Effecting change in the management of diabetes in the hospital setting remains a formidable, yet necessary challenge. The impact of diabetes in our hospitals has reached a tipping point with a reported prevalence of 26% of known diabetes among hospital inpatients, and an additional 12% with unrecognized diabetes or hospital-related hyperglycemia (1). As we strive to deliver safe, high-quality care, there is a need to coordinate an innovative, inter-professional, quality improvement effort to address the needs of this growing, inpatient population.
The 2008 Canadian Diabetes Association Clinical Practice Guidelines (CDA CPG) is the first issue to provide guidance on in-hospital management of diabetes in Canada. The 2008 CDA CPG outlines in-hospital glycemic targets and includes guidance on management practices for a variety of subgroups. The 2008 CDA CPG also encourages the coordination of a multidisciplinary steering committee to provide educational programs, standardized insulin order sets, policies and protocols. Protocols regarding hypoglycemia are highly encouraged, as it remains a major impediment to achieving optimal glycemic control (1). As a growing body of evidence makes its way to best practice guidelines, it is important to identify the shortcomings within the in-hospital processes that potentiate barriers to successful implementation.
Part of the dilemma is that most hospitals are operating at capacity with limited front line staff, making an involved chronic disease, increasingly difficult. In addition, insulin is rated one of the top high-alert medications by the Institute for Safe Medication Practices (2). As a result, clinical inertia sets in and fear of hypoglycemia reinforces the dependence on sliding scale insulin (3). If left without coordinated quality improvement efforts, these challenges can foster systemic gaps in communication, coordination and treatment in diabetes management (4).
Gaps in communication occur frequently amongst patients, nursing staff, personal support workers, physicians, endocrinologists and all health care providers involved in patient care. The primary line of communication within the hospital setting is through documentation. Unfortunately, medication orders, sliding scales and blood glucose results, among others are often written in different locations and can be illegible or misinterpreted, which can lead to medication errors, especially when using paper charts. Communication regarding the arrival of meals, nutritional intake and detection of hypoglycemia, can also become fragmented for a variety of reasons, including a patient’s altered mental status, physical wellbeing, or simply due to the organized chaos that arises when managing multiple, acute and/or chronic conditions. Additionally, breaking down the silos of communication between inpatient and outpatient settings continues to challenge our efforts, as information and necessary referrals fail to complete a patient’s full circle of care.
Similar to communication, gaps in coordination can occur within the multitude of in-hospital processes. At times, meals can be poorly coordinated with insulin administration and a new nil per os (NPO) status, poor appetite or brief interruptions in enteral feeds or total parenteral nutrition (TPN) can be overlooked among existing insulin regimens. Furthermore, health care providers may be unevenly educated and updated on best practice guidelines in diabetes management, leading to a fragmented effort in optimizing glycemic control, patient safety and quality of care.
Gaps in best practice treatment also continue to be a barrier. Although sliding scale insulin administration persists within the culture of inpatient diabetes management, it continues to be a reactionary approach. With the emergence of a variety of insulins, a continuum of ebb and flow stages of acuity in disease states, and an underlying fear of hypoglycemia, the sole use of sliding scale insulin maintains a barrier to optimal glycemic control. Treating hypoglycemia can also pose a challenge to glycemic control with incorrect methods of treatment, limited retesting and the tendency to over treat. Other obstacles include limited availability and access to point of care blood glucose monitors and other supplies.
These barriers can become increasingly difficult for patients who have previously been accustomed to self-management practices. When admitted, control is often relinquished to the hospital team, leaving patients with a sense of disempowerment and dependence. These patients are entitled to the security of knowing their diabetes will be managed to the best of our abilities. Closing these gaps in communication, coordination and treatment may perhaps be the start in providing this sense of security.
Despite these challenges, a silver lining can be found among the many health care providers, of all disciplines, whose passion for diabetes drives initiatives to help close some of these gaps, improve quality of care and support them in meeting the needs of this inpatient population. Sunnybrook Health Sciences Centre (SHSC) is one of the many hospitals embarking on an integrated, quality improvement initiative. Spearheaded by Dr. Julia Lowe at SHSC, an inter-professional team named the Diabetes Inpatient Committee (DIC) has been working towards implementing effective regimens and protocols that optimize care. The aim is to optimize in-hospital glycemic control, minimize incidence of hypoglycemia, provide ongoing educational support for patients and health care providers, and improve patient safety and quality of care. The essential element for the success of this initiative has been inter-professional collaboration within the assessment, planning, implementation and evaluation stages. This provided the opportunity to build on each other’s thoughts, ideas, experience and creativity, as well as gain inter-departmental support for a hospital wide, system level approach.
To date, the DIC has developed a number of insulin order sets to support the provision of insulin regimens and limit dependence on sliding scale insulin at SHSC. New blood glucose monitoring records have also been developed to encourage two hour post-prandial blood glucose testing, which will also help detect hypoglycemia in those with a poor appetite. Hypoglycemia algorithms and tool kits have been made available to all units to help navigate the variety of treatment methods and allow for convenient and timely treatment. Education materials have been made available to both health care providers and patients through a variety of media outlets – print, television and the internet. Ongoing in-services will be provided to support health care providers and to assist in ensuring the sustainability of these initiatives, diabetes champions will be trained on each unit to teach, guide and advocate for improved inpatient diabetes management. A qualitative study will also be conducted to describe the inpatient experience and capture this unique perspective.
Similar to other quality improvement initiatives, evaluating these efforts in a way that truly captures the true nature of its effects on blood glucose, patient experience, workplace culture and confidence among health care providers is a challenge. However, hospital wide glucometrics data for SHSC via networked point of care blood glucose monitors will provide ongoing data on glycemic control. Regular chart audits will provide information on changes in ordering practices and use of insulin order sets. Interviews with health care providers and patient questionnaires will provide insight into the value and efficacy of the initiatives.
Improving inpatient diabetes management can be a daunting task. However, quality improvement is a journey and every step forward is worth every ounce of our efforts. As health care providers working in diabetes, we have an opportunity to learn from each other and share ideas within our inter-professional and inter-organizational community in the hopes of effecting change in our immediate environment. We are fortunate to work amongst a broader community of health care providers who share the same goals of providing the best possible care for our patients. In order to create a comprehensive and integrated circle of care for patients living with diabetes, the hospital setting must not be forgotten.
About the Author:
Jasmine Arellano is a Registered Dietitian at Sunnybrook Health Sciences Centre in Toronto. She is currently working with the Sunnybrook Family Health Team and the Sunnybrook Diabetes Education (SUNDEC) program. She is also a member of the Diabetes Inpatient Committee (DIC) and is pursuing her Masters degree in Adult Education and Community Development at the Ontario Institute for Studies in Education (OISE).
- Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008; 32 (suppl 1): S1-S201.
- Institute for Safe Medication Practices. ISMP’s list of high-alert medications; 2008 [cited 2010 Aug 25]. Available from: http://www.ismp.org/Tools/highalertmedications.pdf
- Brillon D J, Lubitz C C, Rivera C, Seley J J, Sinha N. The perils of inpatient hyperglycemia management: How we turned apathy into action. Dia Spectr. 2007; 20(1): 18-21.
- Amin A, Braithwaite S S, Magee M, Maynard G, Schnipper J L, Sharretts J M; Society of Hospital Medicine Task Force. The case for supporting inpatient glycemic control programs now: The evidence and beyond. J Hosp Med. 2008 Sep; 3(5 Suppl): 6-16.