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Published on November 01, 2018

NKCH Combats Comorbidities With Glycemic Control Programs

Glycemic control is imperative for hospitalized patients with diabetes who are at risk for adverse events brought on by hyperglycemia or hypoglycemia. In early December, two new glycemic control programs at North Kansas City Hospital will bring improved monitoring and treatment to patients with diabetes mellitus.

One provides nationally-validated physician orders to give bedside nurses clear-cut instructions for determining insulin drip dosing. The protocol will allow nurses on the second floor intensive care unit to take patient insulin needs and glucose control rates of change into account.

In the second, patients on insulin pumps will complete daily logs. These patients will have been determined to be appropriate for continuation of insulin pump therapy. Kept at the bedside, patients will self-document their glucose levels, boluses, basal rates, carbohydrate ratios and other levels. Bedside nurses will scan the document into the electronic medical record each day.

Glycemic Control

“With better glycemic control, we improve the safety of our patients with cancer, cardiac disease and other serious illnesses, or those who have had surgery. These programs help us ensure that our patients are protected,” said Richard Hellman, MD, FACE, FACP, an endocrinologist with Hellman & Rosen Endocrine Associates.

He noted that tight glycemic control of hospitalized patients improves their responses to chemotherapy, heart failure, pneumonia, urinary tract infections and other issues. “We’re already seeing objective signs of progress that glycemic control programs protect patients. We’ve made improvements in lowering the incidence of very low blood sugars and in how quickly nurses respond to and treat patients,” Dr. Hellman said.

Those improvements are a result, in part, of the Hypoglycemic Treatment Challenge, a monthly competition between nursing units to reduce hypoglycemic treatment times. Since the program began in September 2017, the average treatment time across hospital units has dropped by 19 minutes (35%), and average time to resolution of hypoglycemic episode has dropped by 26 minutes (37%). Overall, the hospital has seen a 7% drop in hypoglycemic events.

Hospitalizations Among Adults ≥ 18 Years

Cause of Hospitalization Number in Thousands Crude Rate Per 1,000 Persons With Diabetes (95% Cl)
Diabetes as any listed diagnosis 7,155 327.2  (311.3-343.1)
Major cardiovascular disease 1,539 70.4  (66.8-73.9)
Ischemic heart disease 400 18.3  (17.3-19.3)
Stroke 251 11.5  (10.9-12.1)
Lower-extremity amputation 108 5.0  (4.7-5.2)
Diabetic ketoacidosis 168 7.7  (7.3-8.1)

CI: Confidence interval    Data source: United States Diabetes Surveillance System, 2014

Joint Effort

The programs are spearheaded by the glycemic control subcommittee, which formed in June 2017. The multidisciplinary committee includes staff from food and nutrition, the laboratory, nursing education, nursing, performance improvement, pharmacy and risk management, along with emergency medicine, endocrinology, hospitalist and pathology physicians.

“I have been impressed by how many people are stepping up, and the team has worked beautifully together,” said Dr. Hellman, committee chair. “This is a shining example of what can be achieved when the entire hospital works together to achieve a common goal.”

Comorbidities

In 2014, 7.2 million hospital patients in the U.S. aged 18 and older were discharged with a diagnosis of diabetes, according to the Centers for Disease Control and Prevention. The report, published in 2017, showed -major cardiovascular diseases, lower-extremity amputations and diabetic ketoacidosis accounted for the most prevalent comorbidities

“About 87% of patients with Type 2 diabetes have at least one other comorbid condition, and many of them have multiple comorbidities. These conditions are ultimately what bring them to the hospital,”
Dr. Hellman said.

Their comorbid conditions worsen without adequate diabetes treatment. “When people come into the hospital and they have diabetes or prediabetes, the stress of the medical or surgical care can often cause their blood sugars to be very high,” Dr. Hellman said. “There is very strong scientific evidence that significant hyperglycemia and hypoglycemia in critically ill patients increases the rate of overall complications, infections, morbidity and mortality, lengthening hospital stays and increasing costs.”

Richard Hellman, MD, FACE, FACP

Richard Hellman, MDDr. Hellman received his medical degree from Chicago Medical School. He completed his residency in internal medicine at the University of Kansas School of Medicine, followed by a fellowship in endocrinology.