Getting a handle on glucose control

Yes, you can make a difference

It has long been argued that either you can't make a difference in patients' glucose levels during an inpatient stay, or it didn't make much difference in the long term if you did. But given what physicians know about inpatients with poor glucose control — they heal more slowly, have longer lengths of stay, and are at risk for more complications, among other things — Reza Rofougaran, MD, an endocrinologist at St. Mary's Hospital in St. Louis, wanted to take a stab at it.

What he and his colleagues did proved that physicians can make a difference, and make a difference that lasts long after the patient has left the hospital. "We have to strive for the optimal," says Rofougaran. "And we know that when blood sugar is better, the patient does better. I couldn't accept that it can't be helped that their blood sugar is bad."

Rofougaran sat down with his colleague, the head of hospital medicine and practice group leader for IPC The Hospitalist Company, Philip Vaidyan, MD, as well as other hospitalists, chief of medicine Morey Gardner, MD, nursing staff, the ICU attending, and administrative leadership. House staff were also involved, as St. Mary’s is a teaching institution.

Everyone involved seemed enthusiastic, he recalls. They all knew that high blood sugar delayed healing, used more hospital resources, led to complications, and increased length of stay. Controlling it could provide many benefits — to the patient and the hospital. "The culture has always been that you can't have a dramatic or lasting impact in four or five days," says Vaidyan. "We brought disciplines together to change that culture."

Looking at what other institutions were doing offered some help, but few were addressing the issue, so Rofougaran and his team started from scratch. "I knew from my own practice that if blood sugar looked good, nurses would hold off on basal insulin, so we started by challenging that."

Much of what he and his team did involved teaching and talking — whether it was to nurses on the night shift or physicians who were dubious that what they were doing would work. "We tried to convince them one physician at a time that blood sugar is as important as any other aspect of care," says Rofougaran. Surgeons were the most difficult to convince — a couple were "very opposed" to the efforts. Eventually, everyone came around, particularly after the nurses started demanding that physicians provide orders that went along with the new regime.

They continued to talk and teach through grand rounds and morbidity and mortality conferences. If a patient had high blood sugar, someone was going to ask why.

Another aspect of the program was to ensure that the work they did controlling blood sugar in the hospital translated across the continuum of care. Vaidyan notes that hospitalists often take care of unassigned patients who have issues with access to primary care. Some of those patients are not known to be diabetic until they are in the hospital. They now make sure that those patients have an appointment set with another physician before they leave the hospital. Rofougaran has seen patients himself, provided his cell phone number, and had patients report blood sugar levels directly to him for days or even weeks; he has given medication samples or otherwise gone above and beyond to make sure that patients have care when they are in the community, Vaidyan says.

About a fifth of the patients who come into St. Mary's are uninsured or underinsured, so strategies that can help avert readmission make a real difference to the hospital and the patient financially.

The doctors also worked on in-hospital transitions of care. Hypoglycemia in the ICU-to-floor transition is a good example of work they did. Vaidyan says that they now actively monitor the patients and don't discontinue tube feedings without notifying the entire care team. They also make sure that patients who might be out having tests have food delivered to them wherever they are, rather than sitting in their room while the patient is elsewhere in the hospital. That was a particular problem with dialysis patients.

"This isn't just one person's job or responsibility," Rofougaran says. "This has to be something that goes across all groups."

The results were remarkable. "I wasn't sure it would work," says Rofougaran. "Maybe it wasn't possible to make a difference like everyone said. I figured if we could get 20% of the patients in range it would be great." The results were rather more significant: 90% of patients have blood sugar within a range set by treatment teams for them; average blood glucose among diabetics went from 180 mg/dl before the program started six years ago to 120-130 mg/dl in 2010.

Rofougaran says he is happiest about the contribution to the community that the program has made. "We had a lot of patients with poor control of their diabetes. We have sent them home in good control and addressed their barriers to getting care. I feel great about that."

He also derives satisfaction from how much better patients feel when their blood sugar is controlled. "About 30 percent have diabetes or high blood sugar. They get sicker more often and come to us sicker. But when we control their sugar, they feel better."

Vaidyan says they have worked hard to anticipate issues, look at potential problems like comorbidities or whether the patient is taking steroids. "We don't have to chase this problem and deal with wild fluctuations. We can be proactive and watch them closely as a team."

For more information on this topic, contact:

  • Philip Vaidyan, MD, FACP, Clinical Assistant Professor of Medicine, St. Louis University, Practice Group Leader, IPC The Hospitalist Company, and Director of Hospital Medicine, St. Mary's Health Center. St. Louis, MO. Email: pVaidyan@pol.net. Telephone: (314) 283-5823.
  • Reza Rofougaran, MD, FACE, Director, Diabetes and Endocrinology, SSM St. Mary's Health Center, St. Louis, MO. Email: rofougaranr@pol.net.