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

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.