There are two medical conditions that clearly impact quality, costs and patient safety but are often not addressed because their critical role in patient recovery may not be top-of-mind for many clinicians when dealing with a myriad of treatment concerns for the hospitalized patient.
The healthcare industry is undergoing a transformation to value-based reimbursement models, which reward patient care innovations that improve quality, reduce costs and ensure patient safety. As a result, many leading hospitals are transforming their approach to quality, patient safety and infection control by embracing the values of a high-reliability organization and seeking solutions that can enhance their abilities to manage certain medical conditions more proactively. There are two medical conditions that clearly impact quality, costs and patient safety but are often not addressed because their critical role in patient recovery may not be top-of-mind for many clinicians when dealing with a myriad of treatment concerns for the hospitalized patient.
Approximately 40 percent of patients admitted to hospitals experience extremes in blood glucose, resulting in either hyperglycemia or hypoglycemia.1 Although these swings in glycemic control are most generally associated with diabetes, other factors such as trauma, drug reactions and stress can lead to either an increase or decrease in blood sugar among non-diabetic patients. Studies show that these fluctuations put patients at risk. Hyperglycemia is associated with poor wound healing, higher admission rates to the ICU and longer hospital stays. Hypoglycemia also represents a significant patient safety risk, and if not treated, symptoms could even lead to brain damage or death. However, in addition to the issues surrounding these two conditions, the level of glycemic control throughout a hospital impacts several other conditions that not only influence the quality of patient care but also result in potential reimbursement penalties. Progressive hospitals today are addressing this by implementing hospital wide glycemic management programs that are demonstrating improved results. In one study, an optimized program for the management of blood glucose levels resulted in a 34 percent decrease in mortality, 46 percent decrease in sepsis, 41 percent decrease in dialysis, 50 percent decrease in blood transfusions, and a 44 percent decrease in polyneuropathy in 1,548 critically ill patients.2
Although organizations such as the American Diabetes Association and the American Association of Clinical Endocrinology have endorsed more aggressive blood sugar management for patients in the hospital, addressing inpatient glycemic management is a challenge due to the complex hospital environment in which multiple providers care for patients, each with different focuses and concerns related to treatment and recovery. An additional barrier to glucose control is the varying levels of knowledge among clinicians related to glycemic management and insulin dosing and their importance to overall outcomes. Because of a variety of factors such as the stress response to illness, varying nutrient intake levels and variability in insulin sensitivity, insulin dosing in hospital patients is often very difficult to calculate and needs frequent adjustments.
Even when a hospital implements a standardized approach to manage glycemic levels, the challenge is finding the right processes and technology to meet the needs of all patients, regardless of where they are located within the hospital or what level of glycemic management expertise the nurse or physician may have. The most common approach to glycemic management for inpatients may be a care plan that prompts nurses to take appropriate steps to intervene in the case of fluctuating blood sugar levels. Most often paper-based, these protocols tend to be static and require manual calculation of insulin dose adjustments. The time-consuming process of calculating insulin dosing and notifying physicians of the need for intervention, not only takes more nursing time away from the patient's bedside, but can also delay patient treatment.
Development of robust methodologies to improve quality and safety must be key objectives for any hospital aspiring to achieve the operational processes of a high-reliability organization. Some hospitals have found a way to successfully reduce complications that are often exacerbated by fluctuating blood glucose levels by putting each of the following best practices in place to support organization-wide improvements in the management of patients' blood sugar.
1. Enterprise-wide implementation of scientifically-based protocols
The use of evidence-based care protocols is critical to a successful glycemic management program. Because patients with fluctuating blood sugar levels can be admitted to one of many units or departments within a hospital, there is often a varying level of experience with glycemic management among hospital staff as well as physicians. While the need to maintain blood glucose at safe levels is understood, there are different opinions about what levels are considered acceptable, when to use insulin and how insulin dosage should be determined. In fact, some clinicians believe a slightly elevated blood sugar level is preferable to the potentially dangerous complication of hypoglycemia, or low blood glucose.
Evidence-based care guidelines used throughout the organization — not just in one department or unit or for one patient — ensure a quality of treatment that is not based on an individual clinician's glycemic control knowledge or experience. Developing protocols that can be used in all situations, requiring their use by staff and physicians and supporting their use through ongoing education for staff creates a consistent, evidence-based care environment that optimizes glycemic management for all patients.
2. Integrated technology support of accurate dosing and quality improvement
Although staff and physician education is essential to consistent use of glycemic management guidelines, many hospitals find that even with standardized treatment protocols and guidelines, the level of glycemic management is still not consistent with their goals and have turned to implementing technology that can further enhance application of the care plans. Just as increased access to patient information through electronic medical records and computerized drug references have improved efficiency of nursing care, the use of a computerized glycemic management system enhances clinicians' ability to proactively manage blood glucose levels.
While clinicians control the actual dosage administered to a patient, the additional support provided by a sophisticated automated system that can integrate with the organization's health information systems improves the efficacy and safety of the therapy. When dosage recommendations rely on an algorithm that considers the individual patient's insulin sensitivity based on reaction to previous doses, time between readings and current blood glucose levels, the efficacy of the therapy is improved. Intravenous, subcutaneous and pediatric systems that guide proper dosage alert clinicians to unexpected changes in insulin levels and integrate with the organization's EMR not only provide more complete information to support treatment recommendations, but also enable the compilation of glycemic management data to promote hospital-wide performance improvement initiatives.
3. Multi-disciplinary glycemic management steering committee
The collection of patient-level as well as patient population data can be used to guide adjustments to the glycemic management protocol, identify units or clinicians for which additional education is needed, or drive other diabetes-related education or clinical initiatives. A multi-disciplinary glycemic management steering committee, dedicated to glycemic management best practices, can oversee the processes, analyze the data for quality improvement initiatives and keep the issue top-of-mind throughout the organization.
As the program develops and matures, this group can also evaluate new glycemic management products such as systems that further improve inpatient surveillance and patient care as well as technology that assists in managing discharge dosage calculations for the transitions to home. Finally, the members of such a committee can serve as expert support for unit supervisors or medical staff with questions or concerns about control of blood glucose levels for inpatients.
Enterprise-wide implications
Today's hospital leader is faced with an overwhelming number of financial, regulatory and organizational challenges. In fact, hospital leaders will face a new layer of reimbursement penalties when CMS reduces Medicare payments by up to 1 percent for hospitals and long-term care facilities that don't make the grade for eight hospital-acquired conditions beginning in fiscal year 2015. Several of the HACs can be impacted by the level of blood glucose control and management within an organization.
Prioritizing which initiatives have the greatest effect on issues such as value-based purchasing requirements, HACs, lengths of stay and readmissions, is a constant effort to balance organizational needs, patient safety, quality care and available resources.
The good news for hospital executives considering a progressive glycemic management program is that there are already industry supported, proven best practices, processes and cost effective technology systems that can be implemented throughout the entire organization to maximize results. While measurement of blood glucose levels has not yet reached a status as a sixth vital sign, hospital leaders that recognize its importance to overall outcomes can take positive steps to ensure quality patient care, minimize the risk of reimbursement penalties and incur significant cost savings
Laurel Fuqua, RN, MSN, is the chief clinical innovation officer for Glytec.
1 Swanson C, et al. An Update on Inpatient Glycemic Control in U.S. Hospitals. 2011.
2 Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367