Putting patients first: hospitals change diabetes care

June 14, 2009
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In a unique example of cooperation, Grand Rapids’ three hospitals are changing their approach to treating diabetics in hopes of improving patient care and reducing costs.

The hospitals are tossing out the long-time “sliding scale” approach used for decades to administer insulin to people admitted to hospitals in favor of an approach more tailored to individuals.

High blood sugar is a concern in hospitals because it can make people more vulnerable to infections and result in sicker patients, longer stays and re-admissions within 30 days. Hospital-acquired infections are on the list of preventable occurrences that Medicare, followed by many commercial insurers, stopped covering last year.

While 8 percent of the general population has diabetes, the disease affects 23 percent of those admitted to Spectrum Health hospitals.

“If you have diabetes, your risk for other health problems is also higher. We developed an insulin-dosing program that is very much individualized to each patient,” said Dr. Greg Deines, medical director of diabetes services at Spectrum Health.

“It was a change to the way it was done in the past. In general, insulin was dosed in a one-size-fits-all fashion. But a person who weighs 100 pounds doesn’t need the same amount as someone who weighs 300 — yet that’s what the standard has been for many, many years,” Deines said.

The American Diabetes Association, the American College of Endocrinology and the American Association of Clinical Endocrinologists recommended changes in 2003. In 2007, Spectrum Health convened a multi-disciplinary team that spent 18 months reviewing the way diabetics were being treated and choosing the evidence-based changes, Deines said. He said it included representatives from a variety of hospital departments, including quality, nutrition, nursing, research and pharmacy.

“We looked at the treatment process for people with diabetes down to the level of unit secretaries, down to the level of how do we manage diabetes in the X-ray department. Have we got enough glucose monitors distributed through the hospital? Any time we looked at making a change or a solution to one of the problems, we had to involve every single one of these teams and players in the process,” he said. “It involved changing a lot of inertia in health systems.”

 Under the sliding scale protocol, which was taught in medical schools and is common throughout the country, patients are given long-acting insulin every four to six hours with little regard to diet. The result is that blood glucose sometimes ranges too high or too low.

“It goes back to the 1920s, when insulin was first developed,” Deines said. “Back at that time, we didn’t have the ability to check blood glucose frequently. … Since that time there’s been more mathematical formulas that take into account how sensitive an individual person is to insulin, and you can customize that insulin dose to fit that person. There’s been a large push over the last four years, five years, to really dose insulin the right way.”

In the modern process, called basal bolus dosing, diabetics test their own blood prior to meals and set insulin doses themselves, taking diet into consideration. The process may be handled easily by the patient at home, Deines said. But inside a hospital, with many people dealing with a variety of patient conditions, it becomes more complicated.

“When you’re sick and you’re in the hospital, and you have three departments who each have their own care plan and their tasks, those three events were not happening in a coordinated manner,” Deines said.

In addition, some diabetics manage the disease at home without insulin, using diet, exercise and oral medication, but once admitted to the hospital, they are put on insulin, at least temporarily. Sometimes the stress of illness or injury can push up glucose levels, even for hospitalized patients who are not diabetic. Deines said that in the hospital, blood glucose needs to remain below 180 ml/dl to keep healing on track and infection at bay.

“When we show our staff and physicians evidence-based recommendations and proactive changes to improve patient care, they readily embrace that,” said Dr. David Dull, vice president for quality for Spectrum’s Grand Rapids operations.

Saint Mary’s Health Care and Metro Health, aware of the 2003 recommendation to modify inpatient diabetes treatment, were looking at their own procedures. The hospitals found that resident and intern physicians doing rotations at multiple sites were coping with multiple systems for glycemic management.

Thus the West Michigan Hospital Diabetes-Glycemic Management Collaborative was produced last November. The group meets once a month to “sit down and look at how can we be on the same page, with dosing insulin the same way. Each of the institutions has decided that basal bolus dosing is the right way to do it and they will not be using the old sliding-scale protocols in the future,” Deines said.

The collaborative also issued a letter to local physicians in May to explain the changes and the consortium’s goals.

Debbie Corwin, a registered nurse for Metro Health who is a part of the committee and has provided staff education for the protocol change, said the hospital has been moving toward the changes since shortly after its move to Wyoming. “This is actually internationally something that’s changing in almost all hospitals because it is now best practice,” said Corwin, who is diabetic and helped to educate Metro’s nursing staff on the new protocol last fall.

She said the consortium is hoping to hammer out the use of similar protocol, language and discharge planning. For example, she said, diabetics often have heart disease, and those patients often are transferred to Spectrum Health when their care demands are beyond what is available at Metro Health. “We want them to treat the patient the same way that we do,” she said.

A major concern for the consortium is transitioning patients with blood glucose issues to outpatient care “so that they don’t bounce back,” Corwin said. “Readmission costs money, too. Quite a bit of revenue is lost on that if we have a lot of bounce back.”

The consortium now is considering a research project to study the impact of the new protocols and discharge planning on patient health and re-admissions after they leave the hospital, Deines said.

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