Closing the Gap Between Current and Optimal Glycemic Management

“It’s only when you drop yesterday’s assumptions that you can glimpse tomorrow’s patterns and possibility. To see deeper, unsee first.” – Umair Haq

Clinical inertia is a term that has been used to define the resistance to a new therapeutic treatment. Across healthcare, we see clinical inertia often, but perhaps the best example is the treatment of hyperglycemia. The way we have managed hyperglycemia, with paper protocols and sliding-scale insulin, is no longer the best practice, yet it remains pervasive.

The Problem with Sliding-Scale Insulin

For more than 80 years, hospitals have been using sliding-scale insulin to manage hyperglycemia in non-critical care units. In 1934, Elliot Joslin created the first iteration of sliding-scale insulin known as “rainbow coverage.” The original sliding scale would recommend specific amounts of regular insulin after testing a patient’s urine for glucose based on its color. While we have moved away from the rainbow coverage testing, the sliding-scale method has not dramatically changed. Our method of testing glucose and the type of insulin administered has been improved to better support patient care, but the practice remains reactive. We continue to treat hyperglycemia after it has occurred.

Numerous studies dating as far back as even the 1970s have shown that using sliding-scale insulin is an ineffective way to manage blood glucose. Because this method is essentially chasing rather than preventing hyperglycemia, a “roller coaster” effect with dramatic blood glucose variability is often seen among hospitalized patients, and as a result, patients are more likely to experience adverse patient outcomes and longer length of stay.

Optimizing Glycemic Management

In order to close the gap between the current and optimal glycemic practices, there needs to be a paradigm shift. Leading diabetes experts and specialty societies have all recommended that we must transition away from sliding-scale insulin regimens to consistent use of basal-bolus-correction protocols. In a recent webinar, Monarch’s EVP and Chief Clinical Officer, Laurel Fuqua, and Healthcare Corporation of America’s (HCA’s) VP of Diabetes Care, Dr. Thomas Garthwaite, shared best practices and strategies for making this transition. As the two discussed, overcoming clinical inertia and the systemic use of sliding-scale insulin is a complicated endeavor, but it is needed now more than ever. With diabetes patients now commonly representing more than 25% of the inpatient population and fewer endocrinologists working in the inpatient setting, adoption of evidence-based glycemic management care practices must be standardized to avoid an increase in infection, length of stay and cost of care.

For HCA, a 179-hospital system with more than 37,000 physicians and 80,000 nurses, this standardization is all the more necessary. They began an enterprise-wide standardization program after collecting data that showed more than 24 million glucose tests were administered in 2016 and there was an opportunity to improve hypoglycemia and hyperglycemia rates. Their program, which included improved SubQ and IV order sets, implementation of EndoTool® IV and SubQ, real-time risk stratification, and dedicated clinicians to educate, guide and troubleshoot, has seen positive results and the potential to reduce length of stay by almost one day, as Dr. Garthwaite explains during the webinar.

While their program is still in its early stages, further adoption is planned and their continued attention to the data will help drive this standardization. The process to close the gap between current and optimal glycemic management is not an easy task as it affects nearly every caregiver and specialty in the hospital setting, but the use of technology such as EndoTool can help. By “unseeing” and adopting the recommended glycemic management best practices, you can overcome clinical inertia and impact the quality, safety and cost of care at your organization. The impact on patient care is worth the effort.