Where: SSM St. Mary's Health Center, a 525-bed teaching hospital in St. Louis, Mo.
The issue: Improving glucose control of inpatients with diabetes.
As director of the diabetes program at St. Mary's, endocrinologist Reza Rofougaran, MD, was naturally concerned about the glucose control of the hospital's patients. But back in 2005, he didn't sense that many others shared his concern. “It always had been thought, for two to three days of hospitalization, if the sugars are high, so what, it's really not a big deal in the course of the long term,” Dr. Rofougaran said.
However, in light of growing evidence about the potential harms of high glucose for inpatients, he decided it was important to change that assumption. He soon found a willing partner: Philip Vaidyan, FACP, director of hospital medicine at St. Mary's and practice group leader with IPC The Hospitalist Company. “Both Dr. Vaidyan and I thought this is not something we are going to accept,” said Dr. Rofougaran. “We aligned our teams and groups to tackle this.”
With the approval of the hospital administration, they hired a diabetes educator and dietitian and convened a diabetes committee, which included physicians, the dietitian and nurses and pharmacists. The committee identified a number of problems that were impairing glucose control, including the use of sliding-scale insulin, disconnects between insulin dispensing and meal service, and a general lack of attention to glucose control, and set up a hospital-wide improvement program to address them.
How it works
To tackle the attention problem, the physicians offered education to physicians and nurses all over the hospital. “Any time I found a chance, I would go and talk and say, ‘Look, this is really the new stuff. This is what we want to do. If they have an infection and the blood sugar is 300, no matter what you do, you are not going to get the best result,’” said Dr. Rofougaran. “At like 2 a.m. we went there for the night shift nurses.”
Meetings to teach new insulin protocols (which were developed as part of the improvement program) were mandatory for residents. Then, starting with the intensive care unit and gradually expanding, the program leaders made clinicians accountable for their patients' blood sugars. “If the blood sugar's high, why? And didn't we do anything? What could we do for that? One nurse at a time, one doctor at a time, one floor at a time is what it took,” said Dr. Rofougaran.
“There were several grand rounds on hyperglycemia management in the ICU or for surgical patients,” said Dr. Vaidyan. “We moved away from reactive glycemic control to proactive.”
The effects of the intervention were seen in patients' blood glucose levels. In January 2006, the average of ICU patients' blood glucose was 180 mg/dL. By January 2007, the average had dropped to 136.5 mg/dL.
The program leaders faced, and dealt with, the usual skepticism toward a new quality improvement program, but one of their toughest challenges came from an unexpected area. The doctors wanted to fix the problem of patients receiving their mealtime insulin without their meals. For example, if patients went to dialysis at the time lunch was served, then the food needed to be taken to them in the dialysis center. However, it took some convincing to get meals served away from patients' rooms. “It sounds easy but it was really a major, major victory to convince people to deliver the tray,” said Dr. Rofougaran.
The physicians are also working to help their patients maintain glucose control after discharge. That effort has involved arranging outpatient physicians and appointments for the patients, or when that isn't possible, setting up an appointment with Dr. Rofougaran.
“If they could not go and see their primary care doctor within a week, he was willing to see them once or twice after they get out of the hospital,” said Dr. Vaidyan.
“The number of people who came into the hospital with poor control was so high it was amazing,” said Dr. Rofougaran. “We found these people with A1cs of 9, 10, 11, 12 who came in for other things. If not for this initiative, they would go back home as they were.”
Words of wisdom
“You need to have an endocrinologist who will be focusing at least half of their time in inpatient care. It's really hard to find an endocrinologist who is interested in taking care of inpatients,” said Dr. Vaidyan.