In hospitalised patients, hypoglycaemia and hyperglycaemia are associated with worse outcomes. Clinical inertia & inattention to diabetes are major barriers to achieving optimal glycaemic control. We investigated the effect of a novel Glucose Alert Pathway (GAP) and Connectivity Blood Glucose Meter (CBGM) technology on nursing & medical staff action in response to suboptimal glycaemia.
The study was a 3-months prospective, pre- & post- implementation audit on two wards at a tertiary hospital. The intervention consisted of two components: GAP (paper-based glucose management & clinical escalation guide) coupled with CBGM. Consecutive inpatients with diabetes were assessed for BGL measures, diabetes treatment & hospital outcomes. The primary outcome was appropriate staff action on patient-days with reportable BGLs (defined as BGL <4.0, or >15.0, or two consecutive BGL >10.0 mmol/L). Appropriate nursing staff action was defined as notifying medical staff. Appropriate medical staff action was defined as reviewing or adjusting diabetes treatment. Secondary outcomes were adverse glycaemic days (patient-days with BGL <4.0 or >15.0 mmol/L), and hospital complications.
We recruited 157 patients (359 patient-days during baseline, and 311 patient-days during intervention periods). Reportable BGLs occurred in 148 (42%) and 114 (37%) patient-days during baseline and intervention periods respectively (p=0.12). Appropriate nursing staff action increased from 34% at baseline, to 58% at intervention (p<0.001). Similarly, appropriate medical staff action increased from 33% to 50% (p=0.004). However, there was no increase in diabetes medication adjustment (24% vs. 29%, p=0.3) or endocrinology consults (14% vs. 17%, p=0.6). There was a significant 24% decrease in adverse glycaemic days as a proportion of all patient-days (29% vs. 22%, p=0.03) but no difference in hospital complications.
The GAP coupled with CBGM technology, increased nursing & medical staff attention to diabetes. However there was ongoing clinical inertia, with little action to adjust diabetes medications or seek endocrinologist assistance. Overall, the intervention resulted in a significant reduction in adverse glycaemic days.