Watch out for diabetes in hospitalized patients

First-ever advice is offered to all comers

Diabetic patients are hospitalized more often, for longer periods of time and at greater cost than patients without the disease. But sometimes the fact that they have the disease is overlooked in the process. This often leads to the detriment of patients and providers alike.

"It’s a reality. When a diabetic patient enters the hospital for any reason, the focus on diabetes is frequently lost in the inpatient setting," says Robert Stone, MBA, executive vice-president of the Diabetes Treatment Centers of America (DTCA) in Nashville, TN.

Stone’s organization has devised guidelines to help improve outcomes for the 3 million patients with diabetes who are admitted to hospitals each year.

DTCA says diabetic patients account for:

o 15% of all hospital admissions;
o 20% of all hospital days;
o 20% of all hospital costs.

Diabetics spend two to three days longer in the hospital than nondiabetic patients with similar complaints, and they consume 30% to 40% more resources than patients without diabetes, Stone says. "In 95% of the cases, the admission has nothing to do with glycemic control. People with diabetes go to the hospital for the same reason everybody else does."

DTCA, a provider of diabetes education and management services to 69 customer hospitals in 29 states and a contractor with HMOs covering 100,000 diabetic lives, provides something most hospitals don’t have: a comprehensive plan for inpatient diabetic management.

"It’s a huge need," Stone says. "It’s never been done, but we knew when we started this about a year ago that we could help hospital and medical staffs identify issues that contribute to the extra stays and adverse outcomes."

So DTCA assembled a panel of primary care physicians, specialists, and other health care professionals representing private practice, health plans, and institutions to develop a set of guidelines for inpatient care.

The initial recommendations were reviewed by DTCA’s scientific advisory council and a panel of faculty specialists at Vanderbilt University in Nashville. In November 1998, DTCA convened a consensus conference of nearly 100 physicians and other health care professionals in Key Largo, FL, to modify and endorse the plans aimed at improving diabetic inpatient outcomes.

"Continued inattention to the unique needs of the inpatient with diabetes is both costly and professionally unacceptable," the panel wrote in a report released to Diabetes Management.

Hospital orders may ignore dietary needs

The panel noted that metabolic control of diabetics requires detailed attention to the patient’s diet, activity, and medications in the outpatient and inpatient settings, but "too often physician orders or even a hospital’s standing orders fail to take into account many aspects of the patients’ pre-admission status and self-management regimen."

Whatever the condition that caused the admission, Stone points out, "Diabetes is an underlying concern. Our goal is to reduce costs by improving the health status of the diabetic population."

Hospital staffs should be able to discharge patients in better glycemic control, he explains, and avoid re-admission for infections or other complications. The panel began with these five goal recommendations:

1. Identify all patients with diabetes.

2. Identify and address any special needs of patients with diabetes.

3. Improve outcomes by optimizing glycemic/metabolic control.

4. Raise the level of awareness of the health care team with respect to the unique challenges of diabetes and current standards of care.

5. Strive for a length of stay equal to that of a patient without diabetes.

The guidelines include a detailed baseline assessment to be performed upon admission by the physician, nurse, or other health care provider. They detail protocol for identification, assessment, and laboratory procedures and list the health care professional who should be responsible for each step along the way and the frequency with which each step should be carried out.

The panel recommends screening consistent with the American Diabetes Association guidelines for all patients over the age of 18 to detect undiagnosed diabetes. In the initial assessment for those with confirmed diagnoses of diabetes, the guidelines recommend a physician-performed detailed history, a documentation of symptoms of diabetes-related comorbidities, and a physical exam with emphasis on diabetes-associated findings.

These laboratory tests are also recommended:

    - serum creatinine;
    - ECG;
    - urinalysis;
    - blood or serum glucose;
    - HbA1c;
    - lipid profile.

Health care professionals are also cautioned to look for conditions that may require special considerations in diabetic patients, including the presence of an insulin pump, pregnancy, coronary and cerebral vascular disease, infectious disease, inpatient surgery, and diabetic ketoacidosis.

The physician and nutritionist are also advised to perform a nutritional assessment for each diabetic patient upon admission to devise a specific nutritional plan for the patient, to reassess the nutrition plan frequently, and to devise a discharge nutrition plan with the appropriate instructions and follow-up.

While the patient is in the hospital, the guidelines require optimal metabolic control, with four times daily glucose monitoring, daily review, and with a goal for fasting blood sugars at 80 to 120 mg/dl and bedtime sugars at 100-140. Blood sugars should not be allowed to exceed 200 without intervention, the panel recommended.

The guidelines also call for detailed education, discharge planning, and follow-up by the entire health care team including demonstrations of the use of blood glucose monitors, self-administration of insulin, if needed, as well as teaching patients how to check their feet. "This population is undersupported from an educational point of view," Stone says. "Our perspective is that this is an adult learning issue that needs reinforcement, support, and encouragement."

DTCA has printed 15,000 copies of the guidelines and plans to distribute them to hospitals, physicians, state licensing boards, payer networks, and anyone else who requests them.

"They are a work in progress, and we anticipate we will issue updated versions as we get additional input and feedback," Stone says.

[Copies of the DTCA Inpatient Management Guidelines for People With Diabetes can be ordered from: Diabetes Treatment Centers of America 1 Burton Hills Blvd., Suite 300, Nashville, TN 37215; Attention: Teresa Mabry. Fax: (615) 665-7697. Robert Stone can be reached at (615) 665-7760.]