For most of recent history, it has been standard practice to tolerate hyperglycemia and expect some hypoglycemia when caring for diabetic patients in the hospital. This attitude stems from the many barriers to controlling glucose levels in hospitalized patients (e.g., the stress of acute illness and the changes in diet and medications that occur on admission to the hospital). In addition, most diabetic patients are hospitalized for illness other than their diabetes. In these situations, glycemic control may not be a priority, and fear of hypoglycemia may be prominent.
However, in recent years, there has been a change in attitude regarding glycemic control in the hospitalized patient. Recently, clinical studies have shown that hyperglycemia leads to poor outcomes in some hospitalized patients, prompting the American College of Endocrinology and the American Association of Clinical Endocrinologists to publish a position statement on inpatient diabetes and metabolic control.1 In addition, best practice strategies for controlling glucose levels in hospitalized patients have been recently reviewed.2
At the same time, hospitalists have emerged on the scene, bringing with them a new awareness of the gaps between the best practice and real practice. In real practice, both hyperglycemia and hypoglycemia are common, and insulin use in the hospital is often guided by strategies that are based on simplicity, instead of strategies that are based on established principles of diabetes management. There has been remarkably little attention given to the management of diabetes and hyperglycemia in noncritically ill hospitalized patients, and glucose levels are often far outside of the recommended range in this group.
SHM’s Glycemic Control Task Force
The Glycemic Control Task Force was assembled with the intent of improving glycemic control in hospitals nationally by providing hospitalists with an understanding of the best practice of glycemic control in the hospital, and by providing them with the tools and skills to make real changes in their own systems. With the assistance of a grant from Sanofi-Aventis, the Glycemic Control Summit was held on Oct. 20, 2005, in Chicago. A distinguished panel of experts attended, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. The goals of the meeting were as follows:
- To identify the currently available resources pertinent to glycemic control in the hospital (e.g., resources related to best practice, education, quality improvement, awareness, clinical tools, research, metrics/quality parameters);
- To identify the gaps in those resources; and
- To assemble several focused work groups to address the major gaps in the existing resources, and to determine specific interventions or products that could fill those gaps.
The meeting spawned several smaller work groups that will address the major barriers to improving glycemic control in hospitalized patients. These groups were formed in direct response to the gaps that were identified during the meeting. A description of each of the work groups is provided below, highlighting the major gaps that were identified and the strategies being considered to overcome them.
Education: This group will focus on creating case-based, educational materials that will provide physicians, nurses, and other providers with pragmatic examples illustrating the best practice of glycemic control and insulin management in the hospital and at the transition of care. In addition, this group will address patient education issues, educational metrics, and other issues.
Potential deliverables from this group include Web-based, case-based educational modules applicable to CME or to support quality improvement efforts at individual institutions and patient education materials.