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.
Quality improvement process: This group will focus on formulating a how-to resource for performing quality improvement projects related to glycemic control. This group will attempt to provide hospitalists with a practical guideline to help them successfully implement changes in their own institutions. Topics will include forming and leading a multidisciplinary team, setting goals, defining metrics, and identifying process analysis and evaluation methods.
Deliverables from this group will likely include a glycemic control quality improvement workbook that will guide individuals through the complex process of performing robust quality improvement projects in their own hospitals. This workbook will be similar in format to one that is currently available in the “VTE Quality Improvement Resource Room” on the SHM Web site.
Clinical tools: This group will focus on compiling and appraising already existing clinical tools (e.g., standardized order sets, protocols) and identifying the key features of these tools and the differences among them. The emphasis will be on either compiling or creating ready-to-use clinical tools.
Potential deliverables from this group include a collection of tools that will have substantial built-in decision support and will be useful in a range of settings. These might include standardized order sets, protocols, and charting tools.
Metrics: This group will focus on defining useful metrics for performing glycemic control research and quality improvement projects. This group intends to define the best ways to measure glycemic control, balancing measures, process measures, and other specific outcomes. These metrics will allow hospitals to examine their current performance and to develop quality standards for inpatient glycemic control.
Care transitions: This group is charged with beginning to identify and address the many challenges that are faced when diabetic and/or hyperglycemic patients move from one care setting to another (e.g., ICU to general ward, hospital to outpatient setting). The work done by this group is likely to have an impact on all of the other groups.
Potential deliverables from this group include a set of standards that can be applied to care transitions. There may also be specific clinical tools developed to improve the process of these care transitions, such as checklists, order sets, and protocols.
Promotional: This group will focus on creating national awareness of the importance of glycemic control in hospitals, particularly at the administrative level. This may include efforts to partner with relevant medical societies, regulatory agencies, and other professional organizations focused on improving glycemic control.
Goals and Timelines
The three-month goal is for each of the focus groups is to further delineate the gaps in the existing resources, and to further refine the specific deliverables that they will produce. Each group will need to determine specific goals and timelines.
An intermediate-term goal is the formation of a white paper that will describe, in detail, the existing glycemic control resources, the gaps in these resources, and the need for additional work in these areas.
In addition, work on the glycemic control quality improvement workbook is under way, and this resource will be used in the “Quality Improvement Precourse” that will take place May 3, 2006, at the SHM Annual Meeting.
The work being done by this task force will lead to a collection of high-quality, user-friendly resources that will enhance awareness of the issue of inpatient glycemic control and facilitate the implementation of effective inpatient diabetes quality improvement across the nation. The longer term goal will be to bring about demonstration projects in the area of inpatient glycemic control and advance the science of diabetes care in the hospital.
- American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Prac. 2004;10:77-82.
- Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.
Non-Physician Provider Task Force Progress
Annual meeting workshop plans, plus continued Web development
Shm’s Non-Physician Provider Task Force has continued to meet via conference calls on a regular basis. The task force now has representation from the ranks of nurse practitioners, physician assistants, hospitalist clinical care coordinators, health systems pharmacists, and hospitalist physicians. We realize that there are many other professionals vital to hospital medicine and plan to recruit more representatives from the SHM member ranks as qualified individuals are brought to our attention.
Task force members will provide important contributions to the annual meeting. The special interest forum on non-physician providers in hospital medicine has been growing each year. This forum is an important venue for exchanging ideas and meeting fellow professionals. It also gives the task force members a chance to make contact with individuals who want to get involved in Non-Physician Provider Task Force activities.
This year task force members Scarlett Blue, RNC, MSN, CNA, and Ryan Genzink, PAC, will lead the forum. Mitchell Wilson, MD, will lead a workshop, “Integrating Non-Physician Providers into Hospital Medicine Services.” National trends that include decreasing availability of generalist physicians, decreasing workloads for resident physicians, and the rapid growth in hospital medicine as a specialty will make this workshop vital to SHM members faced with these pressures.
The task force remains interested in developing a network for communication within the community of professionals in hospital medicine who have an interest in non-physician provider issues and practice. The Hub-and-Spoke initiative is intended to provide a network to allow more individuals to provide input to the task force. The forum at the annual meeting will be an opportunity to meet task force members, exchange e-mail addresses, and discuss how to become involved.
SHM’s Web site has a link for “Non-Physician Provider Resources,” and the task force has continued to work on the content of this site. The priorities for expansion include adding staffing models, billing and documentation resources, value added by non-physician providers, and FAQs. The task force welcomes SHM members to submit documents for posting to the resource center.