Endocrinology - Diabetes Management Service
The Diabetes Management Service (DMS) provides 24/7 concurrent ad-hoc care for the management of hyperglycemia and diabetes-related consults to all adult inpatient in most of the different hospital units. The glycemic control is a critical element of inpatient care that has received increasing focus and attention from the healthcare community and several national agencies over the last few years. Successful diabetes management significantly improves patient outcomes, decreases readmission rates, shortens the hospital length of stay, and is now recognized as a key driver in improving the quality of care while significantly reducing the cost of providing hospital care.
A little history...
The concept of an inpatient Diabetes Management Service has been gaining traction in large medical centers nationwide as a mechanism for improving patient outcomes, decreasing readmission rates, reducing cost of care, and shortening hospital length of stay. In a consensus conference position statement issued in December 2003, the American Association of Clinical Endocrinologists concluded that:
- “Hyperglycemia in hospitalized patients…is an independent risk factor for adverse outcomes.”
- “It is now apparent that new approaches and intensified efforts at metabolic regulation may improve short, intermediate and long-term outcomes in patients with diabetes in the hospital…”
The growing recognition that glycemic control is a critical element of inpatient care has prompted several national agencies, including the National Quality Forum (NQF), University Health Consortium (UHC), Centers for Medicare and Medicaid (CMS), and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) to make inpatient diabetes management a focus of quality improvement efforts and outcomes tracking.
The MUSC response to this challenge has taken two forms. The first was the creation, in September 2003, of a multidisciplinary Hospital Diabetes Task Force (HDTF) led by Dr. Kathie Hermayer of the Division of Endocrinology and Diabetes in the Department of Medicine and composed of representatives from Medicine, Surgery, Nursing, Pharmacy, Nutrition, Laboratory Medicine and Hospital Administration. The HDTF has been responsible for developing and overseeing the implementation of standardized nursing flow sheets for diabetic patients, order sets for subcutaneous and intravenous insulin administration, protocols for management of hypoglycemia and hyperglycemia, and systems for tracking outcomes for quality improvement. The task force, in particular Dr. Hermayer and three hospital-supported inpatient Certified Diabetes Educators (CDE), have also taken the lead in educating physician and nursing staff in the proper use of the new protocols and procedures.
The second response took the form of an inpatient Diabetes Management Service (DMS), which was launched in July 2004, directed by Dr. Hermayer, staffed by faculty in the Division of Endocrinology and financially supported by the Department of Medicine. DMS has taken the lead in the implementation of the new policies and procedures established by the HDTF. DMS automatically provides concurrent care for the management of adult inpatient hyperglycemia under prior agreement from participating services as part of a team approach to optimized patient care. DMS also provides consultative diabetes care to all adult inpatient services on request. At present DMS has an established working agreement with Vascular Surgery, Transplant Surgery, Bariatric Surgery and Cardiothoracic Surgery. Overall, the inpatient services that utilize the DMS include Neurosurgery, GI surgery, Transplant Surgery, Orthopedic Surgery, GI transplant, Critical Care/Surgery, Trauma Surgery, PACU, CT Surgery, OB/GYN, Neurology, Psychiatry, General Medicine, Nephrology, Pulmonary Medicine, Cardiology, Oncology, and Gastroenterology/Hepatology. DMS is available year round with Endocrinology Attending and Fellow 24/7 on-call coverage. DMS employs intravenous insulin drips, intensive multiple dose subcutaneous insulin regimens, and individualized insulin and/or oral agent therapy to maintain blood glucose levels within evidence-based target ranges. The DMS oversees the transition from intravenous to subcutaneous insulin, from ICU to ward bed, and from inpatient to outpatient treatment regimen. Increasingly, the DMS is coordinating post-discharge outpatient follow up visits to reduce the incidence of readmissions related to poor outpatient glycemic control. For example, all diabetic renal transplant patients are seen weekly for the first four weeks post transplant by the endocrinology service on the same day as their transplant clinic follow up. DMS, working with the hospital CDEs, also plays a major role in patient education in post discharge diabetes care.
MUSC's leadership in managing diabetes
Currently, our DMS team consists of one Attending Endocrinologist, one Endocrinology Fellow, two Nurse Practitioners/CDEs employed by the Division of Endocrinology, three Hospital Certified Diabetes Educators employed by MUSC Hospital (who share responsibility for all inpatient diabetes education) and one Hospital Nutritionist. They provide DMS 24/7 upon consult requests of the medical services at MUHA and Kindred Hospital/
The MUSC DMS has been instrumental in implementing new hospital-wide procedures to tighten inpatient glycemic control and reduce adverse events associated with insulin administration. Three recent MUSC outcomes studies document the positive impact of DMS:
- Implementation of the MUSC hypoglycemia treatment protocol significantly reduced the number of moderate to severe hypoglycemic episodes. Comparing hospital laboratory blood glucose readings from June 2004 (pre-protocol) with those from June 2005 (post-implementation), the data showed that the rate of mild hypoglycemic events (blood glucose 50-69 mg/dl) was reduced by 17% (p = 0.057); moderate hypoglycemic events (blood glucose 40-49 mg/dl) were reduced by 49% (p = 0.028); and severe hypoglycemic events (blood glucose <40 mg/dl) were reduced by 312% (p < 0.0001) (American Diabetes Association 66th Scientific Sessions, Abstract #952752, 2006).
- Implementation of an IV insulin infusion calculator that employs a novel MUSC-developed user interface in the Cardiothoracic Intensive Care Unit has markedly improved glycemic control in diabetic patients during the critical first 48 hours post-operation. Use of the calculator significantly reduced mean blood glucose from 154 to 118 (non-diabetic patient mean 116); reduced the percentage of patients failing to reach target blood glucose levels of 80-120 mg/dl within 48 hours from 25.8% to 4.6% (non-diabetic patient mean 3.0%); reduced the percentage of individual blood glucose readings >180 mg/dl from 22.9% to 5.8% (non-diabetic patient mean 3.3%); shortened the mean hours to target blood glucose from 22.0 to 8.7 hours (non-diabetic patient mean 5.9 hours); while producing no episodes of severe hypoglycemia (< 40 mg/dl) (American Diabetes Association 66th Scientific Sessions, Abstract #750162, 2006)
- The previously mentioned study of clinical outcomes in renal transplant patients showed that DMS involvement tended to reduce the percentage of recorded blood glucose levels <70 mg/dl (38% versus 19%); reduce the percentage of blood glucose levels >250 (37% versus 21%); and increase the percentage of blood glucose levels within the target range of 70-180 (44% versus 36%) (p = 0.09-0.13). Moreover there was a trend toward reduced graft failure rates from 20% to 6% (p = 0.11) (American Diabetes Association 66th Scientific Sessions, Abstract #952994, 2006).
Patients with glycemia control issues who received early DMS consultations have a significantly shorter length of stay compared to the other patients. Collectivelly, these studies and data analysis is provide strong evidence that within MUSC Hospital, implementation of the DMS has positively impacted patient care and patient safety while shortening the hospital stay and reducing the cost of hospitalization for the patients.
For all inquiries about our DMS program: