Study Zooms In on Glucose Monitoring During Hospital Stays
Those of us with diabetes dedicate a good deal of time and energy to managing our blood glucose levels on a daily basis. In our attention to carbohydrate counting, blood glucose measurement, insulin or oral medication doses, exercise, and diet, we actively and deliberately strive for tight glycemic control to improve our prospects for long-term health. But what happens when glycemic control is no longer in the outpatient setting of daily life? What happens when someone with diabetes goes into the hospital for a procedure, either by design (for example, a scheduled hip replacement) or in an emergency (cardiac arrest)? Although we may not like to think of it, patients with diabetes are at two to four times the risk for heart disease and stroke and may be hospitalized in other emergency situations as well.
Compelling research suggests that inpatient blood glucose control significantly affects morbidity and mortality. Interestingly, this is not only the case for patients with diabetes. Hyperglycemia is common in critically ill patients who do not have diabetes, as a result of the stress of a serious illness or trauma or even of various medicines (for example, steroids). Traditionally, hospitals have focused on administering insulin to patients whose blood glucose levels were above 215 mg/dL (11.94 mmol/l), which is the case for many patients who are not diabetic but who find themselves in the ICU or critical care units.
A study published in 2001 led by Dr. Greet Van den Berghe and colleagues at the Catholic University of Leuven in Belgium, compared outcomes in 1,548 patients who were admitted to a surgical intensive care unit. In half of the patients, blood glucose was monitored conventionally, with insulin administration only at blood glucose levels higher than 215 mg/dL (11.94 mmol/l). The other half of patients received "intensive insulin therapy," indicating that their blood glucose levels were maintained between 80 and 110 mg/dL (4.44 and 6.11 mmol/l), levels that more closely approximate the normal glycemic range.
The results caught the attention of the global medical community. After one year of the study, mortality in the intensively controlled group was down to 4.6% from 8.0% in the conventional group— three lives saved per year due to intensive insulin therapy, from a relatively small group of patients. Overall rates of mortality for hospital were reduced by 34%. Mortality was not the only thing affected by the intensive insulin therapy. Intensive insulin therapy reduced bloodstream infections by 46%, red-cell transfusions by 50%, and kidney failure requiring dialysis by 41%.
Since then, we've seen data from Dr. Anthony Furnary of the Providence St. Vincent Medical Center in Portland Oregon showing that tight glycemic control reduced the rate of mortality for cardiac procedures to 0.9% from 3.9% for patients with diabetes. While Dr. Van den Berghe's team looked at the adverse effects of hyperglycemia in all critically ill patients, Dr. Furnary's team focused only on patients with diabetes. In all cases, these investigators and others have made a compelling case for the importance of tight glycemic control in the hospital.
But while it has been five years since landmark data was published, change is slow. Most hospitals still rely on conventional management of blood glucose. A recent presentation at the Critical Care Congress in San Francisco by Dr. Daleen Aragon of the University of Central Florida reinforced why implementation is so difficult: maintaining tight glycemic control dramatically increases nursing workload. Dr. Aragon's analysis showed that the mean time required to conduct a BG test and respond was 4.7 minutes. A survey of nurses showed that most nurses felt that hourly blood glucose monitoring required too much work and too much time(!). On a 5-point scale, in which 5 is a strong yes and 1 is a strong no, some of the responses included:
- I am concerned about the many fingersticks performed for BG measurements: 3.7.
- I would prefer that my patient is not on the IV insulin infusion orders in the ICU: 2.4.
- BG monitoring is too much work: 3.0.
- I don't mind monitoring BG: 2.2.
- I believe tight glycemic control helps outcomes: 4.3.
- If I had an automated way to get BG readings, it would make glycemic control easier: 4.8.
As noted in one of our recent columns (October 2005), continuous glucose monitoring could have a significant impact on inpatient management – think about how an automated display of blood glucose could reduce nursing workload and facilitate tight glycemic management! A few companies presented information about continuous glucose monitoring systems in development, some of which were non-invasive, at the Critical Care Congress. We're staying very tuned in on this front.
In late January, the American Association of Clinical Endocrinologists and the American Diabetes Association held a meeting titled "Improving Inpatient Diabetes Care: A Call to Action Conference." Dr. Van den Berghe presented new data showing that intensive insulin therapy is important in the medical ICU as well as in the surgical ICU, the site of the first study. Among patients staying in the medical ICU for three or more days, those receiving intensive insulin therapy had reduced morbidity as well as a drop in mortality from 52% to 43%.
The AACE/ADA meeting addressed strategies for the implementation of tight glucose control in the hospital, reviewing protocols that have been successful for hospitals around the nation. The conference produced a consensus statement, available on the AACE websites (www.aace.com), outlining the evidence in support of the importance of glycemic control and identifying further research that is needed. While there is growing awareness of and interest in glycemic control in the hospital, the standard of care in most hospitals today is far behind where the evidence suggests it needs to be.
So what does this mean for people with diabetes? As always, being an educated consumer of health care can improve your chances of doing well in the healthcare system. If you or a loved one (even a non-diabetic loved one!) must go into the hospital for a planned procedure, or for an emergency, ask your healthcare providers about your glucose levels and their plan for maintaining them. The research on inpatient glycemic control also speaks to the importance of day-to-day glucose management: healthy glucose levels can help reduce the risk of an emergency hospitalization. The research on inpatient management is good news for people with diabetes and providers who care for them, as we now have a tool—tight glucose control—to reduce their risk of morbidity and mortality in the hospital. Make sure you are aggressive on this point if and when you enter the hospital—you'll be doing the institution a favor if you help ensure tight control!
Kelly Close is editor in chief of diaTribe (www.diaTribe.us), a free online newsletter for patients looking for more information on products and research.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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