A Diabetes Management Service to Improve Inpatient Glycemic Control

• Objective: To describe the development and implementation of a hospital diabetes management service. • Methods: Review of the literature and account of the activities of the service and system changes implemented. • Results: There is ample evidence that glycemic control is important for all patients in the acute care setting. It is probable that safe and effective targets will vary with the patient’s acuity, diagnoses, and clinical setting. Tight control is probably most appropriate for the sickest patients in critical care settings; conversely, healthier patients in less acute settings should probably have less aggressive targets that minimize risk of hypoglycemia. Achieving glycemic control in the hospital is possible with the use of IV insulin infusions guided by frequent blood glucose monitoring, and by using subcutaneous insulin and insulin analogues. An IV insulin protocol has been shown to be safer and more effective than ad-lib titration of IV insulin. • Conclusion: The ideal method for glucose control will depend on the clinical setting, anticipated nutritional intake, and the ability to monitor glucose levels and adjust the insulin regimen as clinical conditions change. Continued studies are needed to determine appropriate and specific glycemic control goals and the optimal protocols for achieving them. Hyperglycemia is common among hospitalized patients. While the morbidity associated with longstanding hyperglycemia is well established, hyperglycemia in the acute care setting until recently was thought to be a “normal” and “adaptive” response to illness. However, in vitro and in vivo observations suggest that hyperglycemia, even short lived, results in an increase in inflammatory mediators, immunocompromise, infections, nutritional deficits, and fluid and electrolyte derangements [1]. It is estimated that hyperglycemia occurs in close to 38% of people admitted to the hospital, with an estimated 33% of these having no known history of diabetes [2]. Because diabetes is usually not the patient’s primary diagnosis, treatment efforts are often aimed toward management of the problems for which the patient was admitted, and attention to glucose management may be minimal. Increasing evidence suggests that focused diabetes management of critically ill patients reduces morbidity and mortality and is cost-effective [1]. In this paper, we summarize the evidence that has emerged in the past few years examining hyperglycemia and its control in hospitalized patients and describe our approach to inpatient glycemic control at Brigham and Women’s Hospital (BWH) in Boston, MA. review of studies of in-hospital hyperglycemia treatment and effect on outcomes The first evidence that even short-term hyperglycemia is deleterious came from studies of surgical patients. Pomposelli and colleagues [3] noted an almost threefold increase in postoperative wound infections in patients undergoing “clean” surgery if even a single blood glucose (BG) measurement was over 220 mg/dL in the first 48 perioperative hours on every-6-hour monitoring. Zerr and colleagues [4] observed a similar phenomenon in patients undergoing heart surgery. Initially, a direct relationship between deep sternal wound infections and BG levels on the first and second postoperative days was observed. The authors then sought to lower postoperative BG levels, first with a subcutaneous insulin protocol and then with an intravenous (IV) insulin infusion, the first version of the now-famous Portland Protocol. Maintaining BG levels under 200 mg/dL led to a reduction in wound infection rates (from 2% to 0.6%)—rates comparable with those seen in the nondiabetic population [5]. Subsequently, more effective glycemic control has been associated with additional improvements in outcomes, including improved pump function and fewer arrhythmias [6]. Najarian et al [7] saw a reduction in infections, length of stay, and readmissions by lowering the mean BG from 186.9 mg/dL to 172.5 mg/dL in a non–intensive care unit (ICU) A Diabetes Management Service to Improve Inpatient Glycemic Control Vera T. Fajtova, MD, Shawn G. Anthony, BS, Siobhan McGurk, BS, Rita McCarthy, RNC, CDE, Deborah Homer, NP, Leslie Griffin, MS, RN, ACNP, and James Rawn, MD From the Harvard Medical School, Harvard Vanguard Medical Associates, and Brigham and Women’s Hospital, Boston, MA.