A team effort is how endocrinologist Mercedes Falciglia, MD, describes the Diabetes Now program at UC Health University Hospital.
The multidisciplinary inpatient program, developed by Falciglia in 2006, involves representatives from endocrinology, nursing, pharmacy and dietary, as well as hospital administration. All have made it their mission to improve the care of hospitalized patients with diabetes and high blood glucose (hyperglycemia)—from admission to discharge, and beyond.
"We’ve studied hyperglycemia in the hospital setting and have found that it’s common even in patients without diagnosed diabetes, and that these elevations in blood glucose carry an increased risk of death and complications,” says Falciglia, an associate professor in UC’s endocrinology, diabetes and metabolism division.
While the prevailing assumption that elevated blood sugar in hospitalized patients without recognized diabetes is a consequence of the stress of illness, otherwise known as "stress hyperglycemia,” Falciglia says it’s possible that some patients have diabetes and have never been diagnosed.
Or, she says, it’s possible they may have a pre-disposition to diabetes. She and collaborators David D’Alessio, MD, director of UC’s endocrinology division, and Marta Render, MD, professor of medicine in the division of pulmonary, critical care and sleep medicine, have been investigating this phenomenon through a study funded by the National Institutes of Health.
Although these studies have largely involved the analysis of national databases, Falciglia says it’s those daily one-on-one interactions where you can really see some of the practical implications of blood sugar control within the hospital setting.
"What we know is that there needs to be a systematic approach to treating high blood glucose in the hospital in order to do so effectively and safely,” says Falciglia. "Insulin is one of the few medications labeled as ‘high-alert’ because of its propensity to cause harm if misused.
"That, paired with the fact that hyperglycemia is an abnormality occurring in every corner of the hospital, explains why it takes a coordinated effort to care for these patients.”
Falciglia says diabetes often remains unrecognized and therefore untreated for as long as 10 years.
"Once someone is in the hospital, clinicians can use the Diabetes Now protocols to facilitate the treatment of hyperglycemia in addition to caring for the health issues responsible for the hospitalization that often take top priority,” she says.
Falciglia and her team are working to better manage high blood glucose across the hospital and in the ICU, making the analogy of hyperglycemia among inpatients as similar to gestational diabetes (diabetes during pregnancy): It could be a good predictor for a future diabetes diagnosis.
For that reason, she says, it’s more important than ever to make sure patients leave the hospital with knowledge about diabetes and how to prevent and manage it. But therein lies another challenge.
Falciglia, along with nurses from UC Health and investigators from UC’s College of Nursing, have conducted research to determine what diabetes "survival skills” patients retain once they are discharged from the hospital. It turns out, they retain very little.
"We think we are helping patients by informing them about diabetes while they are in our care, but what we’ve found is that patients remember very little of what we’ve shared,” Falciglia says.
The reality, she says, is that patients are overwhelmed with diabetes education when, understandably, they are focused on the primary health problem that brought them to the hospital in the first place.
No matter the reason for hospital admission or the extent of a patient’s health problems, the Diabetes Now team has recognized the need to find ways to educate patients about diabetes and high blood sugar beyond the hospital’s walls.
Ultimately, Falciglia would like to establish a Diabetes Now outreach program that focuses on communication with primary care providers in the region—alerting them that their patient was not only hospitalized, but was also treated for high blood sugar and should have diagnostic tests for diabetes performed once they have recovered.
"It would be real progress if we could prevent our patients from walking around with diabetes that is unrecognized and untreated for years,” says Falciglia,
"Effective communication between the inpatient and outpatient realms is a key step towards this goal.”
Falciglia, who also serves as associate endocrinology fellowship coordinator, says the experience offered to fellows and residents working with the Diabetes Now team ultimately benefits the community.
"Most of our graduating fellows stay in the greater Cincinnati area and the feedback we’ve received suggests that they are implementing much of what they’ve learned here at UC in other area hospitals.”
Fellows rotating through Diabetes Now take advantage of learning relevant to the Accreditation Council for Graduate Medical Education (ACGME) competencies that emphasize multidisciplinary team work and quality improvement initiatives.
Putting Research Into Practice:
Diabetes Now has already prompted policy changes with regard to insulin coordination at University Hospital.
In 2010, nutritional sciences graduate students in the College of Allied Health Sciences, working with Diabetes Now identified problems with the traditional "bedtime snack” being offered to patients.
Clinicians were finding that many patients receiving a bedtime snack would arise in the morning with high blood sugar. The hospital was able to put policy in place to eliminate the evening snack for patients with diabetes or high blood sugar.
Research findings from this collaboration also have identified areas for improvement relevant to the coordination of timing between meal delivery, consumption and insulin administration—a care process that is critical for the safe and effective treatment of hyperglycemia.
Efforts are under way to design and implement strategies that will address this important process in inpatient diabetes management.