The patient's outpatient treatment regimen should be reassessed based on HbA1c, self‐monitoring prior to admission, and new contraindications based on medical issues. If a change is indicated and the inpatient physician is motivated, there are numerous helpful resources to aid in addressing all the necessary factors surrounding intensification of therapy.

Despite requiring different glycemic control regimens, the information gained from the needs in each setting guide the next, making communication and planning paramount. Important transitions that must be given attention are: (1) admission to the hospital; (2) in‐hospital transitions, including the perioperative period and IV‐to‐SC insulin; and (3) the hospital to outpatient transition. The complexity of such frequent transitions requires planning, education, and clear communication that are best handled with a systems approach and the development of standardized protocols and order sets. Hospitalists, endocrinologists, and other members of the healthcare team should take an aggressive role in developing systems and facilitating optimal transitions to maximize glycemic control. Further studies are needed to determine the best practices among the variety of options discussed in this article.

Medical centers are faced with multiple competing priorities when deciding how to focus their improvement efforts and meet the ever expanding menu of publicly reported and regulatory issues. In this article we expand on the rationale for supporting inpatient glycemic control programs as a priority that should be moved near the top of the list. We review the evidence for establishing glycemic range targets, and also review the limitations of this evidence, acknowledging, as does the American Diabetes Association (ADA), that in both the critical care and non‐critical care venue, glycemic goals must take into account the individual patient's situation as well as hospital system support for achieving these goals.1, 2 We emphasize that inpatient glycemic control programs are needed to address a wide variety of quality and safety issues surrounding the care of the inpatient with diabetes and hyperglycemia, and we wish to elevate the dialogue beyond arguments surrounding adoption of one glycemic target versus another. The Society of Hospital Medicine Glycemic Control Task Force members are not in unanimous agreement with the American Association of Clinical Endocrinologists (AACE)/ADA inpatient glycemic targets. However, we do agree on several other important points, which we will expand on in this article:

• 1

  Uncontrolled hyperglycemia and iatrogenic hypoglycemia are common and potentially dangerous situations that are largely preventable with safe and proven methods.

• 2

  The current state of care for our inpatients with hyperglycemia is unacceptably poor on a broad scale, with substandard education, communication, coordination, and treatment issues.

• 3

  Concerted efforts with changes in the design of the process of care are needed to improve this state of affairs.

DIABETES AND HYPERGLYCEMIA ARE VERY COMMON INPATIENT CONDITIONS

Diabetes mellitus (DM) has reached epidemic proportions in the United States. A reported 9.3% of adults over 20 years of age have diabetes, representing over 20 million persons. Despite increasing awareness, diabetes remains undiagnosed in approximately 30% of these persons.3 Concurrent with the increasing prevalence of diabetes in the U.S. population from 1980 through 2003, the number of hospital discharges with diabetes as any listed diagnosis more than doubled, going from 2.2 to 5.1 million discharges.4 Hospital care for patients with diabetes and hyperglycemia poses a significant health economic burden in the United States, representing over 40 billion dollars in annual direct medical expenditures.5

Hyperglycemia in the hospital may be due to known diabetes, to previously unrecognized diabetes, to prediabetes, and/or to the stress of surgery or illness. Deterioration in glycemic control in the hospital setting is most commonly associated with one or more factors, including stress‐induced release of insulin counterregulatory hormones (catecholamines, cortisol, glucagon, and growth hormone), exogenous administration of high dose glucocorticoids, and suboptimal glycemic management strategies.68 In a Belgian medical intensive care unit (MICU) randomized controlled trial (RCT) of strict versus conventional glycemic control, mean blood glucose (BG) on admission to the unit in the intention to treat group was 162 70 mg/dL (n = 1200),9 and in this group's RCT of 1548 surgical intensive care unit (SICU) patients, BG > 110 mg/dL was observed in over 70% of subjects.10 Mean BG of >145 mg/dL has been reported in 39%11 and BG >200 mg/dL in anywhere from 11% to 31% of intensive care unit (ICU) patients.10, 12 For general medicine and surgery, 1 study of 2030 patients admitted to a teaching hospital revealed that 26% of admissions had a known history of DM and 12% had new hyperglycemia, as evidenced by an admission or in‐hospital fasting BG of 126 mg/dL or more or a random BG of 200 mg/dL or more on 2 or more determinations.13 National and regional estimates on hospital use maintained by the Agency for Healthcare Research and Quality include data concerning diabetes diagnoses alone, without hyperglycemia, and may be displayed by querying its Web site.14 In cardiovascular populations almost 70% of patients having a first myocardial infarction have been reported to have either known DM, previously unrecognized diabetes, or impaired glucose tolerance.15

THE EVIDENCE SUPPORTS INPATIENT GLYCEMIC CONTROL

INPATIENT GLYCEMIC CONTROL IS INCREASINGLY INCORPORATED INTO PUBLIC REPORTING, GUIDELINES, REGULATORY AGENCY, AND NATIONAL QUALITY INITIATIVE PRIORITIES

National quality initiatives, public reporting, pay‐for‐performance, and guideline‐based care continue to play an increasingly important role in the U.S. healthcare system. Over the years these initiatives have focused on various disease states (venous thromboembolism, congestive heart failure, community‐acquired pneumonia, etc.) in an attempt to standardize care and improve patient safety and quality. Inpatient hyperglycemic control is also increasingly being incorporated into public reporting, regulatory compliance, and national quality initiatives.

Professional organizations such as the ADA2 and AACE50 have published guidelines supporting improved glycemic control, the safe use of insulin, and other measures to improve care for hyperglycemic inpatients. The AACE has a Web site dedicated to hospital hyperglycemia.52 The Society of Hospital Medicine48 has created a resource room on its Web site and a workbook for improvement49 on optimizing the care of inpatients with hyperglycemia and diabetes. The guidelines and Web sites help raise awareness and educate physicians and healthcare workers in inpatient glucose management. The American Heart Association has incorporated specific recommendation regarding inpatient diabetic management in its Get With the Guidelines.53

The Joint Commission54 has developed an advanced disease‐specific certification on inpatient diabetes. Disease management programs are important components of complex healthcare systems that serve to coordinate chronic care, promote early detection and prevention, and reduce overall healthcare costs. Certification is increasingly important to providers, payers, and healthcare institutions because it demonstrates a commitment to quality and patient safety. The Joint Commission disease‐specific care certification is a patient‐centered model focusing on the delivery of clinical care and relationship between the practitioner and the patient. The evaluation and resulting certification by the Joint Commission is based on 3 core components: (1) an assessment of compliance with consensus‐based national standards; (2) the effective use of established clinical practice guidelines to manage and optimize care; and (3) an organized approach to performance measurement and improved activities.55 For inpatient diabetes, the Joint Commission program has 7 major elements following the ADA recommendations, including general recommendations regarding diabetic documentation, BG targets, preventing hypoglycemia, diabetes care providers, diabetes self‐management education, medical nutrition therapy, and BG monitoring.54 This mirrors the Call to Action Consensus Conference essential elements for successful glycemic control programs.1

Other organizations such as the Surgical Care Improvement Partnership (SCIP) and National Surgical Quality Improvement Program (NSQIP) have included perioperative glycemic control measures, as it impacts surgical wound infections. The University HealthSystem Consortium (UHC) has benchmarking data and endorses perioperative glycemic control measures, whereas the Institute for Healthcare Improvement (IHI) has focused on safe use of insulin practices in its 5 Million Lives campaign.

HOSPITALIZATION IS A MOMENT OF OPPORTUNITY TO ASSESS AND INTERVENE

The benefits of outpatient glycemic control and quality preventive care are well established, and the reduction of adverse consequences of uncontrolled diabetes are a high priority in ambulatory medicine.5658 Hospitalization provides an opportunity to identify previously undiagnosed diabetes or prediabetes and, for patients with known diabetes, to assess and impact upon the long term course of diabetes.

As a first step, unless a recent hemoglobin A1C (HbA1c) is known, among hospitalized hyperglycemic patients an HbA1C should be obtained upon admission. Greci et al.59 showed that an HbA1c level >6.0% was 100% specific (14/14) and 57% sensitive (12/21) for the diagnosis of diabetes. Among patients having known diabetes, an HbA1C elevation on admission may justify intensification of preadmission management at the time of discharge. If discharge and postdischarge adjustments of preadmission regimens are planned in response to admission A1C elevations, then the modified long‐term treatment strategy can improve the A1C in the ambulatory setting.60 Moreover, the event of hospitalization is the ideal teachable moment for patients and their caregivers to improve self‐care activities. Yet floor nurses may be overwhelmed by the tasks of patient education. For ideal patient education, both a nutritionist and a diabetes nurse educator are needed to assess compliance with medication, diet, and other aspects of care.6163 There also is need for outpatient follow‐up education. Finally, at the time of discharge, there is a duty and an opportunity for the diabetes provider to communicate with outpatient care providers about the patient's regimen and glycemic control, and also, based on information gathered during the admission, to convey any evidence that might support the need for a change of long‐term strategy.64 Unfortunately, the opportunity that hospitalization presents to assess, educate, and intervene frequently is underused.1, 8, 51, 65

LARGE GAPS EXIST BETWEEN CURRENT AND OPTIMAL CARE

Despite the evidence that inpatient glycemic control is important for patient outcomes, and despite guidelines recommending tighter inpatient glycemic control, clinical practice has been slow to change. In many institutions, inpatient glycemic management has not improved over the past decade, and large gaps remain between current practice and optimal practice.

Studies of individual institutions provide several insights into gaps in care. For example, Schnipper et al.66 examined practices on the general medicine service of an academic medical center in Boston in 2004. Among 107 prospectively identified patients with a known diagnosis of diabetes or at least 1 glucose reading >200 mg/dL (excluding patients with diabetic ketoacidosis, hyperglycemic hyperosmolar state, or pregnancy), they found scheduled long‐acting insulin prescribed in 43% of patients, scheduled short‐acting/rapid‐acting insulin in only 4% of patients, and 80 of 89 patients (90%) on the same sliding scale insulin regimen despite widely varying insulin requirements. Thirty‐one percent of glucose readings were >180 mg/dL compared with 1.2% of readings 60 mg/dL (but 11% of patients had at least 1 episode of hypoglycemia). Of the 75 patients with at least 1 episode of hyperglycemia or hypoglycemia, only 35% had any change to their insulin regimen during the first 5 days of the hospitalization.

Other studies have confirmed this concept of clinical inertia (ie, recognition of the problem but failure to act).67 A study by Cook et al.68 of all hospitalized non‐ICU patients with diabetes or hyperglycemia and length of stay of 3 days between 2001 and 2004 showed that 20% of patients had persistent hyperglycemia during the hospitalization (defined as a mean glucose >200 mg/dL). Forty‐six percent of patients whose average glucose was in the top tertile did not have their insulin regimen intensified to a combination of short‐acting/rapid‐acting and long‐acting insulin, and 35% of these patients either had no change in their total daily insulin dose or actually had a decrease in their dose when comparing the last 24 hours with the first 24 hours of hospitalization, a concept they term negative therapeutic momentum.

Perhaps the most well‐balanced view of the current state of medical practice comes from the UHC benchmarking project.69 UHC is an alliance of 90 academic health centers. For the diabetes project, each institution reviewed the records of 50 randomly selected patients over 18 years of age with at least a 72‐hour length of stay, 1 of 7 prespecified Diagnosis Related Group (DRG) codes, and at least 2 consecutive glucose readings >180 mg/dL or the receipt of insulin any time during the hospitalization. Patients with a history of pancreatic transplant, pregnant at the time of admission, receiving hospice or comfort care, or receiving insulin for a reason other than glucose management were excluded. The study showed widespread gaps in processes and outcomes (Table 1). Moreover, performance varied widely across hospitals. For example, the morning glucose in the ICU on the second measurement day was 110 mg/dL in 18% of patients for the median‐performing hospital, with a range of 0% to 67% across all 37 measured hospitals. In the non‐ICU setting on the second measurement day, 26% of patients had all BG measurements = 180 mg/dL in the median‐performing hospital, with a range of 7% to 48%. Of note, hypoglycemia was relatively uncommon: in the median hospital, 2.4% of patient‐days had 1 or more BG readings 50 mg/dL (range: 0%8.6%). Finally, in the median‐performing hospital, effective insulin therapy (defined as short‐acting/rapid‐acting and long‐acting subcutaneous insulin, continuous insulin infusion, or subcutaneous insulin pump therapy) was prescribed in 45% of patients, with a range of 12% to 77% across measured hospitals.

FREQUENT PROBLEMS WITH COMMUNICATION AND COORDINATION

Those who work closely with frontline practitioners striving to improve inpatient glycemic management have noticed other deficiencies in care.1, 70 These include: a lack of coordination between feeding, BG measurement, and insulin administration, leading to mistimed and incorrectly dosed insulin; frequent use of sliding‐scale only regimens despite evidence that they are useless at best and harmful at worst;6, 47, 60, 71 discharge summaries that often do not mention follow‐up plans for hyperglycemic management; incomplete patient educational programs; breakdowns in care at transition points; nursing and medical staffs that are unevenly educated about the proper use of insulin; and patients who are often angry or confused about their diabetes care in the hospital. Collectively, these gaps in care serve as prime targets for any glycemic control program.

HYPOGLYCEMIA IS A PROMINENT INPATIENT SAFETY CONCERN

Hypoglycemia is common in the inpatient setting and is a legitimate safety concern. In a recently reported series of 2174 hospitalized patients receiving antihyperglycemic agents, it was found that 9.5% of patients experienced a total 484 hypoglycemic episodes (defined as 60 mg/dL).72 Hypoglycemia often occurred in the setting of insulin therapy and frequently resulted from a failure to recognize trends in BG readings or other clues that a patient was at risk for developing hypoglycemia.73 A common thread is the risk created by interruption of carbohydrate intake, noted by Fischer et al.73 and once again in the recent ICU study by Vriesendorp et al.74 Sources of error include: lack of coordination between feeding and medication administration, leading to mistiming of insulin action; lack of sufficient frequency in BG monitoring; lack of clarity or uniformity in the writing of orders; failure to recognize changes in insulin requirements due to advanced age, renal failure, liver disease, or change in clinical status; steroid use with subsequent tapering or interruption; changes in feeding; failure to reconcile medications; inappropriate use of oral antihyperglycemic agents, and communication or handoff failures.

It has been difficult to sort out whether hypoglycemia is a marker of severity of illness or whether it is an independent factor leading to poor outcomes. Observational studies lend credibility to the concept that patients having congestive heart failure or myocardial infarction may be at risk for excessive mortality if their average BG resides in the low end of the normal range.7578 Sympathetic activation occurs as the threshold for hypoglycemia is approached, such as occurs at BG = 70 or 72 mg/dL.79 Patients living with BG levels observed to be in the low end of the normal range might experience more severe but unobserved and undocumented episodes of neuroglycopenia. Arrhythmia and fatality have been directly attributed to strict glycemic control.80, 81 We are confronted with the need to interpret well conducted observational studies, evaluating subgroups at risk, and using multivariate analysis to assess the impact of hypoglycemia upon outcomes.82 In such studies, we will need to examine high‐risk subgroups, including cardiac patients, in particular, for the possibility that there is a J‐shaped curve for mortality as a function of average BG.

Unfortunately, clinical inertia exists in response to hypoglycemia just as it does with hyperglycemia. One recent study examined 52 patients who received intravenous 50% dextrose solution for an episode of hypoglycemia.83 Changes to insulin regimens were subsequently made in only 21 patients (40%), and diabetes specialists agreed with the changes for 11 of these patients. The other 31 patients (60%) received no changes in treatment, and diabetes specialists agreed with that decision for only 10 of these patients.

Although some increase in hypoglycemia might be expected with initiation of tight glycemic control efforts, the solution is not to undertreat hyperglycemia. Hyperglycemia creates an unsafe setting for the treatment of illness and disease. Sliding‐scaleonly regimens are ineffective in securing glycemic control and can result in increases in hypoglycemia as well as hyperglycemic excursions.6, 66 Inappropriate withholding of insulin doses can lead to severe glycemic excursions and even iatrogenic diabetic ketoacidosis (DKA). Systems approaches to avoid the errors outlined above can minimize or even reverse the increased risk of hypoglycemia expected with tighter glycemic targets.51

A SYSTEMS APPROACH IS NEEDED FOR THESE MULTIPLE COMPLEX PROBLEMS

Care is of the hyperglycemic inpatient is inherently complex. Previously established treatments are often inappropriate under conditions of altered insulin resistance, changing patterns of nutrition and carbohydrate exposure, comorbidities, concomitant medications, and rapidly changing medical and surgical status. Patients frequently undergo changes in the route and amount of nutritional exposure, including discrete meals, continuous intravenous dextrose, nil per orem (nothing by mouth status; NPO) status, grazing on nutritional supplements or liquid diets with or without meals, bolus enteral feedings, overnight enteral feedings with daytime grazing, total parenteral nutrition, continuous peritoneal dialysis, and overnight cycling of peritoneal dialysis. Relying on individual expertise and vigilance to negotiate this complex terrain without safeguards, protocols, standardization of orders, and other systems change is impractical and unwise.

Transitions across care providers and locations lead to multiple opportunities for breakdown in the quality, consistency, and safety of care.64, 65 At the time of ward transfer or change of patient status, previous medication and monitoring orders sometimes are purged. At the time of discharge, there may be risk of continuation of anti‐hyperglycemic therapy, initiated to cover medical stress, in doses that will subsequently be unsafe.

In the face of this complexity, educational programs alone will not suffice to improve care. Institutional commitment and systems changes are essential.

MARKED IMPROVEMENT IS POSSIBLE AND TOOLS EXIST: A ROADMAP IS IN PLACE

Fortunately, a roadmap is in place to help us achieve better glycemic control, improve insulin management, and address the long list of current deficiencies in care. This is imperative to develop consistent processes in order to achieve maximum patient quality outcomes that effective glycemic management offers. This roadmap entails 4 components: (1) national awareness, (2) national guidelines, (3) consensus statements, and (4) effective tools. As mentioned above, the first two components of this roadmap are now in place.

As these national guidelines become more widely accepted, the next step will be the incorporation of this into programs like Pay‐for Performance and the Physician Quality Reporting Initiative (PQRI), which will impact reimbursement to both hospitals and providers.

Regarding the third component, a recent multidisciplinary consensus conference1 outlined the essential elements needed for successful implementation of an inpatient glycemic control program which include:

• An appropriate level of administrative support.

• Formation of a multidisciplinary steering committee to drive the development of initiatives and empowered to enact change.

• Assessment of current processes, quality of care, and barriers to practice change.

• Development and implementation of interventions including standardized order sets, protocols, policies and algorithms with associated educational programs.

• Metrics for evaluation of glycemic control, hypoglycemia, insulin use patterns, and other aspects of care.

Finally, extensive resources and effective tools are now available to help institutions achieve better inpatient glucose control. The Society of Hospital Medicine (SHM), in conjunction with the ADA, AACE, the American College of Physicians (ACP), the Case Management Society of America (CMSA), the American Society of Consultant Pharmacists, nursing, and diabetic educators have all partnered to produce a comprehensive guide to effective implementation of glycemic control and preventing hypoglycemia.49 This comprehensive workbook is a proven performance improvement framework and is available on the SHM Web site.48 Details and examples of all essential elements are covered in this workbook along with opportunities for marked improvement bolstered by integration of high reliability design features and attention to effective implementation techniques. The remainder of this supplement crystallizes a substantial portion of this material. The AACE has also recently offered a valuable web‐based resource to encourage institutional glycemic control efforts.49

GLYCEMIC CONTROL INITIATIVES CAN BE COST‐EFFECTIVE

Achieving optimal glycemic control safely requires monitoring, education, and other measures, which can be expensive, labor intensive, and require coordination of the services of many hospital divisions. This incremental expense has been shown to be cost‐effective in a variety of settings.1, 84, 85 The costs of glycemic control initiatives have demonstrated a good return on investment via:

• Improved LOS, readmission rates, morbidity, and mortality.

• Improved documentation of patient acuity and related payment for acuity.

• Income generated via incremental physician and allied health professional billing.

CONCLUSION AND SUMMARY

Evidence exists that appropriate management of hyperglycemia improves outcomes, whereas the current state of affairs is that most medical centers currently manage this suboptimally. This is concerning given the magnitude of diabetes and hyperglycemia in our inpatient setting in the United States. To bring awareness to this issue, multiple initiatives (guidelines, certification programs, workbooks, etc.) are available by various organizations including the ADA, AACE, SCIP, NSQIP, IHI, UHC, the Joint Commission, and SHM. However, this is not enough. Change occurs at the local level, and institutional prioritization and support is needed to empower a multidisciplinary steering committee, with appropriate administrative support, to standardize and improve systems in the face of substantial cultural issues and complex barriers. Improved data collection and reporting, incremental monitoring, creation of metrics, and improved documentation are an absolutely necessary necessity to achieve breakthrough levels of improvement.

Now the time is right to make an assertive effort to improve inpatient glycemic control and related issues, and push for appropriate support at your institution to help achieve this in the interest of patient safety and optimal outcomes.

Medical centers are faced with multiple competing priorities when deciding how to focus their improvement efforts and meet the ever expanding menu of publicly reported and regulatory issues. In this article we expand on the rationale for supporting inpatient glycemic control programs as a priority that should be moved near the top of the list. We review the evidence for establishing glycemic range targets, and also review the limitations of this evidence, acknowledging, as does the American Diabetes Association (ADA), that in both the critical care and non‐critical care venue, glycemic goals must take into account the individual patient's situation as well as hospital system support for achieving these goals.1, 2 We emphasize that inpatient glycemic control programs are needed to address a wide variety of quality and safety issues surrounding the care of the inpatient with diabetes and hyperglycemia, and we wish to elevate the dialogue beyond arguments surrounding adoption of one glycemic target versus another. The Society of Hospital Medicine Glycemic Control Task Force members are not in unanimous agreement with the American Association of Clinical Endocrinologists (AACE)/ADA inpatient glycemic targets. However, we do agree on several other important points, which we will expand on in this article:

• 1

  Uncontrolled hyperglycemia and iatrogenic hypoglycemia are common and potentially dangerous situations that are largely preventable with safe and proven methods.

• 2

  The current state of care for our inpatients with hyperglycemia is unacceptably poor on a broad scale, with substandard education, communication, coordination, and treatment issues.

• 3

  Concerted efforts with changes in the design of the process of care are needed to improve this state of affairs.

DIABETES AND HYPERGLYCEMIA ARE VERY COMMON INPATIENT CONDITIONS

Diabetes mellitus (DM) has reached epidemic proportions in the United States. A reported 9.3% of adults over 20 years of age have diabetes, representing over 20 million persons. Despite increasing awareness, diabetes remains undiagnosed in approximately 30% of these persons.3 Concurrent with the increasing prevalence of diabetes in the U.S. population from 1980 through 2003, the number of hospital discharges with diabetes as any listed diagnosis more than doubled, going from 2.2 to 5.1 million discharges.4 Hospital care for patients with diabetes and hyperglycemia poses a significant health economic burden in the United States, representing over 40 billion dollars in annual direct medical expenditures.5

Hyperglycemia in the hospital may be due to known diabetes, to previously unrecognized diabetes, to prediabetes, and/or to the stress of surgery or illness. Deterioration in glycemic control in the hospital setting is most commonly associated with one or more factors, including stress‐induced release of insulin counterregulatory hormones (catecholamines, cortisol, glucagon, and growth hormone), exogenous administration of high dose glucocorticoids, and suboptimal glycemic management strategies.68 In a Belgian medical intensive care unit (MICU) randomized controlled trial (RCT) of strict versus conventional glycemic control, mean blood glucose (BG) on admission to the unit in the intention to treat group was 162 70 mg/dL (n = 1200),9 and in this group's RCT of 1548 surgical intensive care unit (SICU) patients, BG > 110 mg/dL was observed in over 70% of subjects.10 Mean BG of >145 mg/dL has been reported in 39%11 and BG >200 mg/dL in anywhere from 11% to 31% of intensive care unit (ICU) patients.10, 12 For general medicine and surgery, 1 study of 2030 patients admitted to a teaching hospital revealed that 26% of admissions had a known history of DM and 12% had new hyperglycemia, as evidenced by an admission or in‐hospital fasting BG of 126 mg/dL or more or a random BG of 200 mg/dL or more on 2 or more determinations.13 National and regional estimates on hospital use maintained by the Agency for Healthcare Research and Quality include data concerning diabetes diagnoses alone, without hyperglycemia, and may be displayed by querying its Web site.14 In cardiovascular populations almost 70% of patients having a first myocardial infarction have been reported to have either known DM, previously unrecognized diabetes, or impaired glucose tolerance.15

THE EVIDENCE SUPPORTS INPATIENT GLYCEMIC CONTROL

INPATIENT GLYCEMIC CONTROL IS INCREASINGLY INCORPORATED INTO PUBLIC REPORTING, GUIDELINES, REGULATORY AGENCY, AND NATIONAL QUALITY INITIATIVE PRIORITIES

National quality initiatives, public reporting, pay‐for‐performance, and guideline‐based care continue to play an increasingly important role in the U.S. healthcare system. Over the years these initiatives have focused on various disease states (venous thromboembolism, congestive heart failure, community‐acquired pneumonia, etc.) in an attempt to standardize care and improve patient safety and quality. Inpatient hyperglycemic control is also increasingly being incorporated into public reporting, regulatory compliance, and national quality initiatives.

Professional organizations such as the ADA2 and AACE50 have published guidelines supporting improved glycemic control, the safe use of insulin, and other measures to improve care for hyperglycemic inpatients. The AACE has a Web site dedicated to hospital hyperglycemia.52 The Society of Hospital Medicine48 has created a resource room on its Web site and a workbook for improvement49 on optimizing the care of inpatients with hyperglycemia and diabetes. The guidelines and Web sites help raise awareness and educate physicians and healthcare workers in inpatient glucose management. The American Heart Association has incorporated specific recommendation regarding inpatient diabetic management in its Get With the Guidelines.53

The Joint Commission54 has developed an advanced disease‐specific certification on inpatient diabetes. Disease management programs are important components of complex healthcare systems that serve to coordinate chronic care, promote early detection and prevention, and reduce overall healthcare costs. Certification is increasingly important to providers, payers, and healthcare institutions because it demonstrates a commitment to quality and patient safety. The Joint Commission disease‐specific care certification is a patient‐centered model focusing on the delivery of clinical care and relationship between the practitioner and the patient. The evaluation and resulting certification by the Joint Commission is based on 3 core components: (1) an assessment of compliance with consensus‐based national standards; (2) the effective use of established clinical practice guidelines to manage and optimize care; and (3) an organized approach to performance measurement and improved activities.55 For inpatient diabetes, the Joint Commission program has 7 major elements following the ADA recommendations, including general recommendations regarding diabetic documentation, BG targets, preventing hypoglycemia, diabetes care providers, diabetes self‐management education, medical nutrition therapy, and BG monitoring.54 This mirrors the Call to Action Consensus Conference essential elements for successful glycemic control programs.1

Other organizations such as the Surgical Care Improvement Partnership (SCIP) and National Surgical Quality Improvement Program (NSQIP) have included perioperative glycemic control measures, as it impacts surgical wound infections. The University HealthSystem Consortium (UHC) has benchmarking data and endorses perioperative glycemic control measures, whereas the Institute for Healthcare Improvement (IHI) has focused on safe use of insulin practices in its 5 Million Lives campaign.

HOSPITALIZATION IS A MOMENT OF OPPORTUNITY TO ASSESS AND INTERVENE

The benefits of outpatient glycemic control and quality preventive care are well established, and the reduction of adverse consequences of uncontrolled diabetes are a high priority in ambulatory medicine.5658 Hospitalization provides an opportunity to identify previously undiagnosed diabetes or prediabetes and, for patients with known diabetes, to assess and impact upon the long term course of diabetes.

As a first step, unless a recent hemoglobin A1C (HbA1c) is known, among hospitalized hyperglycemic patients an HbA1C should be obtained upon admission. Greci et al.59 showed that an HbA1c level >6.0% was 100% specific (14/14) and 57% sensitive (12/21) for the diagnosis of diabetes. Among patients having known diabetes, an HbA1C elevation on admission may justify intensification of preadmission management at the time of discharge. If discharge and postdischarge adjustments of preadmission regimens are planned in response to admission A1C elevations, then the modified long‐term treatment strategy can improve the A1C in the ambulatory setting.60 Moreover, the event of hospitalization is the ideal teachable moment for patients and their caregivers to improve self‐care activities. Yet floor nurses may be overwhelmed by the tasks of patient education. For ideal patient education, both a nutritionist and a diabetes nurse educator are needed to assess compliance with medication, diet, and other aspects of care.6163 There also is need for outpatient follow‐up education. Finally, at the time of discharge, there is a duty and an opportunity for the diabetes provider to communicate with outpatient care providers about the patient's regimen and glycemic control, and also, based on information gathered during the admission, to convey any evidence that might support the need for a change of long‐term strategy.64 Unfortunately, the opportunity that hospitalization presents to assess, educate, and intervene frequently is underused.1, 8, 51, 65

LARGE GAPS EXIST BETWEEN CURRENT AND OPTIMAL CARE

Despite the evidence that inpatient glycemic control is important for patient outcomes, and despite guidelines recommending tighter inpatient glycemic control, clinical practice has been slow to change. In many institutions, inpatient glycemic management has not improved over the past decade, and large gaps remain between current practice and optimal practice.

Studies of individual institutions provide several insights into gaps in care. For example, Schnipper et al.66 examined practices on the general medicine service of an academic medical center in Boston in 2004. Among 107 prospectively identified patients with a known diagnosis of diabetes or at least 1 glucose reading >200 mg/dL (excluding patients with diabetic ketoacidosis, hyperglycemic hyperosmolar state, or pregnancy), they found scheduled long‐acting insulin prescribed in 43% of patients, scheduled short‐acting/rapid‐acting insulin in only 4% of patients, and 80 of 89 patients (90%) on the same sliding scale insulin regimen despite widely varying insulin requirements. Thirty‐one percent of glucose readings were >180 mg/dL compared with 1.2% of readings 60 mg/dL (but 11% of patients had at least 1 episode of hypoglycemia). Of the 75 patients with at least 1 episode of hyperglycemia or hypoglycemia, only 35% had any change to their insulin regimen during the first 5 days of the hospitalization.

Other studies have confirmed this concept of clinical inertia (ie, recognition of the problem but failure to act).67 A study by Cook et al.68 of all hospitalized non‐ICU patients with diabetes or hyperglycemia and length of stay of 3 days between 2001 and 2004 showed that 20% of patients had persistent hyperglycemia during the hospitalization (defined as a mean glucose >200 mg/dL). Forty‐six percent of patients whose average glucose was in the top tertile did not have their insulin regimen intensified to a combination of short‐acting/rapid‐acting and long‐acting insulin, and 35% of these patients either had no change in their total daily insulin dose or actually had a decrease in their dose when comparing the last 24 hours with the first 24 hours of hospitalization, a concept they term negative therapeutic momentum.

Perhaps the most well‐balanced view of the current state of medical practice comes from the UHC benchmarking project.69 UHC is an alliance of 90 academic health centers. For the diabetes project, each institution reviewed the records of 50 randomly selected patients over 18 years of age with at least a 72‐hour length of stay, 1 of 7 prespecified Diagnosis Related Group (DRG) codes, and at least 2 consecutive glucose readings >180 mg/dL or the receipt of insulin any time during the hospitalization. Patients with a history of pancreatic transplant, pregnant at the time of admission, receiving hospice or comfort care, or receiving insulin for a reason other than glucose management were excluded. The study showed widespread gaps in processes and outcomes (Table 1). Moreover, performance varied widely across hospitals. For example, the morning glucose in the ICU on the second measurement day was 110 mg/dL in 18% of patients for the median‐performing hospital, with a range of 0% to 67% across all 37 measured hospitals. In the non‐ICU setting on the second measurement day, 26% of patients had all BG measurements = 180 mg/dL in the median‐performing hospital, with a range of 7% to 48%. Of note, hypoglycemia was relatively uncommon: in the median hospital, 2.4% of patient‐days had 1 or more BG readings 50 mg/dL (range: 0%8.6%). Finally, in the median‐performing hospital, effective insulin therapy (defined as short‐acting/rapid‐acting and long‐acting subcutaneous insulin, continuous insulin infusion, or subcutaneous insulin pump therapy) was prescribed in 45% of patients, with a range of 12% to 77% across measured hospitals.

FREQUENT PROBLEMS WITH COMMUNICATION AND COORDINATION

Those who work closely with frontline practitioners striving to improve inpatient glycemic management have noticed other deficiencies in care.1, 70 These include: a lack of coordination between feeding, BG measurement, and insulin administration, leading to mistimed and incorrectly dosed insulin; frequent use of sliding‐scale only regimens despite evidence that they are useless at best and harmful at worst;6, 47, 60, 71 discharge summaries that often do not mention follow‐up plans for hyperglycemic management; incomplete patient educational programs; breakdowns in care at transition points; nursing and medical staffs that are unevenly educated about the proper use of insulin; and patients who are often angry or confused about their diabetes care in the hospital. Collectively, these gaps in care serve as prime targets for any glycemic control program.

HYPOGLYCEMIA IS A PROMINENT INPATIENT SAFETY CONCERN

Hypoglycemia is common in the inpatient setting and is a legitimate safety concern. In a recently reported series of 2174 hospitalized patients receiving antihyperglycemic agents, it was found that 9.5% of patients experienced a total 484 hypoglycemic episodes (defined as 60 mg/dL).72 Hypoglycemia often occurred in the setting of insulin therapy and frequently resulted from a failure to recognize trends in BG readings or other clues that a patient was at risk for developing hypoglycemia.73 A common thread is the risk created by interruption of carbohydrate intake, noted by Fischer et al.73 and once again in the recent ICU study by Vriesendorp et al.74 Sources of error include: lack of coordination between feeding and medication administration, leading to mistiming of insulin action; lack of sufficient frequency in BG monitoring; lack of clarity or uniformity in the writing of orders; failure to recognize changes in insulin requirements due to advanced age, renal failure, liver disease, or change in clinical status; steroid use with subsequent tapering or interruption; changes in feeding; failure to reconcile medications; inappropriate use of oral antihyperglycemic agents, and communication or handoff failures.

It has been difficult to sort out whether hypoglycemia is a marker of severity of illness or whether it is an independent factor leading to poor outcomes. Observational studies lend credibility to the concept that patients having congestive heart failure or myocardial infarction may be at risk for excessive mortality if their average BG resides in the low end of the normal range.7578 Sympathetic activation occurs as the threshold for hypoglycemia is approached, such as occurs at BG = 70 or 72 mg/dL.79 Patients living with BG levels observed to be in the low end of the normal range might experience more severe but unobserved and undocumented episodes of neuroglycopenia. Arrhythmia and fatality have been directly attributed to strict glycemic control.80, 81 We are confronted with the need to interpret well conducted observational studies, evaluating subgroups at risk, and using multivariate analysis to assess the impact of hypoglycemia upon outcomes.82 In such studies, we will need to examine high‐risk subgroups, including cardiac patients, in particular, for the possibility that there is a J‐shaped curve for mortality as a function of average BG.

Unfortunately, clinical inertia exists in response to hypoglycemia just as it does with hyperglycemia. One recent study examined 52 patients who received intravenous 50% dextrose solution for an episode of hypoglycemia.83 Changes to insulin regimens were subsequently made in only 21 patients (40%), and diabetes specialists agreed with the changes for 11 of these patients. The other 31 patients (60%) received no changes in treatment, and diabetes specialists agreed with that decision for only 10 of these patients.

Although some increase in hypoglycemia might be expected with initiation of tight glycemic control efforts, the solution is not to undertreat hyperglycemia. Hyperglycemia creates an unsafe setting for the treatment of illness and disease. Sliding‐scaleonly regimens are ineffective in securing glycemic control and can result in increases in hypoglycemia as well as hyperglycemic excursions.6, 66 Inappropriate withholding of insulin doses can lead to severe glycemic excursions and even iatrogenic diabetic ketoacidosis (DKA). Systems approaches to avoid the errors outlined above can minimize or even reverse the increased risk of hypoglycemia expected with tighter glycemic targets.51

A SYSTEMS APPROACH IS NEEDED FOR THESE MULTIPLE COMPLEX PROBLEMS

Care is of the hyperglycemic inpatient is inherently complex. Previously established treatments are often inappropriate under conditions of altered insulin resistance, changing patterns of nutrition and carbohydrate exposure, comorbidities, concomitant medications, and rapidly changing medical and surgical status. Patients frequently undergo changes in the route and amount of nutritional exposure, including discrete meals, continuous intravenous dextrose, nil per orem (nothing by mouth status; NPO) status, grazing on nutritional supplements or liquid diets with or without meals, bolus enteral feedings, overnight enteral feedings with daytime grazing, total parenteral nutrition, continuous peritoneal dialysis, and overnight cycling of peritoneal dialysis. Relying on individual expertise and vigilance to negotiate this complex terrain without safeguards, protocols, standardization of orders, and other systems change is impractical and unwise.

Transitions across care providers and locations lead to multiple opportunities for breakdown in the quality, consistency, and safety of care.64, 65 At the time of ward transfer or change of patient status, previous medication and monitoring orders sometimes are purged. At the time of discharge, there may be risk of continuation of anti‐hyperglycemic therapy, initiated to cover medical stress, in doses that will subsequently be unsafe.

In the face of this complexity, educational programs alone will not suffice to improve care. Institutional commitment and systems changes are essential.

MARKED IMPROVEMENT IS POSSIBLE AND TOOLS EXIST: A ROADMAP IS IN PLACE

Fortunately, a roadmap is in place to help us achieve better glycemic control, improve insulin management, and address the long list of current deficiencies in care. This is imperative to develop consistent processes in order to achieve maximum patient quality outcomes that effective glycemic management offers. This roadmap entails 4 components: (1) national awareness, (2) national guidelines, (3) consensus statements, and (4) effective tools. As mentioned above, the first two components of this roadmap are now in place.

As these national guidelines become more widely accepted, the next step will be the incorporation of this into programs like Pay‐for Performance and the Physician Quality Reporting Initiative (PQRI), which will impact reimbursement to both hospitals and providers.

Regarding the third component, a recent multidisciplinary consensus conference1 outlined the essential elements needed for successful implementation of an inpatient glycemic control program which include:

• An appropriate level of administrative support.

• Formation of a multidisciplinary steering committee to drive the development of initiatives and empowered to enact change.

• Assessment of current processes, quality of care, and barriers to practice change.

• Development and implementation of interventions including standardized order sets, protocols, policies and algorithms with associated educational programs.

• Metrics for evaluation of glycemic control, hypoglycemia, insulin use patterns, and other aspects of care.

Finally, extensive resources and effective tools are now available to help institutions achieve better inpatient glucose control. The Society of Hospital Medicine (SHM), in conjunction with the ADA, AACE, the American College of Physicians (ACP), the Case Management Society of America (CMSA), the American Society of Consultant Pharmacists, nursing, and diabetic educators have all partnered to produce a comprehensive guide to effective implementation of glycemic control and preventing hypoglycemia.49 This comprehensive workbook is a proven performance improvement framework and is available on the SHM Web site.48 Details and examples of all essential elements are covered in this workbook along with opportunities for marked improvement bolstered by integration of high reliability design features and attention to effective implementation techniques. The remainder of this supplement crystallizes a substantial portion of this material. The AACE has also recently offered a valuable web‐based resource to encourage institutional glycemic control efforts.49

GLYCEMIC CONTROL INITIATIVES CAN BE COST‐EFFECTIVE

Achieving optimal glycemic control safely requires monitoring, education, and other measures, which can be expensive, labor intensive, and require coordination of the services of many hospital divisions. This incremental expense has been shown to be cost‐effective in a variety of settings.1, 84, 85 The costs of glycemic control initiatives have demonstrated a good return on investment via:

• Improved LOS, readmission rates, morbidity, and mortality.

• Improved documentation of patient acuity and related payment for acuity.

• Income generated via incremental physician and allied health professional billing.

CONCLUSION AND SUMMARY

Evidence exists that appropriate management of hyperglycemia improves outcomes, whereas the current state of affairs is that most medical centers currently manage this suboptimally. This is concerning given the magnitude of diabetes and hyperglycemia in our inpatient setting in the United States. To bring awareness to this issue, multiple initiatives (guidelines, certification programs, workbooks, etc.) are available by various organizations including the ADA, AACE, SCIP, NSQIP, IHI, UHC, the Joint Commission, and SHM. However, this is not enough. Change occurs at the local level, and institutional prioritization and support is needed to empower a multidisciplinary steering committee, with appropriate administrative support, to standardize and improve systems in the face of substantial cultural issues and complex barriers. Improved data collection and reporting, incremental monitoring, creation of metrics, and improved documentation are an absolutely necessary necessity to achieve breakthrough levels of improvement.

Now the time is right to make an assertive effort to improve inpatient glycemic control and related issues, and push for appropriate support at your institution to help achieve this in the interest of patient safety and optimal outcomes.

Medical centers are faced with multiple competing priorities when deciding how to focus their improvement efforts and meet the ever expanding menu of publicly reported and regulatory issues. In this article we expand on the rationale for supporting inpatient glycemic control programs as a priority that should be moved near the top of the list. We review the evidence for establishing glycemic range targets, and also review the limitations of this evidence, acknowledging, as does the American Diabetes Association (ADA), that in both the critical care and non‐critical care venue, glycemic goals must take into account the individual patient's situation as well as hospital system support for achieving these goals.1, 2 We emphasize that inpatient glycemic control programs are needed to address a wide variety of quality and safety issues surrounding the care of the inpatient with diabetes and hyperglycemia, and we wish to elevate the dialogue beyond arguments surrounding adoption of one glycemic target versus another. The Society of Hospital Medicine Glycemic Control Task Force members are not in unanimous agreement with the American Association of Clinical Endocrinologists (AACE)/ADA inpatient glycemic targets. However, we do agree on several other important points, which we will expand on in this article:

• 1

  Uncontrolled hyperglycemia and iatrogenic hypoglycemia are common and potentially dangerous situations that are largely preventable with safe and proven methods.

• 2

  The current state of care for our inpatients with hyperglycemia is unacceptably poor on a broad scale, with substandard education, communication, coordination, and treatment issues.

• 3

  Concerted efforts with changes in the design of the process of care are needed to improve this state of affairs.

DIABETES AND HYPERGLYCEMIA ARE VERY COMMON INPATIENT CONDITIONS

Diabetes mellitus (DM) has reached epidemic proportions in the United States. A reported 9.3% of adults over 20 years of age have diabetes, representing over 20 million persons. Despite increasing awareness, diabetes remains undiagnosed in approximately 30% of these persons.3 Concurrent with the increasing prevalence of diabetes in the U.S. population from 1980 through 2003, the number of hospital discharges with diabetes as any listed diagnosis more than doubled, going from 2.2 to 5.1 million discharges.4 Hospital care for patients with diabetes and hyperglycemia poses a significant health economic burden in the United States, representing over 40 billion dollars in annual direct medical expenditures.5

Hyperglycemia in the hospital may be due to known diabetes, to previously unrecognized diabetes, to prediabetes, and/or to the stress of surgery or illness. Deterioration in glycemic control in the hospital setting is most commonly associated with one or more factors, including stress‐induced release of insulin counterregulatory hormones (catecholamines, cortisol, glucagon, and growth hormone), exogenous administration of high dose glucocorticoids, and suboptimal glycemic management strategies.68 In a Belgian medical intensive care unit (MICU) randomized controlled trial (RCT) of strict versus conventional glycemic control, mean blood glucose (BG) on admission to the unit in the intention to treat group was 162 70 mg/dL (n = 1200),9 and in this group's RCT of 1548 surgical intensive care unit (SICU) patients, BG > 110 mg/dL was observed in over 70% of subjects.10 Mean BG of >145 mg/dL has been reported in 39%11 and BG >200 mg/dL in anywhere from 11% to 31% of intensive care unit (ICU) patients.10, 12 For general medicine and surgery, 1 study of 2030 patients admitted to a teaching hospital revealed that 26% of admissions had a known history of DM and 12% had new hyperglycemia, as evidenced by an admission or in‐hospital fasting BG of 126 mg/dL or more or a random BG of 200 mg/dL or more on 2 or more determinations.13 National and regional estimates on hospital use maintained by the Agency for Healthcare Research and Quality include data concerning diabetes diagnoses alone, without hyperglycemia, and may be displayed by querying its Web site.14 In cardiovascular populations almost 70% of patients having a first myocardial infarction have been reported to have either known DM, previously unrecognized diabetes, or impaired glucose tolerance.15

THE EVIDENCE SUPPORTS INPATIENT GLYCEMIC CONTROL

INPATIENT GLYCEMIC CONTROL IS INCREASINGLY INCORPORATED INTO PUBLIC REPORTING, GUIDELINES, REGULATORY AGENCY, AND NATIONAL QUALITY INITIATIVE PRIORITIES

National quality initiatives, public reporting, pay‐for‐performance, and guideline‐based care continue to play an increasingly important role in the U.S. healthcare system. Over the years these initiatives have focused on various disease states (venous thromboembolism, congestive heart failure, community‐acquired pneumonia, etc.) in an attempt to standardize care and improve patient safety and quality. Inpatient hyperglycemic control is also increasingly being incorporated into public reporting, regulatory compliance, and national quality initiatives.

Professional organizations such as the ADA2 and AACE50 have published guidelines supporting improved glycemic control, the safe use of insulin, and other measures to improve care for hyperglycemic inpatients. The AACE has a Web site dedicated to hospital hyperglycemia.52 The Society of Hospital Medicine48 has created a resource room on its Web site and a workbook for improvement49 on optimizing the care of inpatients with hyperglycemia and diabetes. The guidelines and Web sites help raise awareness and educate physicians and healthcare workers in inpatient glucose management. The American Heart Association has incorporated specific recommendation regarding inpatient diabetic management in its Get With the Guidelines.53

The Joint Commission54 has developed an advanced disease‐specific certification on inpatient diabetes. Disease management programs are important components of complex healthcare systems that serve to coordinate chronic care, promote early detection and prevention, and reduce overall healthcare costs. Certification is increasingly important to providers, payers, and healthcare institutions because it demonstrates a commitment to quality and patient safety. The Joint Commission disease‐specific care certification is a patient‐centered model focusing on the delivery of clinical care and relationship between the practitioner and the patient. The evaluation and resulting certification by the Joint Commission is based on 3 core components: (1) an assessment of compliance with consensus‐based national standards; (2) the effective use of established clinical practice guidelines to manage and optimize care; and (3) an organized approach to performance measurement and improved activities.55 For inpatient diabetes, the Joint Commission program has 7 major elements following the ADA recommendations, including general recommendations regarding diabetic documentation, BG targets, preventing hypoglycemia, diabetes care providers, diabetes self‐management education, medical nutrition therapy, and BG monitoring.54 This mirrors the Call to Action Consensus Conference essential elements for successful glycemic control programs.1

Other organizations such as the Surgical Care Improvement Partnership (SCIP) and National Surgical Quality Improvement Program (NSQIP) have included perioperative glycemic control measures, as it impacts surgical wound infections. The University HealthSystem Consortium (UHC) has benchmarking data and endorses perioperative glycemic control measures, whereas the Institute for Healthcare Improvement (IHI) has focused on safe use of insulin practices in its 5 Million Lives campaign.

HOSPITALIZATION IS A MOMENT OF OPPORTUNITY TO ASSESS AND INTERVENE

The benefits of outpatient glycemic control and quality preventive care are well established, and the reduction of adverse consequences of uncontrolled diabetes are a high priority in ambulatory medicine.5658 Hospitalization provides an opportunity to identify previously undiagnosed diabetes or prediabetes and, for patients with known diabetes, to assess and impact upon the long term course of diabetes.

As a first step, unless a recent hemoglobin A1C (HbA1c) is known, among hospitalized hyperglycemic patients an HbA1C should be obtained upon admission. Greci et al.59 showed that an HbA1c level >6.0% was 100% specific (14/14) and 57% sensitive (12/21) for the diagnosis of diabetes. Among patients having known diabetes, an HbA1C elevation on admission may justify intensification of preadmission management at the time of discharge. If discharge and postdischarge adjustments of preadmission regimens are planned in response to admission A1C elevations, then the modified long‐term treatment strategy can improve the A1C in the ambulatory setting.60 Moreover, the event of hospitalization is the ideal teachable moment for patients and their caregivers to improve self‐care activities. Yet floor nurses may be overwhelmed by the tasks of patient education. For ideal patient education, both a nutritionist and a diabetes nurse educator are needed to assess compliance with medication, diet, and other aspects of care.6163 There also is need for outpatient follow‐up education. Finally, at the time of discharge, there is a duty and an opportunity for the diabetes provider to communicate with outpatient care providers about the patient's regimen and glycemic control, and also, based on information gathered during the admission, to convey any evidence that might support the need for a change of long‐term strategy.64 Unfortunately, the opportunity that hospitalization presents to assess, educate, and intervene frequently is underused.1, 8, 51, 65

LARGE GAPS EXIST BETWEEN CURRENT AND OPTIMAL CARE

Despite the evidence that inpatient glycemic control is important for patient outcomes, and despite guidelines recommending tighter inpatient glycemic control, clinical practice has been slow to change. In many institutions, inpatient glycemic management has not improved over the past decade, and large gaps remain between current practice and optimal practice.

Studies of individual institutions provide several insights into gaps in care. For example, Schnipper et al.66 examined practices on the general medicine service of an academic medical center in Boston in 2004. Among 107 prospectively identified patients with a known diagnosis of diabetes or at least 1 glucose reading >200 mg/dL (excluding patients with diabetic ketoacidosis, hyperglycemic hyperosmolar state, or pregnancy), they found scheduled long‐acting insulin prescribed in 43% of patients, scheduled short‐acting/rapid‐acting insulin in only 4% of patients, and 80 of 89 patients (90%) on the same sliding scale insulin regimen despite widely varying insulin requirements. Thirty‐one percent of glucose readings were >180 mg/dL compared with 1.2% of readings 60 mg/dL (but 11% of patients had at least 1 episode of hypoglycemia). Of the 75 patients with at least 1 episode of hyperglycemia or hypoglycemia, only 35% had any change to their insulin regimen during the first 5 days of the hospitalization.

Other studies have confirmed this concept of clinical inertia (ie, recognition of the problem but failure to act).67 A study by Cook et al.68 of all hospitalized non‐ICU patients with diabetes or hyperglycemia and length of stay of 3 days between 2001 and 2004 showed that 20% of patients had persistent hyperglycemia during the hospitalization (defined as a mean glucose >200 mg/dL). Forty‐six percent of patients whose average glucose was in the top tertile did not have their insulin regimen intensified to a combination of short‐acting/rapid‐acting and long‐acting insulin, and 35% of these patients either had no change in their total daily insulin dose or actually had a decrease in their dose when comparing the last 24 hours with the first 24 hours of hospitalization, a concept they term negative therapeutic momentum.

Perhaps the most well‐balanced view of the current state of medical practice comes from the UHC benchmarking project.69 UHC is an alliance of 90 academic health centers. For the diabetes project, each institution reviewed the records of 50 randomly selected patients over 18 years of age with at least a 72‐hour length of stay, 1 of 7 prespecified Diagnosis Related Group (DRG) codes, and at least 2 consecutive glucose readings >180 mg/dL or the receipt of insulin any time during the hospitalization. Patients with a history of pancreatic transplant, pregnant at the time of admission, receiving hospice or comfort care, or receiving insulin for a reason other than glucose management were excluded. The study showed widespread gaps in processes and outcomes (Table 1). Moreover, performance varied widely across hospitals. For example, the morning glucose in the ICU on the second measurement day was 110 mg/dL in 18% of patients for the median‐performing hospital, with a range of 0% to 67% across all 37 measured hospitals. In the non‐ICU setting on the second measurement day, 26% of patients had all BG measurements = 180 mg/dL in the median‐performing hospital, with a range of 7% to 48%. Of note, hypoglycemia was relatively uncommon: in the median hospital, 2.4% of patient‐days had 1 or more BG readings 50 mg/dL (range: 0%8.6%). Finally, in the median‐performing hospital, effective insulin therapy (defined as short‐acting/rapid‐acting and long‐acting subcutaneous insulin, continuous insulin infusion, or subcutaneous insulin pump therapy) was prescribed in 45% of patients, with a range of 12% to 77% across measured hospitals.

FREQUENT PROBLEMS WITH COMMUNICATION AND COORDINATION

Those who work closely with frontline practitioners striving to improve inpatient glycemic management have noticed other deficiencies in care.1, 70 These include: a lack of coordination between feeding, BG measurement, and insulin administration, leading to mistimed and incorrectly dosed insulin; frequent use of sliding‐scale only regimens despite evidence that they are useless at best and harmful at worst;6, 47, 60, 71 discharge summaries that often do not mention follow‐up plans for hyperglycemic management; incomplete patient educational programs; breakdowns in care at transition points; nursing and medical staffs that are unevenly educated about the proper use of insulin; and patients who are often angry or confused about their diabetes care in the hospital. Collectively, these gaps in care serve as prime targets for any glycemic control program.

HYPOGLYCEMIA IS A PROMINENT INPATIENT SAFETY CONCERN

Hypoglycemia is common in the inpatient setting and is a legitimate safety concern. In a recently reported series of 2174 hospitalized patients receiving antihyperglycemic agents, it was found that 9.5% of patients experienced a total 484 hypoglycemic episodes (defined as 60 mg/dL).72 Hypoglycemia often occurred in the setting of insulin therapy and frequently resulted from a failure to recognize trends in BG readings or other clues that a patient was at risk for developing hypoglycemia.73 A common thread is the risk created by interruption of carbohydrate intake, noted by Fischer et al.73 and once again in the recent ICU study by Vriesendorp et al.74 Sources of error include: lack of coordination between feeding and medication administration, leading to mistiming of insulin action; lack of sufficient frequency in BG monitoring; lack of clarity or uniformity in the writing of orders; failure to recognize changes in insulin requirements due to advanced age, renal failure, liver disease, or change in clinical status; steroid use with subsequent tapering or interruption; changes in feeding; failure to reconcile medications; inappropriate use of oral antihyperglycemic agents, and communication or handoff failures.

It has been difficult to sort out whether hypoglycemia is a marker of severity of illness or whether it is an independent factor leading to poor outcomes. Observational studies lend credibility to the concept that patients having congestive heart failure or myocardial infarction may be at risk for excessive mortality if their average BG resides in the low end of the normal range.7578 Sympathetic activation occurs as the threshold for hypoglycemia is approached, such as occurs at BG = 70 or 72 mg/dL.79 Patients living with BG levels observed to be in the low end of the normal range might experience more severe but unobserved and undocumented episodes of neuroglycopenia. Arrhythmia and fatality have been directly attributed to strict glycemic control.80, 81 We are confronted with the need to interpret well conducted observational studies, evaluating subgroups at risk, and using multivariate analysis to assess the impact of hypoglycemia upon outcomes.82 In such studies, we will need to examine high‐risk subgroups, including cardiac patients, in particular, for the possibility that there is a J‐shaped curve for mortality as a function of average BG.

Unfortunately, clinical inertia exists in response to hypoglycemia just as it does with hyperglycemia. One recent study examined 52 patients who received intravenous 50% dextrose solution for an episode of hypoglycemia.83 Changes to insulin regimens were subsequently made in only 21 patients (40%), and diabetes specialists agreed with the changes for 11 of these patients. The other 31 patients (60%) received no changes in treatment, and diabetes specialists agreed with that decision for only 10 of these patients.

Although some increase in hypoglycemia might be expected with initiation of tight glycemic control efforts, the solution is not to undertreat hyperglycemia. Hyperglycemia creates an unsafe setting for the treatment of illness and disease. Sliding‐scaleonly regimens are ineffective in securing glycemic control and can result in increases in hypoglycemia as well as hyperglycemic excursions.6, 66 Inappropriate withholding of insulin doses can lead to severe glycemic excursions and even iatrogenic diabetic ketoacidosis (DKA). Systems approaches to avoid the errors outlined above can minimize or even reverse the increased risk of hypoglycemia expected with tighter glycemic targets.51

A SYSTEMS APPROACH IS NEEDED FOR THESE MULTIPLE COMPLEX PROBLEMS

Care is of the hyperglycemic inpatient is inherently complex. Previously established treatments are often inappropriate under conditions of altered insulin resistance, changing patterns of nutrition and carbohydrate exposure, comorbidities, concomitant medications, and rapidly changing medical and surgical status. Patients frequently undergo changes in the route and amount of nutritional exposure, including discrete meals, continuous intravenous dextrose, nil per orem (nothing by mouth status; NPO) status, grazing on nutritional supplements or liquid diets with or without meals, bolus enteral feedings, overnight enteral feedings with daytime grazing, total parenteral nutrition, continuous peritoneal dialysis, and overnight cycling of peritoneal dialysis. Relying on individual expertise and vigilance to negotiate this complex terrain without safeguards, protocols, standardization of orders, and other systems change is impractical and unwise.

Transitions across care providers and locations lead to multiple opportunities for breakdown in the quality, consistency, and safety of care.64, 65 At the time of ward transfer or change of patient status, previous medication and monitoring orders sometimes are purged. At the time of discharge, there may be risk of continuation of anti‐hyperglycemic therapy, initiated to cover medical stress, in doses that will subsequently be unsafe.

In the face of this complexity, educational programs alone will not suffice to improve care. Institutional commitment and systems changes are essential.

MARKED IMPROVEMENT IS POSSIBLE AND TOOLS EXIST: A ROADMAP IS IN PLACE

Fortunately, a roadmap is in place to help us achieve better glycemic control, improve insulin management, and address the long list of current deficiencies in care. This is imperative to develop consistent processes in order to achieve maximum patient quality outcomes that effective glycemic management offers. This roadmap entails 4 components: (1) national awareness, (2) national guidelines, (3) consensus statements, and (4) effective tools. As mentioned above, the first two components of this roadmap are now in place.

As these national guidelines become more widely accepted, the next step will be the incorporation of this into programs like Pay‐for Performance and the Physician Quality Reporting Initiative (PQRI), which will impact reimbursement to both hospitals and providers.

Regarding the third component, a recent multidisciplinary consensus conference1 outlined the essential elements needed for successful implementation of an inpatient glycemic control program which include:

• An appropriate level of administrative support.

• Formation of a multidisciplinary steering committee to drive the development of initiatives and empowered to enact change.

• Assessment of current processes, quality of care, and barriers to practice change.

• Development and implementation of interventions including standardized order sets, protocols, policies and algorithms with associated educational programs.

• Metrics for evaluation of glycemic control, hypoglycemia, insulin use patterns, and other aspects of care.

Finally, extensive resources and effective tools are now available to help institutions achieve better inpatient glucose control. The Society of Hospital Medicine (SHM), in conjunction with the ADA, AACE, the American College of Physicians (ACP), the Case Management Society of America (CMSA), the American Society of Consultant Pharmacists, nursing, and diabetic educators have all partnered to produce a comprehensive guide to effective implementation of glycemic control and preventing hypoglycemia.49 This comprehensive workbook is a proven performance improvement framework and is available on the SHM Web site.48 Details and examples of all essential elements are covered in this workbook along with opportunities for marked improvement bolstered by integration of high reliability design features and attention to effective implementation techniques. The remainder of this supplement crystallizes a substantial portion of this material. The AACE has also recently offered a valuable web‐based resource to encourage institutional glycemic control efforts.49

GLYCEMIC CONTROL INITIATIVES CAN BE COST‐EFFECTIVE

Achieving optimal glycemic control safely requires monitoring, education, and other measures, which can be expensive, labor intensive, and require coordination of the services of many hospital divisions. This incremental expense has been shown to be cost‐effective in a variety of settings.1, 84, 85 The costs of glycemic control initiatives have demonstrated a good return on investment via:

• Improved LOS, readmission rates, morbidity, and mortality.

• Improved documentation of patient acuity and related payment for acuity.

• Income generated via incremental physician and allied health professional billing.

CONCLUSION AND SUMMARY

Evidence exists that appropriate management of hyperglycemia improves outcomes, whereas the current state of affairs is that most medical centers currently manage this suboptimally. This is concerning given the magnitude of diabetes and hyperglycemia in our inpatient setting in the United States. To bring awareness to this issue, multiple initiatives (guidelines, certification programs, workbooks, etc.) are available by various organizations including the ADA, AACE, SCIP, NSQIP, IHI, UHC, the Joint Commission, and SHM. However, this is not enough. Change occurs at the local level, and institutional prioritization and support is needed to empower a multidisciplinary steering committee, with appropriate administrative support, to standardize and improve systems in the face of substantial cultural issues and complex barriers. Improved data collection and reporting, incremental monitoring, creation of metrics, and improved documentation are an absolutely necessary necessity to achieve breakthrough levels of improvement.

Now the time is right to make an assertive effort to improve inpatient glycemic control and related issues, and push for appropriate support at your institution to help achieve this in the interest of patient safety and optimal outcomes.