|Year : 2018 | Volume
| Issue : 5 | Page : 616-620
Effect of implementation of ADA/AACE guidelines on the management of hospitalized hyperglycemic patients through training of residents: A tertiary care center study
BP Amrith1, Prayas Sethi1, Manish Soneja1, Naval Vikram1, Arvind Kumar1, Praveen Aggarwal2, Viveka P Jyotsna3, RM Pandey4, Naveet Wig1
1 Department of Medicine, All India Institute of Medical Science, New Delhi, India
2 Department of Emergency Medicine, All India Institute of Medical Science, New Delhi, India
3 Department of Endocrinology and Metabolism, All India Institute of Medical Science, New Delhi, India
4 Department of Biostatistics, All India Institute of Medical Science, New Delhi, India
|Date of Web Publication||18-Sep-2018|
Department of Medicine, All India Institute of Medical Science (AIIMS), New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hyperglycemia is a common comorbidity in hospitalized patients and may add to adverse outcomes. Various associations have issued guidelines for optimal management of hyperglycemia in ill patients. This study aims to assess the adherence to current guidelines in inpatient setting and the impact of educational interventions on the improvement in adherence to guidelines as well as its effect on the level of blood sugar control and patient outcomes. Materials and Methods: It was a quasi-experimental pretest and posttest study and was done in three phases, viz., observation of current practices, intervention in the form of educational interventions, and its effect on change in practices and patient outcomes. Results: There was statistically significant 22% increase in the use of recommended insulin regimens (P = 0.028). The proportion of blood sugars within recommended range in the first 48 h, mean daily blood sugars, and the incidence of severe hyperglycemia improved in phase 3 vs phase 1 and was statistically significant. On comparing the subgroups, viz., those who followed and those who did not follow the guidelines, the results of the proportion of blood sugar in recommended range and proportions of blood sugar of more than 250 were found to be statistically significant. Conclusion: Dedicated educational interventions help in improving healthcare practices. According to current guidelines, rapid improvement in hyperglycemia and better glycemic control occur with adherence to protocol-based management of hyperglycemia.
Keywords: Education, Hyperglycemia, in patient
|How to cite this article:|
Amrith B P, Sethi P, Soneja M, Vikram N, Kumar A, Aggarwal P, Jyotsna VP, Pandey R M, Wig N. Effect of implementation of ADA/AACE guidelines on the management of hospitalized hyperglycemic patients through training of residents: A tertiary care center study. Indian J Endocr Metab 2018;22:616-20
|How to cite this URL:|
Amrith B P, Sethi P, Soneja M, Vikram N, Kumar A, Aggarwal P, Jyotsna VP, Pandey R M, Wig N. Effect of implementation of ADA/AACE guidelines on the management of hospitalized hyperglycemic patients through training of residents: A tertiary care center study. Indian J Endocr Metab [serial online] 2018 [cited 2019 Feb 20];22:616-20. Available from: http://www.ijem.in/text.asp?2018/22/5/616/241498
| Introduction|| |
Hyperglycemia is a common comorbidity in hospital admissions across all specialties. It can result either from underlying diabetes mellitus, ongoing medications, or stress-induced hyperglycemia secondary to increased release of cortisol.
Improved outcomes associated with intensive control of blood sugar have led American Diabetic Association (ADA) and American Association of Clinical Endocrinologists (AACE) to develop consensus recommendation for inpatient management of hyperglycemia.
The main concerns in the management of hospitalized, critically ill, hyperglycemic patients include maintaining the blood sugars between 140 and 180 mg/dl, with insulin being the preferred agent for glycemic control, hourly monitoring of the blood sugars initially to prevent hypoglycemia in patients on insulin infusion, transition while they are shifted to subcutaneous insulin regimen with a dose of 75–80% of the daily infusional requirement, and an overlap of 1–4 h with infusion before discontinuing it to prevent rebound hyperglycemia. In noncritically ill patients, it is recommended to use scheduled subcutaneous insulin therapy known as basal-bolus insulin therapy. Sliding scale insulin (SSI) should not be used as the standard of care in these patients. A number of studies in the past have concluded that SSI therapy is an ineffective mode of blood sugar control for hospitalized patients. Use of oral hypoglycemic agents is not suitable, owing to the sickness of the admitted patients, organ injury present at the time of admission, need for faster correction of hyperglycemia, erratic food-eating patterns, drugs related to gastrointestinal effects, and the likelihood of hypoglycemic episodes.
In an Indian article by Gangopadhyay et al., consensus statement was issued, which suggested that intervention with scheduled subcutaneous insulin therapy using basal, bolus, and correctional insulin and avoiding SSI therapy are the key to effective management of inpatient hyperglycemia. A safe and effective transition of therapy between home and hospital setting based on hyperglycemic status is essential to avoid large variations in glycemic status.
Despite the knowledge of the fact that good sugar control leads to better outcomes, the physicians often tend to take this issue as low priority. Also, there is a lot of variability regarding the use of insulin  such as preferred use of SSI, inadequate use of insulin infusion, inadequate dosing of basal-bolus regimens, inadequate monitoring, and use of oral drugs for the management of hyperglycemia in inpatient intensive care unit (ICU) setting.
Moreover, the available literature on management of hyperglycemia in hospitalized patients is mainly from the Western part of the world. The body constitution, lifestyle, and dietary habits of Indians significantly differ from those of Western population.
Educating the healthcare providers regarding the practices of management and the need to improve these practices is a way to improve the healthcare at all levels. In a study conducted by Desimone et al., it was found that an educational Inpatient Diabetes Management Program for residents was effective at improving physician knowledge for managing hyperglycemia in hospitalized patients treated with corticosteroids or in preparation for surgical procedures. Educational programs directed at improving overall healthcare provider knowledge for inpatient glycemic management may be beneficial; however, improvements in knowledge do not necessarily result in improved glycemic outcomes. Moreover, simple teaching does not serve the purpose. We need to have a feedback regarding the improvement in an objective way, we need to understand the pitfalls in the applied methods based on nonadherence or partial adherence, further correct it, and observe the change till the desired results are not achieved. So, it is an ongoing process.
Equally important is the method used for educating. A single lecture or symposium may not be enough to convert the knowledge into practice. Other methods may be needed, such as online learning, computer-based interactive modules, hands on workshops, use of posters and pamphlets highlighting the key issues.
So, our aim was to observe the difference in the practices of management of hospitalized hyperglycemic patients after educating the residents about the standard of care practices of management of such patients based on ADA/AACE guidelines.
| Materials and Methods|| |
It was a quasi-experimental pre and posttest study done in three phases (6 months each), viz., observation of current practices of management of hyperglycemia, intervention to reinforce the ADA/AACE guidelines among the residents, nursing staff and assessment of compliance, and change in the outcomes observed.
The study was done in the Medicine ICU of a tertiary care hospital of North India over 2 years period, with 50 patients each in pre and postintervention group. The sample size was decided as a sample of convenience depending on the patient admission records of inpatient hyperglycemia in our hospital and the need to do the three phases of study in a short span of time to come to conclusions regarding the effect of educational interventions over a small group of residents.
Patients with persistent hyperglycemia, age >18 years, and hospital stay >48 hours in the Medicine ICU of our hospital were included in the study in a random fashion. The first phase involved a passive observation of the ongoing practices of management of hyperglycemia. Patients were assessed daily till hospital discharge or mortality. Patient's demographic variables, comorbidities, symptoms, clinical examination findings, disease severity scores at admission such as APACHE II (Acute Physiology and Chronic Health Evaluation) score and baseline investigations were documented.
Series of discussions and debates among the investigators led to the formulation of the plan of action for the intervention phase. The target group of interventional phase was identified to be the residents and the nursing staff of Medicine Ward and ICU. Content of the training material was developed after extensive review of literature and discussions by the investigators. Multiple methods were used to deliver the content using appropriate audio–visual aids. Interactive lectures were designed and delivered by the investigator after careful deliberation. Emphasis was laid on the accuracy, relevance, layout, and technique of presentation. A series of eight interactive lectures was organized. The groups consisted of 8–10 participants each. These lectures lasted for 25–30 min each. Audience involvement was encouraged and discussions were initiated in these sessions. A total of 70 residents were covered in the interactive sessions. One-to-one communication was followed up with the individual audience so as to remind them of the guidelines on management of hyperglycemia and for further clarifications.
The purpose of this intervention was to make the residents aware of the protocols regarding the inpatient hyperglycemia management in a practical and simplified manner. Overall, before the initiation of the third phase, it was ensured that all residents know the simple aspects of management of inpatient hyperglycemia. This was done by one-to-one communication.
The adherence to the guidelines was assessed among the 50 patients. Data were collected by the investigator on a daily basis on all the recruited patients with the use of the proforma as used in the preintervention phase.
Quality indicators included proportion of patients in which recommended insulin regimen is used, proportion of blood glucose recordings within recommended range, mean daily blood sugar during hospital stay, number of episodes of severe hyperglycemia (>250 mg/dl), number of episodes of hypoglycemia (<70 mg/dl), and mortality.
Statistical analysis was done using STATA 11 software. For continuous variables, mean, standard deviation, and median were calculated. Continuous variables with parametric data were compared using t-test and nonparametric data were compared using Wilcoxon analysis. For categorical variables, frequency and percentage were calculated. Categorical variables were compared using Chi-square/Fisher's exact test. A P value of <0.05 was considered statistically significant in multivariable analysis.
| Results|| |
The demographic distribution, clinical, and laboratory profile of the patients in both pre and postintervention groups were comparable, matched, and the difference was not statistically significant. This is shown in [Table 1] and [Table 2].
Dyslipidemia, hypertension, coronary artery disease, and cerebrovascular accidents were the comorbidities in the decreasing order of prevalence in both the phases. Fourteen patients in phase 1 and 16 patients in phase 3 required mechanical ventilation. Patients requiring inotropic support were 8 and 12 in the two phases, pre and post, respectively.
In phase 1, the recommended insulin regimens were used in 18 (36%) of the patients, which increased to 29 (58%) in phase 3. This 22% increase was statistically significant (P = 0.028). Also, there was decrease in usage of sliding scale and premixed insulin in phase 3 when compared to phase 1, but the decrease was not statistically significant. This is summarized in [Table 3].
The glycemic control was assessed in terms of proportion of the blood sugars within recommended range and mean daily blood sugar during the hospital stay. In phase 1, 54.7% ± 8.8 of the blood sugar recordings were within the recommended range, whereas it was 55.2% ± 5.8 in phase 3. There was no significant difference in glycemic control in terms of proportion of the blood sugars within the recommended range. However, mean daily blood sugar in phase 1 was 182 ± 26 mg/dl and in phase 3 was 164 ± 28 mg/dl and this difference was statistically significant (P = 0.001).
Also, the incidents of severe hyperglycemia (>250 mg/dl) were 19.95 ± 7.76% in phase 1 as compared to 13.94 ± 6.26% in phase 3. This decrease was found to be statistically significant.
The proportion of the blood sugars within the recommended range in the first 48 h was 46.7 ± 8.9 in phase 1 and 53.0 ± 8.8 in phase 3. This was statistically significant. In phase 1, six patients had at least one episode of hypoglycemia compared to eight in phase 3 and the difference was not statistically significant.
The findings comparing glycemic control in both groups are summarized in [Table 4]. There was no significant difference in the mortality between phase 1 and phase 3 (P = 0.76). The mortality and the survival groups were analyzed separately, in an attempt to establish predictors of mortality, if any. Only APACHE II was found to be statistically different between the two groups. The P value for univariate analysis with regards to the APACHE II score was 0.01. The univariate analysis of the various mortality predictors is shown in [Table 5].
A subgroup analysis between all the patients of phase 1 and phase 3 who followed the guidelines (n = 47) and who did not follow (n = 53) were done. The results are shown in [Table 6]. The results of the proportion of blood sugar in recommended range and proportions of blood sugar of >250 were found to be statistically significant.
| Discussion|| |
Our study which is based on improving healthcare practice in ICU setting clearly demonstrated a positive impact of repeated educational meetings on adherence to protocols. This was depicted from statistically significant increased use of basal-bolus regimen and insulin infusions as the point of care in critically ill hyperglycemic patients. In the postintervention phase, the compliance to the overall use of guidelines increased by 22%. Even higher improvement could have been possible by ensuring that all the residents involved are actively participating in all the meetings and the education is converted into practice. A review was done by Forsetlund et al. to assess the impact of educational meetings on professional practice by analyzing a total of 81 randomized controlled trials (RCTs) involving more than 11,000 healthcare professionals. They concluded that educational meetings could improve healthcare practices and outcomes.
A review was done by Ivers et al. to assess the impact of audit and feedback on the practice of healthcare workers by analyzing 140 RCTs. The analysis suggested that feedback may be more effective when baseline performance was low; the source is a supervisor or colleague, if provided more than once, if delivered in both verbal and written formats, and when it includes explicit targets and an action plan. In the present study, the investigators who were either seniors or colleagues of the audience provided feedback on the baseline performance. The feedback was provided on multiple occasions in multiple forums. The feedback did have an action plan aimed at the postintervention phase. So, educational meetings followed by effective feedback may help in increasing adherence to protocol-based guidelines.
Use of sliding scale is quite prevalent in the management of hospitalized hyperglycemic patients. This was also found in our study. In a study by Queale et al., sliding-scale insulin regimens when administered alone were associated with a three-fold higher risk of hyperglycemic episodes as compared with no therapies. So, current guidelines recommend against the use of sliding-scale regimens in hospitalized hyperglycemic patients.
A subgroup analysis was done in the present study, which compared the glycemic control between first 48 h and after 48 h. The glycemic control in the first 48 h was significantly better in phase 3 when compared to phase 1, indicating that the glycemic control can be achieved earlier if guideline-based insulin infusion and basal-bolus insulin protocols are followed for hyperglycemia management. Hermayer et al. in a study concluded that with the institution of hospital-wide protocol of the use of insulin infusion and subcutaneous insulin in admitted patients, the percent time needed for blood sugar control decreased by 10% with no increase in the number or severity of hypoglycemic episodes.
There was significant decrease in episodes of severe hyperglycemia in phase 3. This also indicates that basal-bolus regimen helps in better glycemic control and incidence of severe hyperglycemia can be reduced. In a study by Umpierrez et al., it was concluded that a basal-bolus insulin regimen is preferred over SSI in the management of noncritically ill, hospitalized patients with type 2 diabetes.
Maynard et al. in their study concluded that hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms. Chen et al. also demonstrated that following protocol implementation, hypoglycemic incidents significantly decreased, from 1.11 to 0.51 events per patient admission (P < 0.0025). In our study there was no statistical difference in the hypoglycemic events in both the groups. This may be due to the adequate blood sugar monitoring in the ICU setting and modifications in the insulin and use of prompt treatment of hypoglycemia even before the setting of actual hypoglycemia.
There was no significant difference in mortality between the two groups in our study. But the study was not powered to calculate the effect of glycemic control on mortality. However, there is sufficient evidence in literature to support the worse outcomes and increased mortality in critically ill hyperglycemic patients. Mortality risk is greater in hyperglycemic patients without a history of diabetes. Hyperglycemia induces vasoconstriction, inflammation, thrombosis, dehydration, fluid and electrolyte imbalances, and impaired gastric motility.
| Conclusion|| |
Management of inpatient hyperglycemia according to the ADA/AACE guidelines improves the mean daily blood sugars, reduces the time in attaining the recommended blood sugar levels, and reduces the episodes of severe hyperglycemia during hospital stay.
Short-term comprehensive, educational activities directed at teaching the recommended practices improve the adherence to guidelines and may have long-term impact through continued appropriate practices and feedback.
Limitations of the study
The duration of the study was short, with a small sample size to look for the effect of protocolization of the hyperglycemia management. This study had a quasi-experimental design and was a nonrandomized study. The adherence to guidelines was entirely voluntary and was not audited. In this study, barriers to compliance improvement were not measured.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al.
American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009;15:1-17.
Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med 1997;157:545-52.
Gangopadhyay KK, Bantwal G, Talwalkar PG, Muruganathan A, Das AK. Diabetes Consensus Group. Consensus evidence-based guidelines for in-patient management of hyperglycaemia in non-critical care setting as per Indian clinical practice. J Assoc Physicians India 2014;62:6-15.
Knecht LA, Gauthier SM, Castro JC, Schmidt RE, Whitaker MD, Zimmerman RS, et al
. Diabetes care in the hospital: Is there clinical inertia? J Hosp Med 2006;1:151-60.
Schnipper JL, Barsky EE, Shaykevich S, Fitzmaurice G, Pendergrass ML. Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital. J Hosp Med 2006;1:145-50.
Desimone ME, Blank GE, Virji M, Donihi A, DiNardo M, Simak DM, et al
. Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: A randomized controlled trial. Endocr Pract 2012;18:238-49.
Bodnar TW, Iyengar JJ, Patil PV, Gianchandani RY. Can a single interactive seminar durably improve knowledge and confidence of hospital diabetes management? Clin Diabetes Endocrinol 2016;2:20.
Bell DS, Fonarow GC, Hays RD, Mangione CM. Self-study from web-based and printed guideline materials. A randomized, controlled trial among resident physicians. Ann Intern Med 2000;132:938-46.
Hammoud M, Gruppen L, Erickson SS, Cox SM, Espey E, Goepfert A, et al
. Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. To the point: reviews in medical education online computer assisted instruction materials. Am J Obstet Gynecol 2006;194:1064-9.
Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, et al
. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009:CD003030.
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al
. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012:CD000259.
Hermayer KL, Cawley P, Arnold P, Sutton A, Crudup J, Kozlowski L, et al
. Impact of improvement efforts on glycemic control and hypoglycemia at a university medical center. J Hosp Med 2009;4:331-9.
Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, et al
. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007;30:2181-6.
Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med 2009;4:3-15.
Chen HJ, Steinke DT, Karounos DG, Lane MT, Matson AW. Intensive insulin protocol implementation and outcomes in the medical and surgical wards at a Veterans Affairs Medical Center. Ann Pharmacother 2010;44:249-56.
Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 2009;37:3001-9.
Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al
. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004;27:553-91.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]