Commentary

State-of-the-Art Inpatient Diabetes Care: The Evolution of an Academic Hospital

Sara M. Pietras, MD1; Patricia Hanrahan, ANP, CDE1; Lindsay M. Arnold, PharmD, BCPS2; Elliot Sternthal, MD, FACP, FACE1; Marie E. McDonnell, MD1
70% of the hospitals patient population. Approximately 30% of the patients do not speak English as their primary language (2). More than 29000 patients are admitted per year, and approximately 26% of these have a known diagnosis of diabetes mellitus. In the fall of 2004, just preceding the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) consensus statement on the management of inpatient hyperglycemia (3), the hospital administration allocated start-up funds for such a program, designated the Inpatient Diabetes Program (IDP). Several authors have described the creation of successful inpatient diabetes programs, insulin safety committees, and insulin algorithms (4-9), and the availability of toolkits for success and insulin protocols is unprecedented (10-11). There is also published information regarding house staff education and barriers to care (12-13). Here, we add to this important literature by detailing the 5-year evolution of our hospital and the IDP and the steps that were taken to create a comprehensive and sustainable inpatient program (Fig. 1). In the setting of this long-term investment in diabetes care, we highlight a model whereby we incorporate multiple training programs into a hospitalwide consultative service as a method of building a durable academic program that promotes state-of-the art inpatient diabetes care beyond one institution. PRE-IDP (2004-2005): RUMBLINGS OF CHANGE In 2004, AACE and ADA released a joint position statement addressing the inpatient management of diabetes (3). The IDP used this statement to guide goals of therapy and incorporated the team model of patient care endorsed by the position statement. As others have done (14), we created a specialized committee to make therapeutic recommendations and to monitor the outcomes of interventions. The Insulin Safety and Effectiveness Committee included hospital staff who were integral to the daily delivery of inpatient care, including providers who would form the IDP.

Abbreviations: AACE = American Association of Clinical Endocrinologists; ADA = American Diabetes Association; ICU = intensive care unit; IDP = Inpatient Diabetes Program; NP/CDE = nurse practitioner/certified diabetes educator; WEBBI = weight-based basalbolus insulin INTRODUCTION Institutions around the world are striving to develop safe and effective ways to manage hyperglycemia in hospitalized patients. While data regarding the adverse associations of hyperglycemia continue to accumulate, so also does evidence that insulin therapy must be applied thoughtfully for each patient. Hospitals are now struggling with looming gaps in expertise (1), standardization, and clinical inertia in the face of rapidly evolving literature. In 2002 and 2003, endocrinologists at our institution petitioned administrators to create an inpatient team dedicated to the care of hospitalized patients with hyperglycemia. Our hospital, a 626-bed academic teaching institution, is the largest safety-net hospital in New England. It is dedicated to the treatment of the poor and underinsured, who comprise

Submitted for publication November 6, 2009 Accepted for publication February 8, 2010 From the 1Department of Endocrinology, Diabetes, and Nutrition and 2Department of Pharmacy, Boston University Medical Center, Boston, Massachusetts. Address correspondence and reprint requests to Dr. Marie E. McDonnell, 88 E Newton St, Evans 201, Boston Medical Center, Boston, MA 02118. E-mail: marie. mcdonnell@bmc.org. Published as a Rapid Electronic Article in Press at http://www. endocrine practice.org on March 29, 2010. DOI: 10.4158/EP09319.CO 2010 AACE.

512 ENDOCRINE PRACTICE Vol 16 No. 3 May/June 2010

Inpatient Diabetes, Endocr Pract. 2010;16(No. 3) 513

Fig. 1. Timeline of program initiatives. X axis intervals represent 3 months of time. Solid bars indicate active work/time to achieve completion of target intervention, ongoing committees, or development of hospital-wide guidelines. Bars with breaks indicate that ongoing updates were required. Faded bars indicate the time required to prepare for launching initiatives. CPOE, computerized physician order entry; IV, intravenous; WEBBI, weight-based basal-bolus insulin.

514 Inpatient Diabetes, Endocr Pract. 2010;16(No. 3)

Weight-Based Insulin: Empowering Providers At the outset, we began by using a standardized weight-based basal-bolus insulin (WEBBI) guideline for dosing insulin in hospitalized patients (Table 1) (15). Similar methods have been described in prospective studies (7,16). Our approach incorporates 3 patient characteristics: weight, estimated insulin sensitivity, and hypoglycemia risk. This approach underscores that insulin is not a one size fits all medication. In our experience, providers are frustrated by their own lack of knowledge about insulin therapy. For guidance they refer to outpatient recommendations, handbooks, or package inserts, which provide dosing recommendations that are not suitable for hospitalized patients. Conversely, when given the tool of WEBBI, providers feel empowered to leave the sliding scale behind as a lone therapy and to construct effective insulin regimens.

WEBBI dosing fits nicely with the rigors of medical management, and providers grasp the concept behind patienttailored therapy. This tool was made into a medication guideline and was adapted to create a standardized set of insulin orders for use in a computerized physician order entry system. YEAR 1 (2005-2006): THE PARADIGM SHIFT BEGINS, THE 5-YEAR PLAN At the outset, a deliberate plan was laid out to transform the hospital over 5 years. This not only provided a background for a structured set of sequenced interventions, but a timeline to determine success. As such, we intended to shape all areas of inpatient care where diabetes is prevalent by the year 2010.

Table 1 General Guidelines for Insulin Dosing in the Hospitala 1 Hypoglycemia risk factorb 0.3-0.4 units/kg/d Average inpatient Insulin resistantc

TDD Basal insulin

0.5-0.7 units/ kg/d

0.7-1.5 units/ kg/d

50% TDD Glargine every 24 hours or NPH split 2/3 every morning and 1/3 every bedtime, or NPH split 1/2 every morning and 1/2 every evening 30%-50% TDD Lispro or regular Divide this amount by number of doses per day (eg, by 3 for 3 meals daily, or by 4 for every 6-hour dosing for enteral feeds) Rule of 1500d Lispro or regular Give 3 times a day or 4 times a day for meals or at same interval as nutritional insulin for enteral feeds

Nutritional insulin

Correction insulin

Abbreviations: NPH, neutral protamine Hagedorn; TDD, total daily dosage. a Adapted from the Boston Medical Center Pocket Card: Management of Hyperglycemia in Noncritically Ill Inpatients. b Hypoglycemia risk factors include being elderly or having renal or liver insufficiency, pancreatic insufficiency, alcoholism, or type 1 diabetes mellitus. c Insulin resistance factors include glucotoxicity (prolonged high glucose), infection, glucocorticoids, or abdominal obesity. d Rule of 1500 refers to the following: 1500/TDD = correction factor = the effect that 1 unit of insulin will have on the glucose = the interval in a sliding scale. For example, if TDD = 50, then 1500/50 = 30. One unit of insulin should lower blood glucose by 30 mg/dL. Scale: 150-180 mg/dL, 2 units; 181-210 mg/dL, 3 units; 211240, 4 units, etc.

Inpatient Diabetes, Endocr Pract. 2010;16(No. 3) 515

The Shift Begins Solely supported by hospital start-up funds, in 2005 a full-time endocrinologist and a nurse practitioner/certified diabetes educator (NP/CDE) were hired to create the IDP. Because intravenous insulin infusion therapy had already been implemented in the intensive care units, the initial focus of the IDP was to standardize subcutaneous basal-bolus insulin therapy. This was done by using the electronic order sets as the guiding force of change. The order sets were launched as an optional method available to all providers, which allowed for an immediate and concrete intervention where providers could see the effects of this new method. This strategy required us to pour resources into hospitalwide education in a limited time frame (3 months) to prevent a decline in initial enthusiasm. While nursing staff was intensively trained (see following text), IDP representatives conducted case-based practice sessions (targeting medical wards teams) with providers for hands-on training in the real-world use of basal-bolus insulin therapy using the order sets. The IDPs pocket card served as an ongoing reference (Table 1). Electronic Order Sets Initial and all subsequent versions of the computerized physician order entry system order sets contained all elements of WEBBI programs including basal, prandial, and correction insulin. Periodic updates occurred over time in response to provider feedback, ordering patterns, and safety. Distinct order sets guide practitioners in dosing patients who are eating, not receiving nutrition, or receiving enteral or parenteral nutrition. The order sets include a calculated dose range recommendation based on patient weight for basal insulin therapies. Also critical are the default nursing instructions (such as holding nutritional insulin doses when nutrition is held and timing of insulin with meals) to maximize safety and uniformity of care. Provider education was achieved via didactics targeting house officers working on the wards, starting with internal medicine and extending to most inpatient medical and surgical services over 4 years. Outreach to Nursing More than 30 in-service sessions were conducted with the nursing staff during the first year to discuss the impact of hyperglycemia on patient outcomes. Nurses were intensively instructed in the rationale and use of scheduled meal insulin with as-needed supplemental insulin, administered on the basis of capillary glucose level obtained before a meal. The sessions allowed for feedback to the IDP about practical workload issues for the staff, such as shifting morning glucose measurements from the night to the day shift. The IDP facilitated better coordination between nursing and dietary services to ensure that patients received the correct meals in a timely manner. Within 6 months, the timing of fingersticks was permanently and successfully restructured so that it would align with the timing of meals

and insulin administration. In addition, an online educational program was developed and was mandatory for all nurses. The online educational program is now part of a required annual competency for all 1500 nurses working at our institution. Over the years, the NP/CDEs and the IDP pharmacist have served as invaluable liaisons to the nursing staff. They provide continuing support and education, and they are now easily recognized by floor nursing staff as diabetes experts to consult for management or educational concerns. Nursing education is an ongoing process, and nursing participation is integral to the success of any inpatient diabetes program. Additional tools were created to promote the ongoing development and education of the institutions nursing staff, including insulin reference pocket cards and an annual day-long educational symposium open to all nursing staff. The GLUC Service To further support practitioners, the GLUC service was created. This service consisted initially of the IDP diabetologist, the inpatient NP/CDE, and an endocrinology fellow. The fellow carries a pager 24 hours a day and can be reached by any practitioner who types GLUC into the paging system. This provides an easily identifiable way to obtain comprehensive consultative support. The GLUC service expanded rapidly over 2 years, and with a census of more than 30 patients per day during heavy months. The diabetes nurse practitioner service was later separated as a distinct service in part to offload the service heavy areas of the hospital, such as the coronary care unit, and also to give providers the option to collaborate with an NP/CDE to design comprehensive diabetes treatment plans. The nurse practitioner service has evolved to include service for niche populations (eg, postmyocardial infarction and postcerebrovascular accident), as well as patients with unique educational barriers (eg, blindness). Early Targets: Special Populations The IDP partnered with 2 services in the first year: cardiothoracic surgery and cardiologygroups also interested in improving outcomes in hyperglycemic patients. Since that time, all hospitalized patients who undergo cardiothoracic surgery receive routine consultation by the IDP. Our institution contains 5 critical care units. On the basis of emerging data and ongoing discussions with intensive care unit (ICU) leaders regarding risks and benefits of intensive insulin therapy, we created tailored insulin infusion guidelines for critically ill patients. From 2004 to 2009 there were 3 glycemic target ranges: 80 to 120 mg/ dL (surgical ICU), 80 to 150 mg/dL (medical ICU/cardiac care unit), and 120-180 mg/dL (perioperative). In 2009, following the emergence of new data from the NICESUGAR trial (17) and recommendations from AACE and ADA (18), we opened discussions with ICU leaders and

516 Inpatient Diabetes, Endocr Pract. 2010;16(No. 3)

are currently piloting higher target ranges, the results of which are pending. YEAR 2 (2006-2007): SAFETY A Voice for the Hospital At the end of 2005, the Insulin Safety and Effectiveness Committee became an official subcommittee of the hospitals Pharmacy and Therapeutics Committee in order to institutionalize this multidisciplinary group. Currently, the committee consists of a hospitalist, a nurse educator, a floor nurse, a representative from information technology, a nutritionist, the endocrine pharmacist, and the inpatient diabetologists and nurse practitioners. Importantly, the committee has an authoritative role, rather than a consultative one, in hospital clinical practice, which allows the direct and quick implementation of safety recommendations. One of the first projects was streamlining the inpatient formulary to consist of only 4 insulin products, leaving available 1 rapid-, 1 short-, 1 intermediate-, and 1 long-acting insulin. This allowed a complete range of insulin therapy options (9) while eliminating duplicative insulins with similar pharmacokinetics. The final selection of insulin brand was based on hospital preference with the committees supporting advice. After reviewing errors related to insulin use, the committee decided the safest way to provide basal-bolus regimens was to dose each insulin type separately; subsequently, all combination insulins were removed from the inpatient formulary. Providers are given instructions via the computerized physician order entry system on how to care for patients who have been receiving combination insulin at home. All reported errors related to the use of insulin are reviewed by the committee and used to target ongoing education for nursing and house staff. Additionally, in response to errors and requests from clinical staff, the committee allows for a continual, multidisciplinary editing process of the electronic order sets as knowledge and acceptance expands among providers. Important safety additions over time have included precalculated suggested weight-based ranges for basal insulins embedded within the order and a function to easily allow variable doses of nutritional insulin to be given with different meals. In addition, there was a concern about the inpatient use of insulin pumps in patients who use this therapy in the outpatient setting. A specialized and safety-focused order for subcutaneous insulin pump therapy was subsequently created and accompanied by a nursing policy that requires patients to be assessed for their ability to manage their pump and self-administer insulin. YEAR 3 (2007-2008): EXPANSION AND VOLUME The IDP hired 2 more NP/CDEs to work part-time in the hospital. The group now consists of the physician service (GLUC), run by the endocrinology fellow and staff

endocrinologist, and the nurse practitioner service under the umbrella of the IDP. The IDP works closely with a dedicated pharmacist who is the pharmacys representative with insulin and diabetes management expertise. The physician service provides consults for complicated cases through the fellow, rotating residents, and medical students. The nurse practitioner service provides not only management guidance but patient education. The nurse practitioner service currently consists of 1 full time NP/CDE and 2 part-time NP/CDEs (serving as 1 full-time equivalent). The volume on the physician service has been consistently 10 to 20 patients per day in follow-up, with 3 to 5 new consults per day (total, 13 to 25 patients per day). On the nurse practitioner service, the volume ranges from 5 to 8 follow-up patients per day per nurse practitioner, with 4 new consults to divide between nurse practitioners (total, 19 to 28 patients per day). Because the nurse practitioners are also certified educators, this combination provides the unique opportunity for them to act in both roles. Patients with diabetes require individual assessment to determine appropriate self-management and education support, often more challenging in a safety-net health system (19). The recommendations by the NP/CDEs for patients with educational and social barriers have proved invaluable to the success of the program. They assess patients cognitive skill, physical abilities, and literacy to develop a medication or insulin program that will be feasible in the home setting (20-21). Because of the large proportion of inpatients in our institution who do not speak English as their primary language, our service relies heavily on an extensive system of interpreter support available in more than 30 languages, by phone and at the bedside. The NP/CDEs are expert educators and address unique educational barriers, eg, number illiteracy, blindness, and loss of dexterity after stroke (21-22). The NP/CDEs provide careful instructions not only to patients but also to family members, who in some cases may be administering insulin therapy. They address several issues known to present barriers to successful insulin therapy including fear of pain, weight gain, inconvenience, complexity, lack of time, cost, and sense of failure (23-25). YEAR 4 (2008-2009): STANDARDIZATION It has become clear that to complete the full installation of good glycemic control at our institution, we need to partner with all areas and specialties where diabetes is prevalent. We recently partnered with pediatric endocrinology and obstetrics and gynecology to standardize the use of insulin in their patients, and we plan for more outreach to neurology and ophthalmology. Once this has been achieved, the use of order sets in the electronic ordering system can be enforced throughout the hospital to completely eliminate the use of lone sliding scale insulin as an untailored, automatic therapy. Through partnership

Inpatient Diabetes, Endocr Pract. 2010;16(No. 3) 517

with anesthesia and surgery, we have recently undertaken a pilot program to administer intravenous insulin in the operating room for patients with diabetes who are admitted for surgery. This program provides the anesthesiologist with an insulin infusion protocol that has a target glycemic range of 120 to 180 mg/dL. Postoperatively, the patients receive a GLUC consultation to ensure continued glycemic control for the duration of the hospital stay. We have also begun piloting a New-Onset Diabetes Clinical Pathway. Encouraged by the decreased length of stay we have seen in this population since the inception of this program (see Year 5), we created this initiative to empower floor nurses to provide survival skills education to patients admitted with newly diagnosed diabetes. This includes a recommended series of educational topics, patient education materials, and glucose meter teaching. For ease of teaching, a scripted flipchart with graphical representation of specific topics is used. House officer education continues with lectures for the ward teams, monthly lectures in the ICU and cardiac care unit, and rotations for interested residents. In addition to our daily presence in the surgical ICU, we provide routine

consultation for patients on the vascular and podiatry services and patients admitted for weight-loss surgery and renal transplantation. YEAR 5 (2009-2010): OUTCOMES AND OUTLOOK In 2009, we began assessments of long-term and progressive benefits of the IDP, as well as outcomes supported by the literature (18,26). The use of basal insulin in patients with hyperglycemia at our institution has increased from 30% to nearly 60% in patients who are prescribed insulin therapy. Practitioners are now more routinely measuring hemoglobin A1c to assess risk and guide the transition to outpatient care. Consults to the nurse practitioner service for patients with any glucose measurement greater than 200 mg/dL has risen 3-fold over the past few years, demonstrating that providers are increasingly recognizing the value of the NP/CDE expertise and incorporating it into routine practice. The mean point-of-care glucose values in the hospital declined rapidly, and improvements have been maintained (Fig. 2). For this comparison, we excluded the ICUs,

Fig. 2. Change in glycemia over academic years in all inpatient hospital units except intensive care units. Panel A, Change in mean point-of-care glucose values over academic years (eg, 2004 = July 1, 2004, through June 30, 2005). Panel B, Percentage of point-of-care glucose values within goal range (70-180 mg/dL). Panel C, Percentage of all point-of-care values in hypoglycemic ranges below 70 mg/dL. Panel D, Depicts the 661702 plasma glucose measurements obtained over time, along with dashed lines denoting the 5th, 10th, 25th, 50th, 75th, 90th, and 95th measurement percentiles by year. Data collected from the RALS-TGCM tight glycemic control module.

518 Inpatient Diabetes, Endocr Pract. 2010;16(No. 3)

because the number of point-of-care values per patient in the ICU is markedly disproportionate. Since the start of the IDP, more point-of-care glucose values have been between 70 and 180 mg/dL, a range that reflects neither hypoglycemia nor hyperglycemia as supported by AACE (70-180 mg/ dL) (Figs. 2A and 2B). This occurred with only a slight increase in hypoglycemia rates (glucose <70 mg/dL) among all point-of-care values (Fig. 2C). This rate initially rose to above 4% from 3.6%, but along with a decrease in very low glucose values (<40 mg/dL), overall hypoglycemia has been recently stable at 4%, similar to rates published in the literature (27-29). In Figure 2D, glucose percentiles show that there was a proportionate decrease in very high plasma glucose measurements with time, reflected also in the substantial decrease in the value at the 95th percentile (topmost dashed line) from 348 mg/dL in 2004 to 309 mg/dL in 2008.By contrast, the relatively flat slope of the lines depicting the 5th and 10th percentiles indicates stable glucose concentrations over time at the lower end of the spectrum. Hospital average length of stay reduction has been an important goal of the IDP. Length of stay has been used as a surrogate marker of complications and cost (18) and has been directly linked to blood glucose levels, where higher glucose levels predict longer average length of stay (30). Hospital-wide interventions designed to improve glycemic control have reduced average length of stay (31). Between the years of 2005 and 2009 (January through June), average length of stay decreased by 1.1 days in both patients newly diagnosed with diabetes (approximately 235 patients/ month) and patients with known diabetes (approximately 465 patients per month). This reduction is approximately 40% greater than the average length of stay reduction seen in the entire hospital population (0.62 days) over the same time period. From here we have planned further steps as we watch the data evolve. On the basis of outcomes of recent studies, most notably those of NICE-SUGAR (18), we are re-evaluating the goals of care for critically ill patients with hyperglycemia. It is now more clear than ever that this important therapy must be applied in a thoughtful, evidence-based manner. We acknowledge the need for the careful scrutiny of available data that our intensivist colleagues insist on, and we have partnered with them toward evidence-based goals. We look to continue education for patients with newly diagnosed diabetes by implementing the nursing NewOnset Diabetes Pathway hospital-wide. This will allow us to assess the impact of education on length of stay. Training and Provider Education Clearly, caring for hospitalized patients with hyperglycemia is a complex undertaking. Several other successful models of inpatient diabetes care have been published, including models that use advance practice nurses, physician assistants, and endocrinologists (4,6). The optimal program

structure should be tailored to reflect institutional structure, patient acuity, and available provider expertise. We have found a multidisciplinary approach that combines expertise from diabetologists, nurses, pharmacists, and educators to be integral to our success. Another key benefit of the IDP is the intensive instruction it provides to practitioners in training. In addition to endocrinology fellows, the diabetes service has become an elective rotation for medicine and pharmacy residents, as well as nurse practitioner students. Each endocrinology fellow completes 4 month-long rotations on the GLUC service during year 1 of his/her fellowship. In this time, the fellow rapidly develops a comprehensive skill set that allows them to design patient-tailored insulin programs, and then teaches medical residents and students their skills. Repeated use of the WEBBI model offers an opportunity for young physicians to master the art of insulin therapy in an intensive, hands-on environment. The experience promotes diabetes expertise in a time when the prevalence of obesity and diabetes are rising sharply and the call for improved inpatient glycemic control grows louder (18,32). Moreover, the collaboration between physicians-in-training and NP/CDEs is particularly valuable. The physicians learn about the practical barriers to diabetes self-management that plague both patients and providers, while the NP/CDEs receive support with patients who have complicated medical issues. Pharmacists serve an important role in medication management in various inpatient settings. By providing a pharmacy resident the opportunity to train with an inpatient diabetologist, they gain a better understanding of the complexities associated with diabetes management. A key role for all pharmacists is also patient education, including insulin administration and glucose meter teaching. Time spent with NP/CDEs allows for new educational techniques to be acquired, as well as a better understanding of the various devices associated with diabetes management. Finally, the NP/CDEs are locally recognized as diabetes preceptors for various nurse practitioner training programs in Boston. The nursein-training works closely with the IDP NP/CDE and meets weekly with the attendings, students, and other nurses to discuss cases. Overall, the model of multidisciplinary training fosters the mutual education and management support that are fundamental to successful diabetes care (32,33). Given the increasing national prevalence of diabetes, the academic training model for inpatient diabetes care affords a unique opportunity to provide tools for a diverse group of health care trainees who can bring this information to other institutions. A Look Back, and to the Future Our program continues to evolve along with other institutions that have worked toward providing state-of-theart, evidence-based diabetes care to hospitalized patients. We have learned the importance of flexibility as new data emerge. Our experience in initiating protocols has shown

Inpatient Diabetes, Endocr Pract. 2010;16(No. 3) 519

that without continued reinforcement and education, diabetes protocols will fall by the wayside. It is also important to note the potential for burnout among those who work in this field. The constant education of rotating house officers and ambivalence created by data that may be confusing can lead practitioners to feel as frustrated as the nurses and physicians they are supporting. We find the collaborative team approach and the academic organization of our program helpful to maintain interest and stimulate efforts. We are also encouraged as we see more medical house officers independently order well-designed insulin programs.

Many providers tell us they learn more about insulin from treating their patients in the hospital than they ever have in the clinic. Financial aspects of the IDP are becoming increasingly scrutinized in this time of ballooning health care costs. This is challenging because so many aspects of this program do not involve direct reimbursable patient care. As a result, we have optimized billing and demonstrated cost savings, such as reduction in average length of stay. Since 2005, with modest initial hospital investment ($200000 year 1 only toward staffing, and annual 15% director

Table 2 Key Elements and Lessons Learned From the Boston Medical Center Inpatient Diabetes Program Application Multidisciplinary committee Centralized group charged to make decisions and implement changes related to glycemic control Avenue of communication to other leadership groups (eg, Pharmacy and Therapeutics Committee, Medication Safety, Quality Improvement) Streamline insulin ordering to optimize WEBBI use and standardize safety parameters Customize orders to specific patients (eg, receiving parenteral or enteral nutrition, CSII, labor and delivery, ICU vs non-ICU) Direct the elimination of inappropriate lone sliding scale insulin therapy Challenges Maintaining effective membership with providers who have competing time demands Must regularly assess membership and adjust as committee goals and objectives change Order sets require adjustments over time in response to end-user feedback Modification may be difficult in non CPOE system Changes may affect unintended populations in a CPOE system (eg, pediatrics) Requires end-user education and re education Protocol drift necessitates vigilance New clinical staff require specific education to be incorporated into routine training practices Evolving literature makes it challenging to keep clinicians and institutional guidelines current

Standardized order sets

Education

Leadership

Provide regular teaching and education sessions to all clinicians (eg, physicians, nurses, pharmacists) Have tools readily available; pocket cards, nurse champions, and online medication guidelines serve as excellent resources Providers learn to independently manage patients and nurses feel more comfortable providing patient education

3 Inpatient Diabetes Program physician champions serve as spokespersons to achieve institutional buy-in from other clinical leaders and hospital administration Inpatient Diabetes Program leaders from pharmacy and nursing direct implementation of and education for all initiatives

Standardization of inpatient management among diabetes providers Fluctuation of institutional financial support

Abbreviations: CPOE, computerized physician order entry; CSII, continuous subcutaneous insulin infusion; ICU, intensive care unit; WEBBI, weight-based basal-bolus insulin.

520 Inpatient Diabetes, Endocr Pract. 2010;16(No. 3)

full-time equivalent for administrative support time on an ongoing basis), the IDP has been able to maintain adequate billing volume to meet department requirements for each team member. Other costs for the program are minimal, including roughly $1300 per year for pocket card creation and copy fees. Beyond feasibility for individuals and department sections, average length of stay reductions alone should provide support for diabetes-targeted inpatient consultative services. The reduced average length of stay we have seen, and as noted by others (8,31), if applicable to the broad inpatient diabetes population, would translate to millions of dollars in yearly savings for most hospitals. Several successful models have been used (46,8,12,14) to implement both population-targeted and hospital-wide diabetes improvement programs, and here we report the product of an academic inpatient diabetes plan implemented over 5 years in a safety-net hospital (Table 2). For 40 years, hospital medicine has called for improvements in inpatient diabetes care (34), yet clear data, recommendations, and champions in this field have emerged relatively recently (18,26,32,35). Even with this new fervor, the time required to materialize outcomes from a paradigm change can be substantial, and the end of implementation only marks the beginning of standard practice in an institution. Beyond training the trainers, maintaining this new standard requires the same dedicated team approach and a long-term hospital investment. We hope the broad timeline set forth here can serve to inspire and guide others as they work to transform their own institutions. We strive daily to fuel the enthusiasm for the care of this growing and unique patient population, and only time and outcome measurement will tell if these efforts will continue to result in improved care of inpatients with hyperglycemia. ACKNOWLEDGMENT We would like to thank those who have supported this program, with special mention of Lynn White, NP, CDE, and Marina Donahue, NP, CDE, who are members of our team, and Lewis Braverman, MD, for his support of the creation of this program at our institution. We thank Thomas G. Travison, PhD, for his assistance in presenting the glucose data. DISCLOSURE Dr. Marie E. McDonnell has received speaker honoraria from sanofi-aventis. Dr. Elliot Sternthal is a member of the speakers bureau for Eli Lilly, Amylin, and Merck Pharmaceuticals. Dr. Lindsay M. Arnold has participated in advisory board activities for Novo Nordisk. Dr. Sara M. Pietras and Ms. Patricia Hanrahan have no multiplicity of interest to disclose.

REFERENCES
1. Rizza RA, Vigersky RA, Rodbard HW, et al. A model to determine workforce needs for endocrinologists in the United States until 2020. Endocr Prac. 2003;9:210-219. 2. Boston Medical Center Fact Sheet. Boston Medical Center Web site. Available at: www.bmc.org/about.htm. Accessed November 2, 2009. 3. Garber AJ, Moghissi ES, Bransome ED Jr, et al; American College of Endocrinology Task Force on Inpatient Diabetes Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10:77-82. 4. DeSantis AJ, Schmeltz LR, Schmidt K, et al. Inpatient management of hyperglycemia: The Northwestern experience. Endocr Pract. 2006;12:491-505. 5. Magee MF, Clement S. Subcutaneous insulin therapy in the hospital setting: Issues, concerns, and implementation. Endocr Pract. 2004;10(Suppl 2):81-88. 6. Donaldson S, Villanuueva G, Rondinelli L, Baldwin D. Rush University guidelines and protocols for the management of hyperglycemia in hospitalized patients: Elimination of the sliding scale and improvement of glycemic control throughout the hospital. Diabetes Educ. 2006;32:954-962. 7. Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30: 2181-2186. 8. Sadhu AR, Ang AC, Ingram-Drake LA, Martinez DS, Hsueh WA, Ettner SL. Economic benefits of intensive insulin therapy in critically Ill patients: The targeted insulin therapy to improve hospital outcomes (TRIUMPH) project. Diabetes Care. 2008;31:1556-1561. 9. Inzucchi SE. Clinical practice. Management of hyperglycemia in the hospital setting. N Engl J Med. 2006;355: 1903-1911. 10. Society of Hospital Medicine Glycemic Control Resource Room. Society of Hospital Medicine Web site. Available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/ GlycemicControl.cfm. Accessed November 3, 2009. 11. Moghissi ES, Hirsch IB. Hospital management of diabetes. Endocrinol Metab Clin N Am. 2005;34:99-116. 12. Baldwin D, Villanueva G, McNutt R, Bhatnagar S. Eliminating inpatient sliding-scale insulin: A reeducation project with medical house staff. Diabetes Care. 2005;28:1008-1011. 13. Cheekati V, Osburne RC, Jameson KA, Cook CB. Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital. J Hosp Med. 2009;4:E1-E8. 14. Korytkowski M, Dinardo M, Donihi AC, Bigi L, Devita M. Evolution of a diabetes inpatient safety committee. Endocr Pract. 2006;12(Suppl 3):91-99. 15. McDonnell ME, Apovian CM. Diabetes Mellitus. In: Gottschlich MM, DeLegge MH, Mattox T, Mueller C, Worthington P, Guenter P, eds. In: The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based ApproachThe Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007: 676-694.

Inpatient Diabetes, Endocr Pract. 2010;16(No. 3) 521 16. Schnipper JL, Ndumele CD, Lian CL, Pendergrass ML. Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: Results of a clinical trial. J Hosp Med. 2009;4:16-27. 17. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297. 18. Moghissi ES, Korytkowski MT, DiNardo M, et al; American Association of Clinical Endocrinologists, American Diabetes association. American Association of Clinical Endocrinologist and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369. 19. Sarkar U, Piette JD, Gonzales R, et al. Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Patient Educ Couns. 2008;70:102-110. 20. Feddersen E, Lockwood DH. An inpatient diabetes educators impact on length of hospital stay. Diabetes Educ. 1994;20:125-128. 21. Boren SA, Fitzner KA, Panhalker PS, Specker JE. Costs and benefits associated with diabetes education: A review of the literature. Diabetes Educ. 2009;35:72-96. 22. Cavanaugh K, Wallston KA, Gebretsadik T, et al. Addressing literacy and numeracy to improve diabetes care: Two randomized controlled trials. Diabetes Care. 2009;32:2149-2155. 23. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ. 2006;32(Suppl 1):9S-18S. 24. Brunton SA, Davis SN, Renda SM. Overcoming psychological barriers to insulin use in type 2 diabetes. Clin Cornerstone. 2006;8(Suppl 2):S19-S26. 25. Peyrot M, Rubin RR, Lauritzen T, et al; International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers: Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care. 2005;28:2673-2679. 26. Clement S, Braithwaite SS, Magee MF, et al; American Diabetes Association Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals (errata in Diabetes Care. 2004;27:1255 and Diabetes Care. 20044;27:856). Diabetes Care. 2004;27: 553-591. 27. Kosiborod M, Inzucchi SE, Goyal A, et al. Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction. JAMA. 2009;301:1556-1564. 28. Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: Not only treatment but also prevention. Endocr Pract. 2004;10:89-99. 29. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care. 2009;32:1153-1157. 30. Estrada CA, Young JA, Nifong LW, Chitwood WR Jr. Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting. Ann Thorac Surg. 2003;75:1392-1399. 31. Levetan CS, Salas JR, Wilets IF, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med. 1995;99:22-28. 32. Braithwaite SS, Magee M, Sharretts JM, Schnipper JL, Amin A, Maynard G; Society of Hospital Medicine Glycemic Control Task Force. The case for supporting inpatient glycemic control programs now: The evidence and beyond. J Hosp Med. 2008;3(Suppl 5):6-16. 33. Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self-management education. Diabetes Care. 2007;30(Suppl 1):S96-S103. 34. Robbins L. Lets get the sliding scale out of medicine. Med Rec Ann. 1963;56:201. 35. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978-982.