Inpatient Glucose Control:
A Glycemic Survey of 126 U.S. Hospitals
Journal of Hospital Medicine 2009;4:E7–E17. VC 2009 Society of Hospital Medicine.
Curtiss B. Cook, MD, FACP, Gail L. Kongable, RN, MSN, FNP, Daniel Jason Potter, MA, Victor J. Abad, MA, Dora E. Leija, MA, Marcy Anderson, MS, Mayo Clinic College of Medicine, Scottsdale, Arizona. The Epsilon Group Virginia, LLC, Charlottesville, Virginia. Medical Automation Systems, Charlottesville, Virginia.

Despite increased awareness of the value of treating inpatient hyperglycemia, little is known about glucose control in U.S. hospitals. The Remote Automated Laboratory System-Plus (RALS-Plus Medical Automation Systems, Charlottesville, VA) was used to extract inpatient point-of-care bedside glucose (POC-BG) tests from 126 hospitals for the period January to December 2007. Patient-day-weighted mean POC-BG and hypoglycemia/hyperglycemia rates were calculated for intensive care unit (ICU) and non-ICU areas. The relationship of POC-BG levels with hospital characteristics was determined.

A total of 12,559,305 POC-BG measurements were analyzed: 2,935,167 from the ICU and 9,624,138 from the non-ICU. Patient-day-weighted mean POC-BG was 165 mg/dL for ICU and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% for ICU and 31.7% for non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was low at 10.1% for ICU and 3.5% for non-ICU. For ICU and non-ICU there was a significant relationship between number of beds and patient-day-weighted mean POC-BG levels, with larger hospitals ( 400 beds) having lower patient-day weighted mean POC-BG per patient day than smaller hospitals (<200 beds, P < 0.001). Rural hospitals had higher POC-BG levels compared to urban and academic hospitals (P < 0.05), and hospitals in the West had the lowest values.

POC-BG data captured through automated data management software can support hospital efforts to monitor the status of inpatient glycemic control. From these data, hospital hyperglycemia is common, hypoglycemia prevalence is low, and POC-BG levels vary by hospital characteristics. Increased hospital participation in data collection and reporting may facilitate the creation of a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.

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Sliding Scale vs Tight Glycemic Control
Diabetes In Control

Patients treated with TC experienced more blood glucose measurements in the target range as compared with patients treated with SS with relatively low hypoglycemia rates.

Development of hyperglycemia during hospitalization is an area of concern in patients with and without diabetes mellitus. Tight glycemic control has been debated for critically ill and noncritically ill patients with hyperglycemia. Although many studies have been performed in the critically ill, adequate data are not available in the noncritically ill population.

To compare traditional sliding scale (SS) with a tight glycemic control (TC) algorithm. The primary endpoint was the percentage of total blood glucose measurements in the target range of 80-150 mg/dL. The secondary endpoint evaluated was safety, defined as percentage of all blood glucose measurements that were 0-60 mg/dL.

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Inpatient Hyperglycemia Management:

The Voyage Continues!
Dr. Rattan Juneja and Dr. Tim Meakem; Editorial: Crit Care Med 2009 Vol. 37, No. 12

We have known for some time now the strong association between hyperglycemia and increased risk of complications in hospitalized patients. We have also known that in-hospital hyperglycemia confers increased risk of mortality not only in patients with diabetes, but especially in those who manifest hyperglycemia for the first time during critical illness. These findings were supported in the sentinel clinical trial by van den Berghe et al, in which critically ill surgical patients randomized to a tight glucose target of 80 to 110 mg/dL experienced significant reductions in morbidity and mortality when compared with a glucose range of 180 to 200 mg/dL. This trial was the genesis for the concept and promotion of tight glucose control (TGC) in all critically ill patients.

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Glucose Control and Its Implications

for the General Surgeon
MAYA LEGGETT, M.D., BRIAN G. HARBRECHT, M.D. From the Department of Surgery, University of Louisville, Louisville Kentucky, for the American Surgeon.

THERE HAS BEEN AN INCREASING amount of literature over the last few years describing the importance of glucose control in hospitalized patients. Normalization of blood glucose levels in both diabetic and nondiabetic patients has been proposed to improve outcome and reduce the short term and long term adverse consequences of hyperglycemia. Several regulatory or advisory groups have even promoted tight glucose control as a process that should be monitored in critically ill patients to assess the quality of care. More >>

PROS AND CONS:

Tight Perioperative Glycemic Control
Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 6 (December), 2009

Lee A. Fleisher, MD and Bonnie L. Milas, MD, Section Editors of the Journal of Cardiothoracic and Vascular Anesthesia weigh the pros and cons of this subject.

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Glycemic Variability and Mortality in

Critically Ill Patients: The Impact of Diabetes
Journal of Diabetes Science and Technology, Volume 3, Issue 6, November 2009 © Diabetes Technology Society, James Stephen Krinsley M.D., FCCM, FCCP

Glycemic variability (GV) has recently been associated with mortality in critically ill patients. The impact of diabetes or its absence on GV as a risk factor for mortality is unknown.

A total of 4084 adult intensive care unit (ICU) patients admitted between October 15, 1999, and June 30, 2009, with at least three central laboratory measurements of venous glucose samples during ICU stay were studied retrospectively. The patients were analyzed according to treatment era and presence or absence of diabetes: 1460 admitted before February 1, 2003, when there was no specific treatment protocol for hyperglycemia (“PRE”) and 2624 patients admitted after a glycemic control protocol was instituted (“GC”). 3142 were patients without diabetes (“NON”), and 942 were patients with diabetes (“DM”). The coefficient of variation (CV) [standard deviation (SD)/mean glucose level (MGL)] of each patient was used as a measure of GV. More >>

Perioperative Management of Diabetes: Translating Evidence into Practice
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 76 • SUPPLEMENT 4 NOVEMBER 2009

Glycemic control before, during, and after surgery reduces the risk of infectious complications; in critically ill surgical patients, intensive glycemic control may reduce mortality as well. The preoperative assessment is important in determining risk status and determining optimal management to avoid clinically significant hyper- or hypoglycemia.

While patients with type 1 diabetes should receive insulin replacement at all times, regardless of nutritional status, those with type 2 diabetes may need to stop oral medications prior to surgery and might require insulin therapy to maintain blood glucose control. The glycemic target in the perioperative period needs to be clearly communicated so that proper insulin replacement, consisting of basal (long-acting), prandial (rapid-acting), and supplemental (rapid-acting) insulin can be implemented for optimal glycemic control.

The postoperative transition to subcutaneous insulin, if needed, can begin 12 to 24 hours before discontinuing intravenous insulin, by reinitiation of basal insulin replacement. Basal/ bolus insulin regimens are safer and more effective in hospitalized patients than supplemental-scale regular insulin. PDF >

Glycemic Control: How Tight Should it Be?
Nursing, November 2009, By Christine Kessler, RN, ANP, BC-ADM, MN

Consider the latest evidence as you explore the controversial issue of glycemic control in critically ill patients.

PATIENTS WITH DIABETES are often our most challenging. Although diabetes isn’t usually the reason that patients are admitted to the hospital, it’s the fourth most common comorbidity. Half of patients with type 1 and 2 diabetes will face surgery in their lifetime.

During hospitalization, up to 12% of patients who don’t have a history of diabetes will develop hyperglycemia, which is defined as a fasting blood glucose over 126 mg/dL or a random glucose over 200 mg/dL. Surprisingly, these patients will have a nearly 18-fold increased risk of in-hospital mortality compared with the 3-fold risk experienced by patients known to have diabetes. Recent studies have demonstrated that better glycemic control can greatly reduce mortality, morbidity, and hospital costs.

So how tight should glycemic control in hospitalized patients be? Based on recent studies, the answer to that question remains controversial.  More >

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