Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Clinical Diabetes
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Diabetes Spectrum

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Clinical Diabetes
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Diabetes Spectrum
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
Departments

Implementation of an Inpatient Diabetes Management Team in the University Hospital Setting

  1. Gael Ulisse, APRN, CDE
Diabetes Spectrum 2010 Mar; 23(2): 131-133. https://doi.org/10.2337/diaspect.23.2.131
PreviousNext
  • Article
  • Info & Metrics
  • PDF
Loading

A long history of clinical evidence points out the untoward effects of hyperglycemia in humans. Hyperglycemia acutely impairs leukocyte function, immunoglobulin action, wound healing, cardiac metabolism, glomerular filtration, and endothelial function.1 In addition, the stress of critical illness causes an increase in counterregulatory hormones. This leads to alterations in carbohydrate metabolism by increasing peripheral glucose demand and enhancing hepatic glucose production and insulin resistance, which results in a relative insulin deficiency and hyperglycemia.2 Moreover, clinical interventions also predispose patients to hyperglycemia, particularly the use of corticosteroids, vasopressors, and enteral or parenteral nutrition.3

In a study by Umpierrez et al.,4 hyperglycemia (defined as a fasting blood glucose level > 126 mg/dl or a random blood glucose level > 200 mg/dl on two separate occasions) occurred in 38% of hospitalized patients. Twenty-six percent of these patients with hyperglycemia had a known history of diabetes, but 12% had no history of diabetes. Newly discovered hyperglycemia was associated with longer hospital stays, higher admission rates to the intensive care unit, and a greater chance of being discharged to a rehabilitation facility than of being discharged home. The take-home message is that hyperglycemia is common in patients during hospitalization, and this hyperglycemia is associated with adverse outcomes.

A variety of approaches, most involving development and use of intensive insulin therapy protocols to improve glucose management in the hospital setting, seem to improve metabolic outcomes. Whether these approaches improve actual outcomes of morbidity and mortality is not yet known outside of the critical care setting. Several early clinical trials suggest a benefit of intensive glucose control in the critical care setting on morbidity (especially infection), length of stay, hospital costs, and mortality in selected groups of patients.5,6 More recently, clinical trials involving intensive insulin therapy in critical care units demonstrated no reduction in mortality7 and even an increase in mortality with tight glucose control.8 Data for patients who are not critically ill are observational only. Several organizations, including the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists, have endorsed aggressive regimens in all hospitalized patients, and these recommendations have recently been updated related to findings of more recent clinical studies.9

History of the Yale-New Haven Hospital Diabetes Team

Yale-New Haven Hospital (YNHH) is a 1,100-bed teaching hospital affiliated with Yale University Medical School. In 2002, a multidisciplinary committee at YNHH began to change some processes of care to improve inpatient glucose management. Proactive approaches considered included greater use of insulin; less reliance on regular insulin sliding scales as sole therapy; proper timing of capillary blood glucose testing and insulin administration with meals; improvements in data acquisition and recording; ongoing collaboration between nurses, mid-level practitioners (such as nurse practitioners, physician's assistants, and certified nurse specialists), and physicians; and the updating of computer programs. Interventions considered to improve hyperglycemia were including intravenous insulin infusion protocols, subcutaneous insulin regimens using a basal/bolus rationale, and greater utilization of nurse specialists.

By 2004, results were published10 of a clinical study conducted in the hospital medical intensive care unit. The research team implemented an insulin infusion protocol (IIP), which proved to be safe and effective in improving glucose control in critically ill patients. It is a nurse-implemented protocol that provides detailed insulin dosing instructions and requires minimal physician input. The published IIP is now being used in more than 700 hospitals in the United States.

In 2005, the multidisciplinary YNHH committee determined that premeal blood glucose targets for patients with hyperglycemia on noncritical care floors would be 90–150 mg/dl. During this time, all disciplines involved were developing policies and protocols, making computer program changes, and developing multilevel education programs to facilitate initiation of the Inpatient Diabetes Team (IDT). Once the multidisciplinary committee completed all of the above-mentioned groundwork, the new IDT was officially formed, and on 1 July 2005, the IDT started its work.

IDT: Mission Statement, Responsibilities, and Structure

The IDT's mission is to work cohesively with physicians, mid-level practitioners, and staff nurses to improve the quality of metabolic control provided to inpatients with diabetes or stress hyperglycemia at YNHH.

Responsibilities of the IDT include working collaboratively to improve hyperglycemia management in the hospital, whether through medication management or patient education; facilitating patients' transition to post-hospital care; and collecting data to assess achievement of outcomes.

The IDT includes four basic members: an attending physician, an endocrine fellow, a nurse practitioner, and a clinical nurse specialist. Medical students and residents from Yale or from other hospitals and medical programs can choose to work with the IDT as part of an endocrine rotation. The team is led by Silvio Inzucchi, MD, who serves as medical director at Yale and was responsible for conceiving the idea of an inpatient team. Dr. Inzucchi acts as clinical advisor to all team members and provides education about the team and the insulin protocols to incoming residents and interns. He also provides continuing education about the team and about any diabetes-related projects to all hospital services. In addition, he is responsible for reviewing data collected for quality control purposes.

The position of attending physician for the IDT rotates on a monthly basis. The attending physician is always an endocrinologist who has a special interest in diabetes and hyperglycemia in the hospital setting and is available for daily rounds to provide clinical guidance to the remainder of the team members. The physicians can be from Yale or from the greater New Haven, Conn., community.

An advanced practice registered nurse (APRN) is the person primarily responsible for carrying out rounds of each team patient every day. Primary care teams call in new patient consultations directly to the APRN.

Because YNHH is a teaching hospital, there are several medical teams consisting of interns and residents that act as the primary care provider for each hospitalized patient. These primary care teams are also responsible for coordinating care for all consulted specialties caring for each patient.

Each new consultation requires an in-depth patient interview focusing on all aspects of diabetes management: current diagnosis and past medical history; length of time with diabetes and the pre-admission regimen; home management of diabetes (nutrition and exercise plan, blood glucose monitoring, A1C); presence of any complications; and current in-hospital regimen. The interview differs from the usual medical/advanced practice practitioner interview in that all questions relate to diabetes care/management. Because complete and thorough physical examinations are documented by all services involved in a patient's care, the diabetes exam is brief and is pertinent only to those systems that pertain to diabetes and are often omitted from the basic admission physical exam, such as skin assessment and foot screening. Both documentation of the initial interview and documentation of follow-up care pertain only to diabetes management.

Independently or in collaboration with the endocrine fellow, recommendations are made to the patient's primary care team. This process informally involves resident/intern education when using a basal/bolus/correction protocol, the insulin infusion protocol, or the transition from an intravenous to a subcutaneous insulin protocol.

Once patients are admitted to the IDT, the APRN is responsible for visiting every patient every day to collect data, including blood glucose results, nutritional status, changes in patient medications, or new treatments that affect blood glucose levels, such as steroid use, peritoneal dialysis, total parenteral nutrition, or tube feedings. The APRN then makes changes in the diabetes medication regimen based on the day's data, documents these changes, and notifies the responsible primary care team for the patient.

An important part of the patient care plan is to facilitate a smooth transition to post-discharge care and to ensure that the patient has medical follow-up. Since the team started at YNHH, the Yale Diabetes Center has expanded and the IDT APRN works one afternoon per week in the outpatient setting to follow-up with patients who did not have a primary care physician or another clinic to attend for follow-up after discharge.

At YNHH, the APRN position is funded by the hospital and reports directly to Thomas Balcezak, MD, MPH, who is associate chief of staff and administrative director of performance management. Both Dr. Balcezak and Dr. Inzucchi developed the APRN job description, and both are responsible, with input from the endocrine fellows, for evaluating the performance of the APRN. In addition to the above-mentioned IDT responsibilities, the APRN is expected to conduct other professional duties, such as attaining departmental goals/outcomes, participating in community-related diabetes activities, and participating in diabetes-related research as necessary. The APRN is covered on evenings and weekends by the endocrine team. The endocrine team consists of an endocrine fellow and an attending Yale physician who must be available to handle all endocrine problems including diabetes on evening, night, and weekend shifts.

A clinical nurse specialist (CNS) is also part of the IDT. The primary focus of the CNS is to educate all levels of current nursing staff, including writing computerized continuing education programs and orienting new employees about the importance of inpatient management of people with diabetes or hyperglycemia. The CNS also has administrative duties that include preparing the hospital for Joint Commission on Accreditation of Healthcare Organizations and ADA education recognition, writing and testing protocols used by the team, and leading committees to collaborate on writing uniform policies and protocols to promote consistency among all departments treating patients with diabetes. The CNS also assists with patient education, particularly for newly diagnosed patients with diabetes, when time allows. The CNS frequently communicates via phone or meetings with the APRN and the endocrine fellow, if necessary, to ensure that the medication regimen is consistent with patient education goals and vice versa.

The final IDT team member is an endocrine fellow. As the primary consultant on the endocrine team, the fellow sees patients with non-diabetic endocrine problems and meets with the attending physician daily to care for these patients. The fellow then attends rounds with the IDT APRN on a daily basis to collaborate on care for the IDT patients and to provide continuing education for all team members, as well as for visiting residents/students. At least twice a week, the fellow must present a complex case involving a patient with diabetes to the entire team, including the attending physician. The fellow position rotates every 2 months.

Outcome Measurement

Outcomes being measured include consultation volume, discharge volume and lengths of stay, date first seen by the team, documentation accuracy, and glycemic control, measured both as a percentage of hypoglycemic exposure and a percentage of glucose within the target range. The purpose of analysis is to determine whether YNHH inpatients seen by the IDT experience improved blood glucose control 1) after team consultation as compared to before team consultation and 2) as compared to a matched control group who did not receive a team consultation.

The first major analysis of data occurred 1 year after the team started. The 2006 results were positive. Mean blood glucose for patients on the IDT was reduced by 49.5%, with a P value of 0.01. Mean blood glucose for patients not on the IDT was reduced by 16.4%, which was not significant in this analysis. A comprehensive discussion on the results has been published elsewhere.11

Problems, Ongoing Development, and Changes

Problems naturally surfaced as the IDT progressed. These problems included interdisciplinary communications, staff documentation, existing computer programs, and current protocols and highlighted the need for improving communications through education programs and written correspondence, as well as for ongoing informal education on a one-to-one basis between team members and staff. For example, both residents and nursing staff fear hypoglycemia, and they will frequently hold or change an ordered dose of insulin for glucose levels in the low-normal range in an effort to prevent hypoglycemia; this practice results in rebounding high glucose levels. In addition, computer programs are constantly being updated, documentation programs and protocols are continuously revised, and newer types of equipment for blood glucose monitoring will be introduced to facilitate both staff and team responsibilities.

Outcome measures are also revised to better reflect the work of the team. For example, measuring the number of patients achieving target blood glucose levels was not practical because many patients' lengths of stay are short, and frequently the team is not consulted as early as would be desirable. Therefore, the team now measures the relative change in average glucose, which gives a more accurate picture of whether team interventions are resulting in improvements.

To conclude, the YNHH IDT is showing that focused attention to controlling hyperglycemia in hospitalized patients is having significant results.

Footnotes

  • Gael Ulisse, APRN, CDE, is the advanced practice nurse on the Inpatient Diabetes Team at Yale-New Haven Hospital in New Haven, Conn.

    • American Diabetes Association(R) Inc., 2010

    References

    1. ↵
      1. Clement S
      : Better glycemic control in the hospital: beneficial and feasible. Cleve Clin J Med 74:111–120, 2007
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Mizrock SA
      : Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med 98:75–107, 1995
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      1. Inzucchi SE,
      2. Goldberg PA,
      3. Dziura JD,
      4. Lee M,
      5. Halickman J,
      6. Sherwin R
      : Risk factors for poor glycemic control in a medical intensive care unit (ICU) [Abstract]. Diabetes 52 (Suppl. 1):A96, 2003
      OpenUrl
    4. ↵
      1. Umpierrez GE,
      2. Isaacs SD,
      3. Bazargan N,
      4. You X,
      5. Thaler LM,
      6. Kitabehi AE
      : Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978–982, 2002
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      1. Van den Berghe G,
      2. Wilmer A,
      3. Hermans G,
      4. Meersseman W,
      5. Wouters PJ,
      6. Milants I,
      7. Van Wijngaerden E,
      8. Bobbaers H,
      9. Bouillon R
      : Intensive insulin therapy in critically ill patients. N Engl J Med 345:1359–1367, 2001
      OpenUrlCrossRefPubMedWeb of Science
    6. ↵
      1. Furnary AP,
      2. Zerr KJ,
      3. Grunkemeier GI,
      4. Starr A
      : Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67:352–362, 1999
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Van den Berghe G,
      2. Wilmer A,
      3. Hermans G,
      4. Meersseman H,
      5. Wouters PJ,
      6. Milants I,
      7. Van Wijngaerden D,
      8. Bobbaers H,
      9. Bouillon R
      : Intensive insulin therapy in the medical intensive care unit. N Engl J Med 5:449–461, 2006
      OpenUrl
    8. ↵
      1. NICE-SUGAR Study Investigators
      : Intensive versus conventional glucose control in critically ill patients. N Engl J Med 13:1283–1297, 2009
      OpenUrl
    9. ↵
      1. American Diabetes Association
      : Clinical practice recommendations 2010. Diabetes Care (Suppl. 1): 33:543–547, 2010
      OpenUrl
    10. ↵
      1. Goldberg PA,
      2. Siegel M,
      3. Sherwin R,
      4. Halickman J,
      5. Lee M,
      6. Bailey V,
      7. Lee SL,
      8. Dziura J,
      9. Inzucchi SE
      : Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care 27:461–467, 2004
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Bozzo J,
      2. Zhenqiu L,
      3. Ulisse G,
      4. Psarakis H,
      5. Thomas P,
      6. Balcezak T,
      7. Inzucchi SE
      : Using glucometrics to assess the impact of an impatient diabetes management team. Poster presentation at the American Diabetes Association 67th Scientific Sessions, 22–26 June 2007
    PreviousNext
    Back to top

    In this Issue

    March 2010, 23(2)
    • Table of Contents
    • Index by Author
    Sign up to receive current issue alerts
    View Selected Citations (0)
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word about Diabetes Spectrum.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Implementation of an Inpatient Diabetes Management Team in the University Hospital Setting
    (Your Name) has forwarded a page to you from Diabetes Spectrum
    (Your Name) thought you would like to see this page from the Diabetes Spectrum web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    Implementation of an Inpatient Diabetes Management Team in the University Hospital Setting
    Gael Ulisse
    Diabetes Spectrum Mar 2010, 23 (2) 131-133; DOI: 10.2337/diaspect.23.2.131

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Add to Selected Citations
    Share

    Implementation of an Inpatient Diabetes Management Team in the University Hospital Setting
    Gael Ulisse
    Diabetes Spectrum Mar 2010, 23 (2) 131-133; DOI: 10.2337/diaspect.23.2.131
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • History of the Yale-New Haven Hospital Diabetes Team
      • IDT: Mission Statement, Responsibilities, and Structure
      • Outcome Measurement
      • Problems, Ongoing Development, and Changes
      • Footnotes
      • References
    • Info & Metrics
    • PDF

    Related Articles

    Cited By...

    More in this TOC Section

    Departments

    • Smart Connected Insulin Pens, Caps, and Attachments: A Review of the Future of Diabetes Technology
    • Brief Literature Review: The Potential of Diabetes Technology to Improve Sleep in Youth With Type 1 Diabetes and Their Parents: An Unanticipated Benefit of Hybrid Closed-Loop Insulin Delivery Systems
    • Mental Health and Behavioral Screening in Pediatric Type 1 Diabetes
    Show more Departments

    Care Innovations

    • Leveraging Mechanical Forces to Target Insulin Injection–Induced Lipohypertrophy and Fibrosis
    • Development and Implementation of the Readiness Assessment of Emerging Adults With Type 1 Diabetes Diagnosed in Youth (READDY) Tool
    • Smart Connected Insulin Pens, Caps, and Attachments: A Review of the Future of Diabetes Technology
    Show more Care Innovations

    Similar Articles

    Navigate

    • Current Issue
    • Papers in Press
    • Archives
    • Submit
    • Subscribe
    • Email Alerts
    • RSS Feeds

    More Information

    • About the Journal
    • Instructions for Authors
    • Journal Policies
    • Reprints and Permissions
    • Advertising
    • Privacy Policy: ADA Journals
    • Copyright Notice/Public Access Policy
    • Contact Us

    Other ADA Resources

    • Diabetes
    • Diabetes Care
    • Clinical Diabetes
    • Scientific Sessions Abstracts
    • Standards of Medical Care in Diabetes
    • BMJ Open - Diabetes Research & Care
    • Professional Books
    • Diabetes Forecast

     

    • DiabetesJournals.org
    • Diabetes Core Update
    • ADA's DiabetesPro
    • ADA Member Directory
    • Diabetes.org

    © 2021 by the American Diabetes Association. Diabetes Spectrum Print ISSN: 1040-9165, Online ISSN: 1944-7353.