Modern Diabetes Management Program Goes From Academic Medical Center to Community Hospital

Posted Aug 18, 2008.By Miriam E. Tucker

WASHINGTON (EGMN) - A program for inpatient diabetes care that reflects current management approaches was successfully exported from an academic medical center to a neighboring inner-city community hospital, resulting in improved measures of diabetes care and education.

"An educational program in modern diabetic care which targets physicians in the hospital setting can have the beneficial effect of improving the glycemic control in all of the patients with diabetes cared for by these physicians," diabetes educator Maripaz Vazquez, R.N., and her associates said in a poster presented at the annual meeting of the American Association of Diabetes Educators.

The Chicago-based collaboration between Rush University Medical Center and Saint Anthony Hospital was aimed at implementing a series of hospital-wide protocols that brought Saint Anthony into compliance with current standards of the American Diabetes Association (ADA). Core project personnel were a nurse practitioner specializing in diabetes, an inpatient diabetes nurse educator, a data collector, and an endocrinologist. Project committee members also involved representatives from administration, pharmacy, ICU, and the emergency department.

Protocols from Rush were adapted for inpatient diabetes management at Saint Anthony for the emergency room, med-surg units, and telemetry/intensive care units. Pharmacy formulary changes and specific order-sets were developed to support the new protocols. After approval by the program committee, each protocol then became the standard approach for all patients fitting each specific clinical condition. Medical and nursing staff received numerous educational sessions before each protocol was implemented on a nursing unit, and individual education was continued daily thereafter. A pocket guide to inpatient management of hyperglycemia and diabetes was developed and disseminated to all staff.

"A primary goal of the project was to use the inpatient hospital stay as an opportunity for incremental long-term diabetes patient care improvements," Ms. Vazquez and her associates said.

Ms. Vazquez reported outcome data for the 12 months following an initial 3-month baseline data collection period. A total of 66 physicians admitted an average of 100 patients with diabetes per month, of whom 92% had type 2 diabetes; 15% were new diagnoses. The mean patient age was 59 years, and most were either Hispanic (45%) or African American (45%). A majority (72%) were admitted from the emergency room. The primary admitting diagnosis was diabetes in 18%, heart failure in 14%, dehydration in 7%, and pneumonia in 7%. Mean blood glucose on admission was 195 mg/dL.

At 15 months, the sole use of sliding-scale insulin - a retroactive method of dosing insulin that the ADA has recommended against (Diabetes Care 2004:27:553-91) - had been reduced from 23% at baseline to just 4.5%. The use of long-acting insulin formulations (NPH or glargine) increased from 31% to 57%, and the use of mealtime insulin from 28% to 58%. The frequency of obtaining inpatient hemoglobin A

The proportion of patients discharged on improved diabetes therapy - a focus of the educational program - increased significantly from 49% to 72%, while the frequency of inpatient diabetes education rose from 20% to 81% of patients and referrals for follow-up outpatient diabetes education also increased, from 14% to 81%, the investigators reported.

Clinical measures also improved. Mean blood glucose levels on inpatient days 2-5 decreased from 185 mg/dL to 165 mg/dL. The frequency of inpatients having an HbA

"We conclude that these results reflect the positive impact that the multidisciplinary approach of the project had on physician, nurse, and patient education. It is not possible to dissect whether one of these educational targets was more important, and likely all made contributions," Ms. Vazquez and her associates wrote.