Chronic Care Focus: Controlling Diabetes in the ICU

Ms. Sloane is a freelance writer based in Jamesville, New York.

The quality of care for patients with diabetes has gotten better over the last decade in the United States, but there is still much room for improvement. Analysis from 2 federally funded studies recently showed that the probability of patients having an A1C <6 decreased from studies of a few years ago?from 23.4% to only 16.4% currently.¹ In addition, further studies have indicated that only about 40% of patients with diabetes have an A1C <7,² the current standard of care recommended by the American Diabetes Association (ADA).

It is estimated that >20% of patients with diabetes have poor control, qualified as an A1C >9.² Criteria for severe uncontrolled diabetes include fasting blood sugar >250 mg/dL, A1C >10, a random blood sugar >300 mg/dL, and/or ketones in the blood or urine.

Barriers to Intensive Insulin Therapy

No current standard of care regarding intensive glycemic control exists in the hospital setting, most specifically in the intensive care unit (ICU). Nurses training, staff-to-patient ratios, the need to individualize each patient?s care, and dangers of hypoglycemia all present barriers to providing hospitalized patients with intensive insulin therapy. Effective insulin protocols for these patients are urgently needed, because it has been shown that good glycemic control leads to better patient outcomes.

Prior to 2001, it was common practice to think that increased glucose levels in the hospital setting were merely a stress marker and did not need to be treated. High blood sugars in this patient population were either accepted or ignored. In 2001, however, the landmark Van den Berghe study determined that treating hyperglycemia in ICU patients clearly resulted in improved outcomes, including decreased levels of mortality, renal failure, and infection.³

This study made health care professionals take notice. This is a challenging area of diabetes treatment, because no easy formula exists for insulin dosing in a seriously ill patient. The landscape is constantly changing in the ICU, with patients spiking fevers, going on internal feeding, and having to be on steroid tapers, for example. All of these factors affect blood sugars and need to be addressed accordingly with additional insulin.

IV Insulin in the ICU

Intravenous (IV) insulin is underutilized in the ICU but is actually the safest way to treat diabetes in this setting. The downside to this is that more frequent blood glucose monitoring is required for patients on IV insulin, and with the current nursing shortage, this individualized care is not that easy to implement. In addition, some physicians may be fearful of initiating insulin therapy because of the risk of hypoglycemia; however, the risk is really not that great if therapy is managed properly.⁴ The true danger in the hospital setting is uncontrolled hyperglycemia, which, in one study, resulted in a 6-fold increase in nosocomial and wound infections.⁵ In another study, mortality risk for stroke doubled when blood glucose levels remained >140 mg/dL.⁶

One example of establishing a protocol for insulin therapy in the hospital setting was undertaken several years ago by the Georgia Hospital Association and Education Foundation. Known as the Partnership for Health and Accountability, this collaborative approach applies best practices to keep insulin protocols in place for the patient with diabetes and promote patient safety.⁷ This alliance of physicians, nurses, dietitians, pharmacists, diabetes educators, and other health care personnel developed a workable chart that defined insulin dosing per hour and target blood sugar ranges. The health care team meets periodically to go over best practices.

Recommendations of the American Association of Clinical Endocrinologists and the ADA include identifying elevated blood glucose in hospitalized patients, implementing structured protocols, creating education for hospital personnel in caring for patients with diabetes, and planning for a smooth transition to outpatient care.⁸

Considerations for Nursing Homes

With 1 of every 5 individuals aged 60 years or older having diabetes, nursing homes have an extremely large diabetic contingent as well. These patients often have limited cognitive function, poor eyesight, and are unsteady in gait. These characteristics make the elderly patient with diabetes a serious challenge to treat. Because of this, many patients in nursing homes are allowed to have blood sugars much higher than normal to avoid accidents due to possible hypoglycemia. Higher blood sugars in patients of this age group carry a huge risk for cardiovascular complications, to which many patients frequently succumb; approximately 90% of the elderly population has some form of cardiovascular disease or peripheral vascular disease already.⁹

Diabetes care poses many challenges, especially in the hospitalized or long-term care patient. The key to quality of care is quality education of health care professionals. Health care specialty teams need to be identified and educated, meeting periodically to discuss case studies and/or problems that arise. Regular classes need to be established, because learning about new therapies and standards of care is essential.

By sharing best practices, attending seminars, and understanding that we also need to educate patients, so that when they are discharged they can continue to take care of themselves, diabetes can be addressed and controlled properly and thus promote recovery for patients in the hospital or longterm care setting.

References

• Saaddine JB, Caldwell B,Gregg EW, et al. Improvements in diabetes processes of care and intermediate outcomes. Ann Intern Med. 2006;144:465-474.
• Centers for Disease Control & Prevention. National Diabetes Fact Sheet. 2005. www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf.
• Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:449-461.
• Rossetti P, Porecellati F, Bolli G, Fanelli CG. Prevention of hypoglycemia while achieving good glycemic control in type 1 diabetes: the role of insulin analogs. Diabetes Care. 2008;31(suppl):s113-s119.
• Pomposelli JJ, Baxter JK 3rd, Babineau JJ, et al. Early post operative glucose control predicts noscomonial infection rate in diabetic patients. J Parenter Enteral Nutr. 1998:22:77-81.
• Jorgensen HS, Nakayama H, Raascho HO, Olson TS. Stroke in patients with diabetes: The Copenhagen Stroke Study. Stroke.1994;25:1977-1984.
• Stockton L, Baird M, Cook C, Osburne R, Reid J, McGowan K, Jarvis S. Development and implementation of evidence-based guidelines for IV insulin: a statewide collaborative approach. Insulin. 2008(2);67-77.
• American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28(suppl 1):S4-S36.
• Ibrahim R, Hanna MD, Wenger N. Secondary prevention of coronary heart disease in elderly patients. Am Fam Physician. June 2005:42-47.