In the Journals

Virtual glucose management improves glycemic control in hospitalized patients

A virtual glucose management service reduced hyperglycemia and hypoglycemia among hospitalized patients, according to findings published in Annals of Internal Medicine.

“The involvement of diabetes specialists and impatient diabetes teams can reduce length of stay and improve glycemic control and clinical outcomes, but those interventions are time- and resource-intensive,” Robert J. Rushakoff, MD, from the University of California, San Francisco, and colleagues wrote. “Although infrastructure and educational efforts have led to decreased errors in insulin administration and improved glucose control, internal audits continued to show inappropriate initial insulin orders and therapeutic inertia for prescribers at our institution.”

After the implementation of the electronic medical record (EMR) at UCSF in  2012, researchers examined whether a virtual glucose management service (vGMS) improved inpatient glycemic control over a 3-year period (June 1, 2012, to May 31, 2015). They performed cross-sectional analyses of three 12-month intervals (pre-vGMS, transition and vGMS) at UCSF hospitals, measuring the proportion of patient-days classified as hyperglycemic, hypoglycemic and at-goal during these periods.

Using a daily glucose report, Rushakoff and colleagues identified hospitalized adult patients with two or more glucose values of 12.5 mmol/L or greater, or 225 mg/dL or greater (hyperglycemic) and/or a glucose level less than 3.9 mmol/L or less than 70 mg/dL (hypoglycemic) in the previous 24 hours. Recommendations for insulin changes were entered in a vGMS note based on review of the insulin/glucose chart in the EMR.

The proportion of hyperglycemic patients decreased by 39% from 6.6 per 100 patient-days in the pre-vGMS period to 4.9 per 100 patient-days in the vGMS period (–2.5; 95% CI, –2.7 to –2.4). In addition, the researchers observed that the proportion of hypoglycemic patients in the vGMS period lessened by 36% compared with those in the pre-vGMS period (–0.28; 95% CI, –0.35 to –0.22). The findings revealed that 15 severe hypoglycemic events occurred during the vGMS period compared with 47 during the pre-vGMS period (< 2.2 mmol/L or < 40 mg/dL).

“Since implementing the vGMS, we have observed that the improved glycemic control has been sustained and the number of patients in the daily high glucose report has decreased, suggesting that providers are more effectively managing insulin orders,” Rushakoff and colleagues wrote. “An inpatient vGMS is a potentially scalable model that harnesses automated glucose screening and expedited clinical review to enhance the management of patients with diabetes.”

In a related commentary, Gerry Rayman, MD, from Ipswich Hospital NHS Trust in the United Kingdom wrote that this study should be reviewed to include how inpatient diabetes care differs in the U.K. and other countries, where the uptake of electronic health records is limited and different methods may be used to manage hyperglycemia after hospitalization.

“An important downside of the vGMS is the absence of patient and specialist interaction,” Rayman wrote in his editorial. “In the United Kingdom, there is increasing emphasis on patient empowerment and their involvement in care planning. Remote orders without patient involvement would not be readily accepted.” – by Savannah Demko

Disclosures: Rushakoff reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures. Rayman reports no relevant financial disclosures.

A virtual glucose management service reduced hyperglycemia and hypoglycemia among hospitalized patients, according to findings published in Annals of Internal Medicine.

“The involvement of diabetes specialists and impatient diabetes teams can reduce length of stay and improve glycemic control and clinical outcomes, but those interventions are time- and resource-intensive,” Robert J. Rushakoff, MD, from the University of California, San Francisco, and colleagues wrote. “Although infrastructure and educational efforts have led to decreased errors in insulin administration and improved glucose control, internal audits continued to show inappropriate initial insulin orders and therapeutic inertia for prescribers at our institution.”

After the implementation of the electronic medical record (EMR) at UCSF in  2012, researchers examined whether a virtual glucose management service (vGMS) improved inpatient glycemic control over a 3-year period (June 1, 2012, to May 31, 2015). They performed cross-sectional analyses of three 12-month intervals (pre-vGMS, transition and vGMS) at UCSF hospitals, measuring the proportion of patient-days classified as hyperglycemic, hypoglycemic and at-goal during these periods.

Using a daily glucose report, Rushakoff and colleagues identified hospitalized adult patients with two or more glucose values of 12.5 mmol/L or greater, or 225 mg/dL or greater (hyperglycemic) and/or a glucose level less than 3.9 mmol/L or less than 70 mg/dL (hypoglycemic) in the previous 24 hours. Recommendations for insulin changes were entered in a vGMS note based on review of the insulin/glucose chart in the EMR.

The proportion of hyperglycemic patients decreased by 39% from 6.6 per 100 patient-days in the pre-vGMS period to 4.9 per 100 patient-days in the vGMS period (–2.5; 95% CI, –2.7 to –2.4). In addition, the researchers observed that the proportion of hypoglycemic patients in the vGMS period lessened by 36% compared with those in the pre-vGMS period (–0.28; 95% CI, –0.35 to –0.22). The findings revealed that 15 severe hypoglycemic events occurred during the vGMS period compared with 47 during the pre-vGMS period (< 2.2 mmol/L or < 40 mg/dL).

“Since implementing the vGMS, we have observed that the improved glycemic control has been sustained and the number of patients in the daily high glucose report has decreased, suggesting that providers are more effectively managing insulin orders,” Rushakoff and colleagues wrote. “An inpatient vGMS is a potentially scalable model that harnesses automated glucose screening and expedited clinical review to enhance the management of patients with diabetes.”

In a related commentary, Gerry Rayman, MD, from Ipswich Hospital NHS Trust in the United Kingdom wrote that this study should be reviewed to include how inpatient diabetes care differs in the U.K. and other countries, where the uptake of electronic health records is limited and different methods may be used to manage hyperglycemia after hospitalization.

“An important downside of the vGMS is the absence of patient and specialist interaction,” Rayman wrote in his editorial. “In the United Kingdom, there is increasing emphasis on patient empowerment and their involvement in care planning. Remote orders without patient involvement would not be readily accepted.” – by Savannah Demko

Disclosures: Rushakoff reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures. Rayman reports no relevant financial disclosures.