Safety and Quality Initiatives Improve Inpatient Glycemic Management

Points to remember

• Streamlining access to consulting endocrinology staff and facilitating communication among consulting service, primary services, and care providers can improve glycemic control in diabetic patients who present for a surgical procedure.
• Because hyperglycemic emergencies can occur on any inpatient unit, standardization of care is important to ensure that interventions are provided in an expedited manner.
• Ensuring safety and quality in diabetes medication ordering and administration is a high priority because of the increasing prevalence of hyperglycemia and diabetes in the inpatient setting and the high-risk nature of medications used to treat these conditions.

The challenge

Optimal management of hyperglycemia in a hospitalized adult is increasingly recognized as an important therapeutic goal. Inpatient hyperglycemia has been linked to unfavorable clinical outcomes, including:

• Infection
• Postoperative complications
• Increased length of hospital stay
• Continued morbidity after dismissal from the hospital
• Death

In critically ill patients in medical and surgical intensive care units, effective management of hyperglycemia with intravenous insulin infusion can improve mortality and morbidity rates. However, many studies targeting glycemic control with subcutaneous insulin therapy do not focus on hospitalized patients receiving general care. Guided by recommendations from specialty organizations and a commitment to providing excellent and comprehensive care to hospitalized patients with diabetes mellitus, Mayo Clinic has implemented a number of safety and quality initiatives.

Premeal glycemic targets

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Perioperative glycemic management

After examining the current perioperative processes for managing the care of patients with diabetes mellitus, endocrinologists at Mayo Clinic have identified opportunities to improve glycemic control and they have developed an efficient system for providing care to diabetic patients who present for a surgical procedure.

The revised process requires the surgeon to identify a patient with diabetes when listing the patient for surgery. The surgeon then has the option to consult the Diabetes Consulting Service (DCS) for perioperative glycemic management and recommendations on home-going instructions, including blood glucose monitoring and outpatient follow-up.

Perioperative process recommendations

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Streamlining the perioperative process for a patient with diabetes has provided practice consistency, clear delineation of care providers' roles, and improved communication among surgical areas, primary services, and DCS.

Treatment of hyperglycemic emergencies

Hyperglycemic emergencies related to diabetes present with a constellation of associated metabolic abnormalities. Standardization of care in response to hyperglycemic emergencies is important to ensure that interventions are provided in an expedited manner.

To accomplish this goal, Mayo Clinic endocrinologists developed an order set for treatment of adult patients with diabetic ketoacidosis or hyperglycemic hyperosmolar state. Providing guidelines for diagnosis, monitoring, and care of patients with either condition, the order set is initiated in the emergency department and continued in the inpatient unit.

Computer-based monitoring system

Various care providers manage diabetes in patients receiving diabetes-related medications in the hospital setting. To offer oversight for safe and effective diabetes management, Mayo Clinic endocrinologists implemented a computer-based medication monitoring system for the hospital setting.

A series of simple rules related to diabetes medications, glucose monitoring, and blood glucose levels were programmed and applied to a series of databases. When the conditions of a rule are met, a report is generated for follow-up. The reports are monitored daily, and providers are contacted with suggestions to improve patient safety or glycemic control, or both.

This system has been well received by health care providers and should improve glycemic control, promote appropriate and safe insulin use in the hospitals, and improve quality of care.

Management of CSII pumps in the hospital

Managing the care of patients with a continuous subcutaneous insulin infusion (CSII) pump admitted to the hospital is particularly challenging for providers without diabetes expertise. Because providers and patients possess varying degrees of experience in managing diabetes with an insulin pump, Mayo Clinic endocrinologists developed a policy that describes management of a CSII pump in the hospital.

DCS staff see all patients who want to continue using their CSII pump during their hospitalization to assess the patient's recent glucose control and ability to manage the pump. For hospitalized patients who continue to use the CSII pump, the policy provides guidance for insulin ordering, glucose testing, pump refills, site changes, and documentation of pump rates. DCS staff observe patients closely throughout their hospital stay to determine their continued ability to self-manage the pump and whether adjustments to pump rates are required.

Many of these safety and quality initiatives developed to improve inpatient glycemic management at Mayo Clinic are appropriate for use at other medical centers as well.