The modern-day hospital is grappling with an alarming trend. According to a new global study, the number of people with diabetes is growing at a troubling rate and is expected to double by 2050. This is generating a national conversation among health system leaders on inpatient glycemic management strategies, and whether their facilities are doing enough. Hospitals and health systems have long understood the need to reduce preventable hypoglycemia, yet despite a renewed sense of urgency, many of them lack comprehensive glycemic management measures that can drive success.
Hospitals are caught amid a perfect storm that is leaving them vulnerable to events that can negatively impact a patient’s safety. Despite an unwavering commitment to well-being and safety, these facilities are overwhelmed by a growing number of priorities and hampered by a shrinking labor force – which hamstrings their ability to implement a plan for success. The combination of an overworked staff and an abundance of organizational priorities can lead to dangerous patient safety events, like preventable hypoglycemia. In hospitals, inadequate glycemic management has been tied to longer patient stays, higher readmission rates, negative health outcomes, and spiraling costs averaging an additional $10,000 or more per stay.
Comprehensive monitoring and reporting of glycemic management metrics are needed to improve patient care. Without clear-cut ways to measure success, clinicians lack critical information that can help drive improvements in workflows and training. Metrics such as hypoglycemia and hyperglycemia rates and insulin ordering data can be provided in real-time to inform quality decision-making. The fact of the matter is that one in three hospitals don’t have a meaningful way to use glycemic management metrics.
The time for change is now. According to new reporting rules from the Centers for Medicare & Medicaid Services (CMS), hospitals are expected to collect data about rates of hypo and hyperglycemia to accurately assess their facility’s ability to mitigate preventable patient harm. Without a holistic strategy that integrates both health system management and clinical decision support technology, attempts at reform can only get hospitals so far. And for some hospitals that serve particularly high-risk populations, they may be at risk of losing funding and public trust the slower they are to enact change.
Overcoming Barriers to Improved Care
To date, the widespread implementation of glucometrics—the systematic analysis of blood glucose data in patients—has been hindered by several factors. One of the most significant is the fact there has historically been a scarcity of clear national consensus on definitions, standards, and reporting. Most hospitals don’t have access to the same kind of data and analytics for glycemic management that they do for other diseases that CMS prioritizes, such as sepsis and heart disease. This poses a significant limitation to developing standards of care for patients with diabetes.
Meanwhile, a nationwide shortage of nurses and physicians has also held back investments in glycemic event tracking metrics and stalled the transformation of hospital processes.
But progress is now being made. The National Quality Foundation’s (NQF) support for standardized measures for hypoglycemia and hyperglycemia reporting was the first step towards a future free of insulin-related patient safety events. And through the NQF’s support, the current CMS electronic clinical quality measures (eCQMs), are also helping draw attention to the pervasive problem of inpatient dysglycemia.
Adopting standardized glucometrics reporting allows hospitals to easily compare data among patient care units and facilities, spearheading glycemic management improvement efforts across health systems of all sizes.
Without such metrics, however, hospitals limit their ability to drive change and to fully measure success. Even within the field, the true rates of hypo- and hyperglycemia are unknown. For instance, severe hypoglycemic events have been recorded as being anywhere from 62 to 320 episodes per 100 patient years according to estimated numbers.
Health systems share additional challenges preventing the improvement of inpatient diabetes management strategies. For one, there is a widespread knowledge gap between the guidelines and what’s put in practice around inpatient glycemic management, especially as it relates to insulin therapy. Another barrier is difficulty establishing and adhering to best practices when it comes to managing insulin therapy both in the hospital—which typically involves a short stay—and in the transition to a home regimen.
To begin addressing these long-standing challenges, hospitals should first look at defining key metrics to measure the current state of their glycemic management practices and strategies to improve them. Within the hospital setting, collecting real-time data involves tracking key metrics such as:
- Daily Hypoglycemia and Hyperglycemia Patient Safety Events: This includes metrics on patient days spent above, below, or within target blood glucose ranges, which are critical as CMS will now require hospitals to track hyperglycemia rates.
- Rates of Blood Glucose Checks: Blood glucose check rates maintain a record of how often staff are checking blood glucose levels to avoid any preventable patient safety events.
- Utilization Rates of Clinical Decision Support Technology: Clinical decision support technology has the ability to deliver more accurate real-time data to drive patient safety decisions; staff should track utilization rates to determine the success of such tools.
Additionally, glycemic management committees composed of a multidisciplinary care team that includes pharmacists, nurses, physicians, and quality improvement experts can ensure regular conversations about these barriers and approaches to keeping teams on track for success. Glycemic management committees should follow a quality improvement framework that includes:
- Assessing the current state of care and the current data available.
- Identifying gaps in care and their root causes.
- Creating processes to address those gaps.
- Implementing ongoing monitoring of process and outcome metrics.
The Road Ahead
More than a third of hospitalized patients have diabetes or glycemic management issues, regardless of whether diabetes was the principal reason they were admitted, causing the impact of the disease to have rippling effects across the entire health ecosystem. With an increasing number of the inpatient population affected by diabetes, CMS recognizes that health systems cannot afford to wait any longer to initiate change in their glycemic management processes. By implementing comprehensive metrics, establishing glycemic management committees, and investing in a renewed focus on data-driven processes, hospitals can ensure they lead the way to a safer future for all.
About Jordan Messler, MD, SFHM, FACP
Jordan Messler, MD, SFHM, FACP is the Chief Medical Officer with Glytec. He trained in internal medicine at Emory University in Atlanta, and subsequently served as an academic hospitalist at Emory University for several years after residency. He is the former medical director for the Morton Plant Hospitalist group in Clearwater, Florida (serving BayCare Health), where he continues to work as a hospitalist. He is the current physician editor for the Society of Hospital Medicine’s (SHM) blog, The Hospital Leader. In addition, he previously chaired SHM’s Quality and Patient Safety Committee and has been active in several of their national mentoring programs, including Project BOOST and Glycemic Control. He has talked at national conferences on a variety of topics such as teamwork in the hospital, quality and patient safety, the history of hospitals and mentoring quality improvement projects.