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Keep patients' blood sugar at normal levels
Initiative aims to shorten LOS
With its approach to glycemic control, SMS St. Mary's Health Center in St. Louis, aims to shorten lengths of stay and "break the cycle of the revolving hospital door," for patients with diabetes as a primary or secondary condition, says Philip Vaidyan, MD, head of the IPC academic hospitalist program.
A multidisciplinary team worked with Reza Rofougaran, MD, an endocrinologist in private practice to develop a protocol to keep blood sugar levels under control for all patients, even during short hospitalizations, and to ensure that patients without insurance get their prescriptions filled and have a follow-up visit.
Before the protocol was instituted, the average blood glucose level among patients with diabetes in the intensive care was 180 mg/dl. Last year, the average was between 120 mg/dl and 130 mg/dl. Patients with diabetes on the medical/surgical units have an average blood glucose level of 140 mg/dl. About 90% of patients are within the blood sugar goal established by the treatment team.
"Everyone on the hospitalist team realized that there is a problem with inpatient management of diabetes. The mentality at many hospitals has been to practice reactive glucose control when patients are hospitalized for other problems. When patients are in the hospital only two or three days, the practice has been to avoid additional treatment unless the blood sugar level is above 300 mg/dl. We knew we had to change that mentality at our hospital," Rofougaran says.
About 65% of patients with diabetes admitted to St. Mary's already have been diagnosed. The remainder are diagnosed with diabetes while they are in the hospital.
Controlling a diabetic's blood sugar level is important because having blood sugar that is out of control slows the healing process and can increase mortality for surgical, stroke, and heart attack patients, as well as those with infections, such as pneumonia, Vaidyan says.
"We know that if patients with diabetes have an infection and their blood sugars are high, their white blood cells will not work to fight the infection. Wounds are not going to heal when blood sugars are greater than 180 mg/dl. Keeping diabetes under control is important for healing and for helping avoid complications. This in turn helps keep patients off ventilators, out of the intensive care unit, and lowers the length of stay," he adds.
When patients with diabetes are hospitalized, treating the diabetes must be a top priority along with treatment for the medical problem that resulted in the hospitalization, Rofougaran says.
"Patients who have good glycemic control while they are in the hospital have a shorter length of stay than patients with high blood sugar," he points out.
The diabetes initiative was developed by a multidisciplinary team that included nurses, case managers, and pharmacists in addition to Rofougaran, the hospitalist team, and the hospital's certified diabetes nurse educators, Vaidyan says.
The diabetes team educated the physicians, nurses, and the rest of the treatment team on the importance of glycemic control.
"We had to change the culture of the hospital. We did in-service training on every floor and every nursing shift and emphasized that we couldn't keep doing it the old way," Rofougaran says.
Protocols that address diabetes at the onset of treatment are embedded in SSM St. Mary's electronic health record. The protocol alerts the diabetes team if any patient admitted has high or low blood sugar levels.
When case managers review the medical record each morning, they look at patients with high and low blood sugars and determine what is going on with the patient.
"Diabetic teaching nurses review every single patient to determine what they need to keep their blood sugar under control and call the hospitalist or the attending physician when it is appropriate," Vaidyan says.
During the initial assessment, the case manager determines which patients are going to need diabetes education before discharge and alerts the diabetes educator.
"Our goal is to start getting the patients ready for discharge on day 1 so all we have to do is hand them the prescription for their medication when it's time for them to go home. Since we began this proactive approach, we have very few patients whose length of stay has increased because their diabetes issues have not been addressed," Rofougaran says.
In addition to treating patients while they are in the hospital, the diabetes team works to ensure that patients who don't have insurance, are without a medical home, and/or have poor health literacy receive the care they need as they transition from the hospital to the community, he adds.
"Our vision is to get the blood sugar under control while the patient is in the hospital and make sure that he or she has the necessary care after discharge to prevent readmissions, increase patient satisfaction, and enhance the patient's well-being," he adds.
Case managers are an important part of the treatment team because their assessment determines early in the stay which patients need help in accessing or getting their prescriptions filled after discharge, he says.
"Case managers have an important role in helping us prevent readmissions by assuring that patients with no resources and health care access have follow-up care in the community. If they don't have a primary care physician, the case managers call the referral coordinator to identify a community clinic and make sure that they can be seen within a week," he adds.
If patients don't have a physician in the community and can't get into a community clinic within a week after discharge, the case managers can refer them to Rofougaran's office for interim care. Rofougaran's office staff make follow-up calls to make sure patients understand their treatment plan.
Case managers and social workers are often called on to address low health literacy issues, noncompliance issues, and to help patients with no insurance.
"Case managers are an important part of the multidisciplinary team. They ensure that the patients will be able to keep their blood sugar under control after discharge by identifying community resources that can provide supplies and medication to patients who can't afford them. If a patient doesn't get his prescription filled after discharge, it doesn't matter what we do here, the diabetic is likely to develop complications and be rehospitalized," he adds.