About 25% of veterans have diabetes, and the prevalence in the hospital setting is estimated to be even higher. Management of glycemia in hospitalized patients requires balancing the potential benefits of improved control versus the harms of hypoglycemia, which has been associated with increased morbidity and mortality, and prolonged length of stay. The present project builds upon the VA Inpatient Evaluation Center (IPEC) evaluation from March 2009 which involved brief telephone interviews with a limited number of individuals at sites across the VA, identified as having high or low rates of hypoglycemia in ICUs.
The objective of this study was to elaborate on the evidence base for prevention of hypoglycemia in ICU at multiple levels to inevitably shared "best practices" across sites through the IPEC.
The identification of best practices for prevention and correction of hypoglycemia is the key goal. We did this through two specific aims.
Specific Aim 1: Characterize best practices for prevention of hypoglycemia in ICU patients with diabetes at the patient, provider team, microsystem (ICU environment) and macrosystem (facility).
Specific Aim 2: Improve the actionability of IPEC data.
Data was extracted from VA IPEC reports which characterize ICU performance against "average" and "best" performers. We ranked all VA ICUs (n=143) according to prevalence of hypoglycemia in FY2009. Semi-structured telephone interviews (n=17) were conducted with key informants (Physicians, Nurses and Pharmacists). Site visits (n=5) with high and low performing sites were also conducted to identify "strong" practices at patient, practice team and organizational levels.
Hypoglycemia rates ranged from four to 10%. Use of the following practices was found: comprehensive teams with real-time evaluation of hypoglycemia (23.5%); nurse to nurse counseling for hypoglycemia avoidance (17.6%); nurse driven protocols (94.1%); and training in the use of protocols addressing both hypoglycemia and hyperglycemia (88.2%). Few sites reported the use of technology such as a smart pump (17.6%) or availability of a glucose meter at every bedside (5.9%). For the minority of patients able to eat, nutrition practices also varied; there was little use of consistent carbohydrate-diets or meals timed with insulin. Surprisingly, two sites utilized sliding scale insulin only, one site reported not having a hypoglycemia protocol and one site reported that nurses were required to call physicians when patients had lows. There was no clear distinction between high and low performing sites in terms of practices that a priori were considered potentially better. Among the potential explanations for this finding include small sample size, a change in guidelines and practices during the study's time period, and the possibility that sites with low rates of hypoglycemia are under treating hyperglycemia. Differences in hypoglycemic rates across sites may also be due to differences in patient population with some patients being more susceptible to blood sugar lows than others due to their medical condition.
An important result of this study has been the decision to share protocols between sites via the IPEC website. The next step is to increase awareness of the availability of these protocols to VA sites across the country.
None at this time.
Health Systems, Diabetes and Related Disorders
Treatment - Observational
Diabetes, QUERI Implementation, Acute illness, Care Management