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Introduction
The articles on these pages represent the culmination of 3 years of effort by the Society of Hospital Medicine (SHM) Glycemic Control Task Force. In this brief introduction, we share a few insights and comments about this multidisciplinary collaborative effort to address the care of inpatients with hyperglycemia.
The SHM Glycemic Control Task Force was assembled in 2005, with the intent of improving the care of inpatients with diabetes. We wished to provide hospitalists and quality improvement teams with an understanding of the best practices to achieve safe glycemic control in the hospital. Additionally, this task force sought to identify tools and strategies to obtain improved communication, medication safety, education, and other aspects of care. A distinguished panel of experts attended their inaugural meeting in Chicago, Illinois, in October 2005, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. A roster of the individuals and organizations is given in the Appendix.
Many members of the SHM Glycemic Control Task Force also participated in the Call to Action consensus conference1 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) in January 2006. Both groups identified several barriers to improvement, and methods to overcome these barriers were summarized in this quote from the Consensus Conference,
Successful implementation of a program to improve glycemic control in the inpatient setting should include the following components:
-
An appropriate level of administrative support.
-
Formation of a multidisciplinary steering committee to drive the development of initiatives.
-
Assessment of current processes, quality of care, and barriers to practice change.
-
Development and implementation of interventions including standardized order sets, protocols, policies, and algorithms with associated educational programs.
-
Metrics for evaluation.
Both groups also called for a web‐based compendium of tested tools and strategies to assist local improvement teams.
After countless hours of development and revision by the SHM Glycemic Task Force and the Resource Room team, such a compendium addressing all of these components was launched on the SHM web site in the form of the SHM Glycemic Control Resource Room.2 A comprehensive implementation guide3 is available for downloading free of charge, and serves as the centerpiece of the Resource Room. Subsequently, this comprehensive but somewhat sprawling implementation guide evolved into these more sophisticated and concise articles.410 The topics include a review of the rationale for improving inpatient glycemic control,4 an important call for standardizing the metrics of glycemic control,9 subcutaneous insulin regimens and order sets,5, 6 insulin infusion protocols,7 transitions of care,8 and the business case for glycemic control.10 It has been a long but rewarding and educational journey, drawing on the collective experience from dozens of institutions in all kinds of inpatient care settings. A few key points and insights seem worth sharing.
THE IMPROVEMENT EFFORT IS NOT JUST ABOUT REACHING A GLYCEMIC TARGET
The term glycemic control team and the label for the SHM Glycemic Control Task Force itself are somewhat misnomers. Task Force members agree that desirable institutional glycemic target ranges should be established, but many among us believe the glycemic targets endorsed by national guidelines (ref ADA and AACE guidelines)11, 12 are too stringent. Furthermore, we believe that achieving glycemic control is just one small part of the needed improvement efforts. Uncontrolled hyperglycemia is common, potentially dangerous, and largely preventable with safe and proven methodsbut so are the iatrogenic hypoglycemia episodes, substandard education, poor communication, lack of care coordination, and inadequate monitoring that typify care of the hyperglycemic inpatient. We address all of these issues and urge the adoption of this broader perspective.
THE EVIDENCE IS INCOMPLETEBUT ACTION IS REQUIRED
We acknowledge gaps and inconsistencies in the literature surrounding inpatient diabetes management and the controversy around tight glycemic control. In many cases, high level evidence is not available to guide the formulation of protocols, order sets, or other improvement tools. We are all struck by how pervasive the lack of evidence is. What is the best metric for inpatient glycemic control or hypoglycemia? What is the best regimen for a patient on continuous tube feedings? Which insulin infusion protocol is superior in reaching and maintaining a glycemic target range?
Rather than make no recommendations or accept negative inertia on the basis of less than perfect evidence, we make recommendations based on the best evidence available. When we make recommendations based on consensus opinion or the collective experience from dozens of medical centers, rather than randomized trials, we have made every effort to make this clear in the text of the articles. In our view, incomplete evidence is not an adequate excuse to persist in the unacceptable status quo, clinging on to methods (such as sliding scale insulin regimens) that have been shown to be ineffective and potentially dangerous.1315
COLLABORATION PAYS DIVIDENDS
It takes a multidisciplinary approach to make substantial improvement in glycemic control of hospitalized patients. By the same token, it is unlikely that any one group can advance the national agenda for improved care as well as a multidisciplinary coordinated effort. Team members, especially the endocrinologists and hospitalists, collaborated skillfully throughout this effort. The hospitalists learned a tremendous amount from the expertise, insight, and mastery of the literature, offered by the endocrinology members, whereas the endocrinologists appreciated the front line expertise and practical quality improvement approach of the hospitalist members. This collaboration serves as a model for making guidelines and best practices become more of a practical reality for a variety of important clinical problems. Hospitalists can partner with and learn from a variety of other disciplines, while they assist these disciplines on effective improvement and implementation efforts. On a more personal note, this work has fostered mutual respect, friendship, and career long collaborative opportunities. The potential for these same opportunities with nursing, pharmacy, and all medical and surgical fields seems compelling and exciting.
THERE'S MORE!
By the time this is published, these articles will be integrated into the third iteration of the SHM Glycemic Control Resource Room. This online resource has already undergone 2 major revisions since its inception just a few years ago, reflecting SHM's dedication to the continuous improvement of the products and services that it offers. The Glycemic Control Implementation Guide and Resource Room will continue to be a work in progress. We highly encourage and welcome constructive criticism and feedback via E‐mail to
NEXT STEPS
More research and demonstration projects are obviously needed in this field. Local collaborative activities have sprung up in several cities and regions, as well as Glycemic Control Champions courses. A longitudinal mentoring program (similar to the SHM Venous Thromboembolism Prevention collaborative) would undoubtedly be beneficial, and may become available within the next year or so. These items and more will be promoted and posted in the resource room whenever possible.
Finally, the next step is up to you and the institutions in which you workyou have to decide, as individuals and institutions, if you believe the status quo is good enough. We believe that if you look, you'll find the care of our inpatients with diabetes and hyperglycemia disturbingly suboptimal, and hope that the work of the SHM Glycemic Control Task Force can help you rapidly improve on this state of affairs.
APPENDIX: GLYCEMIC CONTROL TASK FORCE
The Society of Hospital Medicine thanks all the members of the Glycemic Control Task Force, who encompass a distinguished panel of experts with representation from the AACE, ADA, ACP, and other organizations whose expertise was essential to the construction of the Glycemic Control Resource Room and the Implementation Guide for Glycemic Control and Prevention of Hypoglycemia.
Hospitalists
Representing the Society of Hospital Medicine
-
Gregory Maynard, MD. Lead Author and Editor of Glycemic Control Implementation Guide (web product); Glycemic Control Initiative Project Director; Clinical Professor of Medicine and Chief, Division of Hospital Medicine. University of California, San Diego (UCSD) Medical Center, San Diego, California.
-
David H. Wesorick, MD. Co‐editor of Glycemic Control Implementation Guide (web product); Clinical Assistant Professor of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
-
Cheryl O'Malley, MD. Associate Program Director, Internal Medicine Faculty, Medicine/Pediatrics Banner, Good Samaritan Medical Center; Clinical Assistant Professor of Medicine, University of Arizona College of Medicine, Phoenix, Arizona.
-
Kevin Larsen, MD. Assistant Professor of Internal Medicine, University of Minnesota; Associate Program Director, Internal Medicine Residency, Hennepin County Medical Center, Minneapolis, Minnesota.
-
Jeffrey L. Schnipper, MD, MPH. Associate Physician, Brigham and Women's Hospital, Boston, Massachusetts
-
Alpesh Amin, MD, MBA, FACP. Executive Director and Vice Chair, University of California (UC) Irvine Hospitalist Program, Irvine, California.
-
Lakshmi Halasyamani, MD. Associate Chair, Department of Medicine, St. Joseph Mercy Medical Center, Ann Arbor, Michigan.
-
Mitchell J. Wilson, MD. Associate Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
Representing the American College of Physicians
-
Doren Schneider, MD. Associate Program Director, Internal Medicine Residency Director, Ambulatory Service Unit, Abington Adult Medical Associates; Assistant Professor of Medicine, Temple University School of Medicine, Abington, Pennsylvania.
Endocrinologists
Representing the American Diabetes Association
-
Andrew J. Ahmann, MD. Associate Professor of Medicine, Director, Diabetes Center, Oregon Health & Science University, Portland, Oregon.
-
Michelle F. Magee, MD. Associate Professor of Medicine, Georgetown University School of Medicine Medstar Diabetes and Research Institutes, Washington Hospital Center, Washington, DC.
Representing the American Association of Clinical Endocrinologists
-
Richard Hellman, MD, FACP, FACE. Clinical Professor of Medicine, University of MissouriKansas City, North Kansas City, Missouri.
Endocringology Expert Panel
-
Susan Shapiro Braithwaite, MD, FACP, FACE. Clinical Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
-
Mary Ann Emanuele, MD, FACP. Professor of Medicine, Endocrinology, Cell Biology, Neurobiology, and Anatomy Biochemistry, Loyola University Medical Center, Maywood, Illinois.
-
Irl B. Hirsch, MD. Professor of Medicine, University of Washington, Seattle, Washington.
-
Robert Rushakoff, MD. Clinical Professor of Medicine, Director, Diabetes Program, University of California, San Francisco (UCSF)/Mt. Zion, San Francisco, California.
-
Silvio E. Inzucchi, MD. Professor of Medicine, Clinical Director, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut.
Education
-
Marcia D. Draheim, RN, CDE. Program Supervisor, Diabetes Center, St Luke's Hospital, Cedar Rapids, Iowa.
-
Sharon Mahowald, RN, CDE. Inpatient Diabetes Coordinator, Hennepin County Medical Center, Minneapolis, Minnesota.
Financial
-
Adam Beck, MHS, FABC. MedStar Research Institute, Washington, DC.
Pharmacists
-
Stuart T. Haines, PharmD, FASHP, FCCP, BCPS. Associate Professor/Vice Chair for Education, University of Maryland School of Pharmacy Baltimore, Maryland.
Representing the American Society of Consultant Pharmacists
-
Donald K. Zettervall, RPh, CDE, CDM. Owner/Director, The Diabetes Education Center, Old Saybrook, Connecticut.
Case Management
Representing the Case Management Society of America
-
Cheri Lattimer, RN, BSN. Executive Director, Case Management Society of America, Little Rock, Arkansas.
-
Nancy Skinner, RN, CCM. Director, Case Management Society of America Principle Consultant, Riverside HealthCare Consulting, Whitwell, Tennessee.
Dietetics
-
Carrie Swift, MS, RD, BC‐ADM. Dietetics Coordinator, Veterans Affairs Medical Center, Walla Walla, Washington.
SHM Staff Members
-
Geri Barnes and Joy Wittnebert.
Glycemic Control Resource Room Project Team
-
Greg Maynard, Jason Stein, David Wesorick, Mary Ann Emanuele, Kevin Larsen, Geri Barnes, Joy Wittnebert, and Bruce Hansen.
- Inpatient Diabetes and Glycemic Control: A Call to Action Conference. Position statement. AACE, February 2006. Available at: http://www.aace.com/meetings/consensus/IIDC/IDGC0207.pdf. Accessed October 2006. Garber et al. Endocr Pract.2006;12(suppl 3):3–13.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm. Accessed May2008.
- Society of Hospital Medicine Glycemic Control Task Force. Implementation guide: improving glycemic control, preventing hypoglycemia, and optimizing care of the inpatient with hyperglycemia and diabetes. Published January 2007 on the Society of Hospital Medicine Website. Available at: http://www.hospitalmedicine.org. Accessed May2008.
- ,,,,,.The case for supporting inpatient glycemic control programs now: the evidence and beyond.J Hosp Med.2008;3(5 suppl 5)( ):S6–S16.
- ,,,,.Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non‐critically ill adult patient.J Hosp Med.2008;3(5 suppl 5)( ):S17–S28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 suppl 5)( ):S29–S41.
- ,.Designing and implementing insulin infusion protocols and order sets.J Hosp Med.2008;3(5 suppl 5)( ):S42–S54.
- ,,,.Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia.J Hosp Med.2008;3(5 suppl 5)( ):S55–S65.
- ,,,,,.Society of Hospital Medicine glycemic control task force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(suppl 5):S66–S75.
- ,.Practical strategies for developing the business case for hospital glycemic control teams.J Hosp Med.2008;3(suppl 5):S76–S83.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10(1):77–82.
- Standards of medical care in diabetes‐‐2008.Diabetes Care.2008;31(suppl 1):S12–S54.
- ,,.Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus.Arch Intern Med.1997;157(5):545–552.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30(9):2181–2186.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1(3):141–144.
The articles on these pages represent the culmination of 3 years of effort by the Society of Hospital Medicine (SHM) Glycemic Control Task Force. In this brief introduction, we share a few insights and comments about this multidisciplinary collaborative effort to address the care of inpatients with hyperglycemia.
The SHM Glycemic Control Task Force was assembled in 2005, with the intent of improving the care of inpatients with diabetes. We wished to provide hospitalists and quality improvement teams with an understanding of the best practices to achieve safe glycemic control in the hospital. Additionally, this task force sought to identify tools and strategies to obtain improved communication, medication safety, education, and other aspects of care. A distinguished panel of experts attended their inaugural meeting in Chicago, Illinois, in October 2005, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. A roster of the individuals and organizations is given in the Appendix.
Many members of the SHM Glycemic Control Task Force also participated in the Call to Action consensus conference1 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) in January 2006. Both groups identified several barriers to improvement, and methods to overcome these barriers were summarized in this quote from the Consensus Conference,
Successful implementation of a program to improve glycemic control in the inpatient setting should include the following components:
-
An appropriate level of administrative support.
-
Formation of a multidisciplinary steering committee to drive the development of initiatives.
-
Assessment of current processes, quality of care, and barriers to practice change.
-
Development and implementation of interventions including standardized order sets, protocols, policies, and algorithms with associated educational programs.
-
Metrics for evaluation.
Both groups also called for a web‐based compendium of tested tools and strategies to assist local improvement teams.
After countless hours of development and revision by the SHM Glycemic Task Force and the Resource Room team, such a compendium addressing all of these components was launched on the SHM web site in the form of the SHM Glycemic Control Resource Room.2 A comprehensive implementation guide3 is available for downloading free of charge, and serves as the centerpiece of the Resource Room. Subsequently, this comprehensive but somewhat sprawling implementation guide evolved into these more sophisticated and concise articles.410 The topics include a review of the rationale for improving inpatient glycemic control,4 an important call for standardizing the metrics of glycemic control,9 subcutaneous insulin regimens and order sets,5, 6 insulin infusion protocols,7 transitions of care,8 and the business case for glycemic control.10 It has been a long but rewarding and educational journey, drawing on the collective experience from dozens of institutions in all kinds of inpatient care settings. A few key points and insights seem worth sharing.
THE IMPROVEMENT EFFORT IS NOT JUST ABOUT REACHING A GLYCEMIC TARGET
The term glycemic control team and the label for the SHM Glycemic Control Task Force itself are somewhat misnomers. Task Force members agree that desirable institutional glycemic target ranges should be established, but many among us believe the glycemic targets endorsed by national guidelines (ref ADA and AACE guidelines)11, 12 are too stringent. Furthermore, we believe that achieving glycemic control is just one small part of the needed improvement efforts. Uncontrolled hyperglycemia is common, potentially dangerous, and largely preventable with safe and proven methodsbut so are the iatrogenic hypoglycemia episodes, substandard education, poor communication, lack of care coordination, and inadequate monitoring that typify care of the hyperglycemic inpatient. We address all of these issues and urge the adoption of this broader perspective.
THE EVIDENCE IS INCOMPLETEBUT ACTION IS REQUIRED
We acknowledge gaps and inconsistencies in the literature surrounding inpatient diabetes management and the controversy around tight glycemic control. In many cases, high level evidence is not available to guide the formulation of protocols, order sets, or other improvement tools. We are all struck by how pervasive the lack of evidence is. What is the best metric for inpatient glycemic control or hypoglycemia? What is the best regimen for a patient on continuous tube feedings? Which insulin infusion protocol is superior in reaching and maintaining a glycemic target range?
Rather than make no recommendations or accept negative inertia on the basis of less than perfect evidence, we make recommendations based on the best evidence available. When we make recommendations based on consensus opinion or the collective experience from dozens of medical centers, rather than randomized trials, we have made every effort to make this clear in the text of the articles. In our view, incomplete evidence is not an adequate excuse to persist in the unacceptable status quo, clinging on to methods (such as sliding scale insulin regimens) that have been shown to be ineffective and potentially dangerous.1315
COLLABORATION PAYS DIVIDENDS
It takes a multidisciplinary approach to make substantial improvement in glycemic control of hospitalized patients. By the same token, it is unlikely that any one group can advance the national agenda for improved care as well as a multidisciplinary coordinated effort. Team members, especially the endocrinologists and hospitalists, collaborated skillfully throughout this effort. The hospitalists learned a tremendous amount from the expertise, insight, and mastery of the literature, offered by the endocrinology members, whereas the endocrinologists appreciated the front line expertise and practical quality improvement approach of the hospitalist members. This collaboration serves as a model for making guidelines and best practices become more of a practical reality for a variety of important clinical problems. Hospitalists can partner with and learn from a variety of other disciplines, while they assist these disciplines on effective improvement and implementation efforts. On a more personal note, this work has fostered mutual respect, friendship, and career long collaborative opportunities. The potential for these same opportunities with nursing, pharmacy, and all medical and surgical fields seems compelling and exciting.
THERE'S MORE!
By the time this is published, these articles will be integrated into the third iteration of the SHM Glycemic Control Resource Room. This online resource has already undergone 2 major revisions since its inception just a few years ago, reflecting SHM's dedication to the continuous improvement of the products and services that it offers. The Glycemic Control Implementation Guide and Resource Room will continue to be a work in progress. We highly encourage and welcome constructive criticism and feedback via E‐mail to
NEXT STEPS
More research and demonstration projects are obviously needed in this field. Local collaborative activities have sprung up in several cities and regions, as well as Glycemic Control Champions courses. A longitudinal mentoring program (similar to the SHM Venous Thromboembolism Prevention collaborative) would undoubtedly be beneficial, and may become available within the next year or so. These items and more will be promoted and posted in the resource room whenever possible.
Finally, the next step is up to you and the institutions in which you workyou have to decide, as individuals and institutions, if you believe the status quo is good enough. We believe that if you look, you'll find the care of our inpatients with diabetes and hyperglycemia disturbingly suboptimal, and hope that the work of the SHM Glycemic Control Task Force can help you rapidly improve on this state of affairs.
APPENDIX: GLYCEMIC CONTROL TASK FORCE
The Society of Hospital Medicine thanks all the members of the Glycemic Control Task Force, who encompass a distinguished panel of experts with representation from the AACE, ADA, ACP, and other organizations whose expertise was essential to the construction of the Glycemic Control Resource Room and the Implementation Guide for Glycemic Control and Prevention of Hypoglycemia.
Hospitalists
Representing the Society of Hospital Medicine
-
Gregory Maynard, MD. Lead Author and Editor of Glycemic Control Implementation Guide (web product); Glycemic Control Initiative Project Director; Clinical Professor of Medicine and Chief, Division of Hospital Medicine. University of California, San Diego (UCSD) Medical Center, San Diego, California.
-
David H. Wesorick, MD. Co‐editor of Glycemic Control Implementation Guide (web product); Clinical Assistant Professor of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
-
Cheryl O'Malley, MD. Associate Program Director, Internal Medicine Faculty, Medicine/Pediatrics Banner, Good Samaritan Medical Center; Clinical Assistant Professor of Medicine, University of Arizona College of Medicine, Phoenix, Arizona.
-
Kevin Larsen, MD. Assistant Professor of Internal Medicine, University of Minnesota; Associate Program Director, Internal Medicine Residency, Hennepin County Medical Center, Minneapolis, Minnesota.
-
Jeffrey L. Schnipper, MD, MPH. Associate Physician, Brigham and Women's Hospital, Boston, Massachusetts
-
Alpesh Amin, MD, MBA, FACP. Executive Director and Vice Chair, University of California (UC) Irvine Hospitalist Program, Irvine, California.
-
Lakshmi Halasyamani, MD. Associate Chair, Department of Medicine, St. Joseph Mercy Medical Center, Ann Arbor, Michigan.
-
Mitchell J. Wilson, MD. Associate Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
Representing the American College of Physicians
-
Doren Schneider, MD. Associate Program Director, Internal Medicine Residency Director, Ambulatory Service Unit, Abington Adult Medical Associates; Assistant Professor of Medicine, Temple University School of Medicine, Abington, Pennsylvania.
Endocrinologists
Representing the American Diabetes Association
-
Andrew J. Ahmann, MD. Associate Professor of Medicine, Director, Diabetes Center, Oregon Health & Science University, Portland, Oregon.
-
Michelle F. Magee, MD. Associate Professor of Medicine, Georgetown University School of Medicine Medstar Diabetes and Research Institutes, Washington Hospital Center, Washington, DC.
Representing the American Association of Clinical Endocrinologists
-
Richard Hellman, MD, FACP, FACE. Clinical Professor of Medicine, University of MissouriKansas City, North Kansas City, Missouri.
Endocringology Expert Panel
-
Susan Shapiro Braithwaite, MD, FACP, FACE. Clinical Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
-
Mary Ann Emanuele, MD, FACP. Professor of Medicine, Endocrinology, Cell Biology, Neurobiology, and Anatomy Biochemistry, Loyola University Medical Center, Maywood, Illinois.
-
Irl B. Hirsch, MD. Professor of Medicine, University of Washington, Seattle, Washington.
-
Robert Rushakoff, MD. Clinical Professor of Medicine, Director, Diabetes Program, University of California, San Francisco (UCSF)/Mt. Zion, San Francisco, California.
-
Silvio E. Inzucchi, MD. Professor of Medicine, Clinical Director, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut.
Education
-
Marcia D. Draheim, RN, CDE. Program Supervisor, Diabetes Center, St Luke's Hospital, Cedar Rapids, Iowa.
-
Sharon Mahowald, RN, CDE. Inpatient Diabetes Coordinator, Hennepin County Medical Center, Minneapolis, Minnesota.
Financial
-
Adam Beck, MHS, FABC. MedStar Research Institute, Washington, DC.
Pharmacists
-
Stuart T. Haines, PharmD, FASHP, FCCP, BCPS. Associate Professor/Vice Chair for Education, University of Maryland School of Pharmacy Baltimore, Maryland.
Representing the American Society of Consultant Pharmacists
-
Donald K. Zettervall, RPh, CDE, CDM. Owner/Director, The Diabetes Education Center, Old Saybrook, Connecticut.
Case Management
Representing the Case Management Society of America
-
Cheri Lattimer, RN, BSN. Executive Director, Case Management Society of America, Little Rock, Arkansas.
-
Nancy Skinner, RN, CCM. Director, Case Management Society of America Principle Consultant, Riverside HealthCare Consulting, Whitwell, Tennessee.
Dietetics
-
Carrie Swift, MS, RD, BC‐ADM. Dietetics Coordinator, Veterans Affairs Medical Center, Walla Walla, Washington.
SHM Staff Members
-
Geri Barnes and Joy Wittnebert.
Glycemic Control Resource Room Project Team
-
Greg Maynard, Jason Stein, David Wesorick, Mary Ann Emanuele, Kevin Larsen, Geri Barnes, Joy Wittnebert, and Bruce Hansen.
The articles on these pages represent the culmination of 3 years of effort by the Society of Hospital Medicine (SHM) Glycemic Control Task Force. In this brief introduction, we share a few insights and comments about this multidisciplinary collaborative effort to address the care of inpatients with hyperglycemia.
The SHM Glycemic Control Task Force was assembled in 2005, with the intent of improving the care of inpatients with diabetes. We wished to provide hospitalists and quality improvement teams with an understanding of the best practices to achieve safe glycemic control in the hospital. Additionally, this task force sought to identify tools and strategies to obtain improved communication, medication safety, education, and other aspects of care. A distinguished panel of experts attended their inaugural meeting in Chicago, Illinois, in October 2005, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. A roster of the individuals and organizations is given in the Appendix.
Many members of the SHM Glycemic Control Task Force also participated in the Call to Action consensus conference1 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) in January 2006. Both groups identified several barriers to improvement, and methods to overcome these barriers were summarized in this quote from the Consensus Conference,
Successful implementation of a program to improve glycemic control in the inpatient setting should include the following components:
-
An appropriate level of administrative support.
-
Formation of a multidisciplinary steering committee to drive the development of initiatives.
-
Assessment of current processes, quality of care, and barriers to practice change.
-
Development and implementation of interventions including standardized order sets, protocols, policies, and algorithms with associated educational programs.
-
Metrics for evaluation.
Both groups also called for a web‐based compendium of tested tools and strategies to assist local improvement teams.
After countless hours of development and revision by the SHM Glycemic Task Force and the Resource Room team, such a compendium addressing all of these components was launched on the SHM web site in the form of the SHM Glycemic Control Resource Room.2 A comprehensive implementation guide3 is available for downloading free of charge, and serves as the centerpiece of the Resource Room. Subsequently, this comprehensive but somewhat sprawling implementation guide evolved into these more sophisticated and concise articles.410 The topics include a review of the rationale for improving inpatient glycemic control,4 an important call for standardizing the metrics of glycemic control,9 subcutaneous insulin regimens and order sets,5, 6 insulin infusion protocols,7 transitions of care,8 and the business case for glycemic control.10 It has been a long but rewarding and educational journey, drawing on the collective experience from dozens of institutions in all kinds of inpatient care settings. A few key points and insights seem worth sharing.
THE IMPROVEMENT EFFORT IS NOT JUST ABOUT REACHING A GLYCEMIC TARGET
The term glycemic control team and the label for the SHM Glycemic Control Task Force itself are somewhat misnomers. Task Force members agree that desirable institutional glycemic target ranges should be established, but many among us believe the glycemic targets endorsed by national guidelines (ref ADA and AACE guidelines)11, 12 are too stringent. Furthermore, we believe that achieving glycemic control is just one small part of the needed improvement efforts. Uncontrolled hyperglycemia is common, potentially dangerous, and largely preventable with safe and proven methodsbut so are the iatrogenic hypoglycemia episodes, substandard education, poor communication, lack of care coordination, and inadequate monitoring that typify care of the hyperglycemic inpatient. We address all of these issues and urge the adoption of this broader perspective.
THE EVIDENCE IS INCOMPLETEBUT ACTION IS REQUIRED
We acknowledge gaps and inconsistencies in the literature surrounding inpatient diabetes management and the controversy around tight glycemic control. In many cases, high level evidence is not available to guide the formulation of protocols, order sets, or other improvement tools. We are all struck by how pervasive the lack of evidence is. What is the best metric for inpatient glycemic control or hypoglycemia? What is the best regimen for a patient on continuous tube feedings? Which insulin infusion protocol is superior in reaching and maintaining a glycemic target range?
Rather than make no recommendations or accept negative inertia on the basis of less than perfect evidence, we make recommendations based on the best evidence available. When we make recommendations based on consensus opinion or the collective experience from dozens of medical centers, rather than randomized trials, we have made every effort to make this clear in the text of the articles. In our view, incomplete evidence is not an adequate excuse to persist in the unacceptable status quo, clinging on to methods (such as sliding scale insulin regimens) that have been shown to be ineffective and potentially dangerous.1315
COLLABORATION PAYS DIVIDENDS
It takes a multidisciplinary approach to make substantial improvement in glycemic control of hospitalized patients. By the same token, it is unlikely that any one group can advance the national agenda for improved care as well as a multidisciplinary coordinated effort. Team members, especially the endocrinologists and hospitalists, collaborated skillfully throughout this effort. The hospitalists learned a tremendous amount from the expertise, insight, and mastery of the literature, offered by the endocrinology members, whereas the endocrinologists appreciated the front line expertise and practical quality improvement approach of the hospitalist members. This collaboration serves as a model for making guidelines and best practices become more of a practical reality for a variety of important clinical problems. Hospitalists can partner with and learn from a variety of other disciplines, while they assist these disciplines on effective improvement and implementation efforts. On a more personal note, this work has fostered mutual respect, friendship, and career long collaborative opportunities. The potential for these same opportunities with nursing, pharmacy, and all medical and surgical fields seems compelling and exciting.
THERE'S MORE!
By the time this is published, these articles will be integrated into the third iteration of the SHM Glycemic Control Resource Room. This online resource has already undergone 2 major revisions since its inception just a few years ago, reflecting SHM's dedication to the continuous improvement of the products and services that it offers. The Glycemic Control Implementation Guide and Resource Room will continue to be a work in progress. We highly encourage and welcome constructive criticism and feedback via E‐mail to
NEXT STEPS
More research and demonstration projects are obviously needed in this field. Local collaborative activities have sprung up in several cities and regions, as well as Glycemic Control Champions courses. A longitudinal mentoring program (similar to the SHM Venous Thromboembolism Prevention collaborative) would undoubtedly be beneficial, and may become available within the next year or so. These items and more will be promoted and posted in the resource room whenever possible.
Finally, the next step is up to you and the institutions in which you workyou have to decide, as individuals and institutions, if you believe the status quo is good enough. We believe that if you look, you'll find the care of our inpatients with diabetes and hyperglycemia disturbingly suboptimal, and hope that the work of the SHM Glycemic Control Task Force can help you rapidly improve on this state of affairs.
APPENDIX: GLYCEMIC CONTROL TASK FORCE
The Society of Hospital Medicine thanks all the members of the Glycemic Control Task Force, who encompass a distinguished panel of experts with representation from the AACE, ADA, ACP, and other organizations whose expertise was essential to the construction of the Glycemic Control Resource Room and the Implementation Guide for Glycemic Control and Prevention of Hypoglycemia.
Hospitalists
Representing the Society of Hospital Medicine
-
Gregory Maynard, MD. Lead Author and Editor of Glycemic Control Implementation Guide (web product); Glycemic Control Initiative Project Director; Clinical Professor of Medicine and Chief, Division of Hospital Medicine. University of California, San Diego (UCSD) Medical Center, San Diego, California.
-
David H. Wesorick, MD. Co‐editor of Glycemic Control Implementation Guide (web product); Clinical Assistant Professor of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
-
Cheryl O'Malley, MD. Associate Program Director, Internal Medicine Faculty, Medicine/Pediatrics Banner, Good Samaritan Medical Center; Clinical Assistant Professor of Medicine, University of Arizona College of Medicine, Phoenix, Arizona.
-
Kevin Larsen, MD. Assistant Professor of Internal Medicine, University of Minnesota; Associate Program Director, Internal Medicine Residency, Hennepin County Medical Center, Minneapolis, Minnesota.
-
Jeffrey L. Schnipper, MD, MPH. Associate Physician, Brigham and Women's Hospital, Boston, Massachusetts
-
Alpesh Amin, MD, MBA, FACP. Executive Director and Vice Chair, University of California (UC) Irvine Hospitalist Program, Irvine, California.
-
Lakshmi Halasyamani, MD. Associate Chair, Department of Medicine, St. Joseph Mercy Medical Center, Ann Arbor, Michigan.
-
Mitchell J. Wilson, MD. Associate Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
Representing the American College of Physicians
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Doren Schneider, MD. Associate Program Director, Internal Medicine Residency Director, Ambulatory Service Unit, Abington Adult Medical Associates; Assistant Professor of Medicine, Temple University School of Medicine, Abington, Pennsylvania.
Endocrinologists
Representing the American Diabetes Association
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Andrew J. Ahmann, MD. Associate Professor of Medicine, Director, Diabetes Center, Oregon Health & Science University, Portland, Oregon.
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Michelle F. Magee, MD. Associate Professor of Medicine, Georgetown University School of Medicine Medstar Diabetes and Research Institutes, Washington Hospital Center, Washington, DC.
Representing the American Association of Clinical Endocrinologists
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Richard Hellman, MD, FACP, FACE. Clinical Professor of Medicine, University of MissouriKansas City, North Kansas City, Missouri.
Endocringology Expert Panel
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Susan Shapiro Braithwaite, MD, FACP, FACE. Clinical Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina.
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Mary Ann Emanuele, MD, FACP. Professor of Medicine, Endocrinology, Cell Biology, Neurobiology, and Anatomy Biochemistry, Loyola University Medical Center, Maywood, Illinois.
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Irl B. Hirsch, MD. Professor of Medicine, University of Washington, Seattle, Washington.
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Robert Rushakoff, MD. Clinical Professor of Medicine, Director, Diabetes Program, University of California, San Francisco (UCSF)/Mt. Zion, San Francisco, California.
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Silvio E. Inzucchi, MD. Professor of Medicine, Clinical Director, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut.
Education
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Marcia D. Draheim, RN, CDE. Program Supervisor, Diabetes Center, St Luke's Hospital, Cedar Rapids, Iowa.
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Sharon Mahowald, RN, CDE. Inpatient Diabetes Coordinator, Hennepin County Medical Center, Minneapolis, Minnesota.
Financial
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Adam Beck, MHS, FABC. MedStar Research Institute, Washington, DC.
Pharmacists
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Stuart T. Haines, PharmD, FASHP, FCCP, BCPS. Associate Professor/Vice Chair for Education, University of Maryland School of Pharmacy Baltimore, Maryland.
Representing the American Society of Consultant Pharmacists
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Donald K. Zettervall, RPh, CDE, CDM. Owner/Director, The Diabetes Education Center, Old Saybrook, Connecticut.
Case Management
Representing the Case Management Society of America
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Cheri Lattimer, RN, BSN. Executive Director, Case Management Society of America, Little Rock, Arkansas.
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Nancy Skinner, RN, CCM. Director, Case Management Society of America Principle Consultant, Riverside HealthCare Consulting, Whitwell, Tennessee.
Dietetics
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Carrie Swift, MS, RD, BC‐ADM. Dietetics Coordinator, Veterans Affairs Medical Center, Walla Walla, Washington.
SHM Staff Members
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Geri Barnes and Joy Wittnebert.
Glycemic Control Resource Room Project Team
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Greg Maynard, Jason Stein, David Wesorick, Mary Ann Emanuele, Kevin Larsen, Geri Barnes, Joy Wittnebert, and Bruce Hansen.
- Inpatient Diabetes and Glycemic Control: A Call to Action Conference. Position statement. AACE, February 2006. Available at: http://www.aace.com/meetings/consensus/IIDC/IDGC0207.pdf. Accessed October 2006. Garber et al. Endocr Pract.2006;12(suppl 3):3–13.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm. Accessed May2008.
- Society of Hospital Medicine Glycemic Control Task Force. Implementation guide: improving glycemic control, preventing hypoglycemia, and optimizing care of the inpatient with hyperglycemia and diabetes. Published January 2007 on the Society of Hospital Medicine Website. Available at: http://www.hospitalmedicine.org. Accessed May2008.
- ,,,,,.The case for supporting inpatient glycemic control programs now: the evidence and beyond.J Hosp Med.2008;3(5 suppl 5)( ):S6–S16.
- ,,,,.Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non‐critically ill adult patient.J Hosp Med.2008;3(5 suppl 5)( ):S17–S28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 suppl 5)( ):S29–S41.
- ,.Designing and implementing insulin infusion protocols and order sets.J Hosp Med.2008;3(5 suppl 5)( ):S42–S54.
- ,,,.Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia.J Hosp Med.2008;3(5 suppl 5)( ):S55–S65.
- ,,,,,.Society of Hospital Medicine glycemic control task force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(suppl 5):S66–S75.
- ,.Practical strategies for developing the business case for hospital glycemic control teams.J Hosp Med.2008;3(suppl 5):S76–S83.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10(1):77–82.
- Standards of medical care in diabetes‐‐2008.Diabetes Care.2008;31(suppl 1):S12–S54.
- ,,.Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus.Arch Intern Med.1997;157(5):545–552.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30(9):2181–2186.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1(3):141–144.
- Inpatient Diabetes and Glycemic Control: A Call to Action Conference. Position statement. AACE, February 2006. Available at: http://www.aace.com/meetings/consensus/IIDC/IDGC0207.pdf. Accessed October 2006. Garber et al. Endocr Pract.2006;12(suppl 3):3–13.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm. Accessed May2008.
- Society of Hospital Medicine Glycemic Control Task Force. Implementation guide: improving glycemic control, preventing hypoglycemia, and optimizing care of the inpatient with hyperglycemia and diabetes. Published January 2007 on the Society of Hospital Medicine Website. Available at: http://www.hospitalmedicine.org. Accessed May2008.
- ,,,,,.The case for supporting inpatient glycemic control programs now: the evidence and beyond.J Hosp Med.2008;3(5 suppl 5)( ):S6–S16.
- ,,,,.Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non‐critically ill adult patient.J Hosp Med.2008;3(5 suppl 5)( ):S17–S28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 suppl 5)( ):S29–S41.
- ,.Designing and implementing insulin infusion protocols and order sets.J Hosp Med.2008;3(5 suppl 5)( ):S42–S54.
- ,,,.Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia.J Hosp Med.2008;3(5 suppl 5)( ):S55–S65.
- ,,,,,.Society of Hospital Medicine glycemic control task force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(suppl 5):S66–S75.
- ,.Practical strategies for developing the business case for hospital glycemic control teams.J Hosp Med.2008;3(suppl 5):S76–S83.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10(1):77–82.
- Standards of medical care in diabetes‐‐2008.Diabetes Care.2008;31(suppl 1):S12–S54.
- ,,.Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus.Arch Intern Med.1997;157(5):545–552.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30(9):2181–2186.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1(3):141–144.