Rita Louard, MD, FACE
In both intensive care unit (ICU) and non-ICU hospital settings, quality improvement for diabetic patients is measured by glucose control, care coordination, patient education, and reducing length of stay and capillary blood glucose utilization.
The Montefiore Clinical Diabetes Program integrates quality improvement efforts into daily operations, forming multidisciplinary diabetes treatment teams, providing specialized training for physicians and nurses, and consistently using proven treatment protocols.
- Management of Hypoglycemia and Hyperglycemia
Hypoglycemia (low blood sugar) can develop in diabetic patients, particularly in response to diet, medication (including certain types of oral diabetes drugs), and certain medical conditions. While usually mild, if left untreated hypoglycemia can worsen and lead to seizures, coma, and death.
Historically, insulin for diabetic patients has been prescribed reactively, with doses determined by blood glucose levels, activity level, and meals. While frequently used, this approach, known as sliding-scale insulin coverage, has been shown to have limited therapeutic success. By delaying insulin until hyperglycemia appears, the regimen promotes large swings in glucose control and fails to meet basal insulin requirements.
Intensive insulin therapy is used in ICUs worldwide to tightly regulate diabetic patients’ blood sugar. However, this therapy significantly increases the risk of hypoglycemia in critically ill patients, according to the recently published NICE-SUGAR study, the largest intensive insulin therapy trial to date. The study found that patients with tightly controlled blood glucose (81-108) had more hypoglycemic episodes and increased mortality over those who were conventionally controlled (<180).
Montefiore’s glycemic control strategies for ICU patients currently focus on continuous insulin infusion therapy (CIIT), a more moderate protocol with a goal of maintaining glucose levels between 80 and 120 mg/dl. In light of the NICE-SUGAR study, a more moderate protocol with a goal of maintaining glucose levels between 80 and 140 will be adopted.
Blood glucose level fluctuation is thought to play a role in acute myocardial infarction (AMI), and persistent hyperglycemia (high blood sugar) may predict adverse cardiac effects even in nondiabetic patients. Einstein-Montefiore investigators from the Divisions of Cardiology and Endocrinology are currently examining the effects of close glycemic monitoring and control on AMI outcomes.
- Diet and Nutrition
Many patients benefit from receiving a regular diet consistent in carbohydrates instead of a restrictive diet for diabetes. Diabetic patients at Montefiore's Moses and Weiler divisions may choose a consistent carbohydrate meal option, in which they receive roughly the same amount of carbohydrates from meal to meal and day to day. Menus are planned to help control patients' blood sugar and/or diabetes, and in some cases medications are ordered based on the carbohydrate content of the diet. Consistent carbohydrate diets have been found to help diabetic patients manage their blood sugar.
- Patient Education
Targeted education on hypoglycemia (recognition and treatment, carbohydrates, glucose monitoring, and insulin injection technique) is given to all patients new to insulin. This instruction starts early in the hospital stay and is supplemented by patient education materials.
- Prescriber Education
Internet-based learning modules on diabetes medications have been developed based on identified educational needs for physicians and nurses. Data collected on reasons for "inappropriate" orders is used to guide the content of these modules.
- Testing and Monitoring
Bedside capillary blood glucose monitoring has enabled care providers to more rapidly obtain an additional "vital sign" for diabetic patients and make therapeutic decisions, improving management and conceivably shortening hospital stays. In addition, replacing the traditional venipunctures with capillary blood glucose tests has enhanced patient comfort and satisfaction.
More regular use of the A1c test, a common blood test that measures average blood sugar level for the past 2-3 months, has enabled Montefiore diabetes care providers to better determine if treatment measures are successful or need to be adjusted.
Since the glycemic control initiative was begun in 2005:
- Mean glucose levels in ICU patients have stabilized around 145, a reasonable target as defined by the NICE-SUGAR study.
- Hypoglycemic episodes have been rare, occurring in 1-3% of patients.
- Diabetic patients currently have shorter lengths of stay (by 1.4 days) than nondiabetic patients in both the Moses and Weiler divisions.
In light of new evidence and critical care concerns, Montefiore ICU patients' glycemic level target range will be 80-140 mg/dL. Hypoglycemic episodes in the ICU will be closely tracked.
Standing order sets (tests, medications, dietary requirements, and other required services) will be created to treat non-ICU patients with hypoglycemia.
Length of stay and gylcemic extremes (<70 and >300) will be used as quality measures.