Diabetes in hospitalized patients is ubiquitous. It is so common that every inpatient provider deals with it frequently, probably every single day. Every provider is familiar with most if not all of the treatments available for diabetes, especially the commonly used insulins – and the hospital system has excellent diabetes management protocols. As a result, we are happy to report that these guidelines are almost universally used on our inpatients and our diabetes management is excellent – confirmed on a recent pilot study done at Mercy.
Everything above is true except for one sentence – see if you have already spotted the outlier.
Much to my surprise, there is a metric that is used as a relative marker of how well hospitals treat patients with diabetes. It is the percentage of the time that fingerstick glucoses are over 200. I had not even known such a metric existed until I learned this week that in NYS the average is 20% of the time that glucoses are measured to be high, and only 80% of the time are they under 180. The logic is that with utilization of current best practices, there should be fewer times that glucoses take the Up Escalator to 200+, so the percentage of abnormal glucoses is the current best marker for quality of diabetes care on a hospital or system level. Remember that average – 20% to be mediocre (middle of the pack). Now anticipate what you think you (and your system) are at.
Glucose control in the hospital is a conundrum, however. One issue is that many providers are concerned (perhaps too concerned) about hypoglycemia. Another is that in the outpatient world there is increasing focus on personalized diabetes goals, especially in the elderly, and a greater number of situations where clinicians de-escalate the diabetes care. And with patients coming in on sometimes complex regimens and departing home within a few days, there is a lot of work and tinkering to make changes that only are in place for a few days before sending our patients back out in to the real world again.
But it turns out it really, really is different. Inpatient and outpatient are definitely NOT the same when it comes to diabetes. Why? Mortality – higher when blood sugars are higher. Infections, especially postop – higher when the glucoses are higher. Pneumonia outcomes – worse when the sugars are higher. Not important enough? There’s more but we can save that for the didactic lecture hour. The point is clear – it is critical to have first-class diabetes management in all our inpatients – ICU, perioperative patients, and non-ICU medical patients. They are each a little different, but the results need to be good in all 3 spheres.
What is the US standard for 2019? It is to keep blood sugars under 180 at all times. This simply will not happen with a laissez-faire approach to elevated blood sugars. Especially not when patients are sick with their stress hormones in 5th gear, frequently septic, and often pummeled with mega doses of corticosteroids – common inpatient scenarios.
So how much better were we than the merely “average” hospitals in NY? It turns out our sites ranged from 23-33%. Each institution fell below the mean, some far below the mean.
Why? More to come on this subject. But some practices in need of improvement were identified right away. One is not using the protocols at all, not using the right diabetes protocol (Low, medium and high intensity) and not making daily adjustments to the insulin regimen in response to the glucose results. Another issue identified is underuse of insulin. Many patients who should be on insulin (based on their blood sugars) are instead kept on their outpatient regimens with no insulin at all. This won’t work for these people. And sometimes it is a fundamental knowledge gap. Not just the general guidelines, but sometimes the fundamentals. For example, an order for daily glargine insulin prn (which we have seen) suggests that some of the basics are not understood by all.
A pilot program is getting started at Mercy to see how best to make diabetes care excellent for everyone, and then to spread those learnings through the system. In the meantime, brush up on the protocols we already have, look at the current inpatient guidelines, and remember to panic. Yes – panic when you are getting called about blood sugars or looking at your patients’ blood sugars and seeing those red flag numbers – 180 or above. That means it is probably time to act. It’s OK to be sweet – just not too sweet. Next time we look at those percentages, let’s let them reflect that it’s being done right!
