Manage your hospitalize diabetic patients to improve outcomes and lower the cost of care

By Christopher Cheney

Hospitals could save millions of dollars with better glycemic control of patients with diabetes.

In 2017, per capita healthcare expenditures for hospital care were estimated at $4,966 for patients with diabetes and $1,202 for patients without diabetes, according to the American Diabetes Association. Riverside Healthcare found that better management of hypoglycemic patients at their facility led to an estimated savings of $544,756 annually, and that by reducing length of stay in critical care units due to the implementation of a computer-guided insulin protocol they achieved a $2.1 million in savings in a year.

"There are high healthcare costs with the poor management of blood sugar. Costs associated with diabetes in hospitals include length of stay—these patients tend to stay in the hospital longer than other patients. They need more treatments—insulin management is a major cost for these patients. They need more interventions. They also have more readmissions than other patients," says Betsy Kubacka, MSN, an endocrinology advanced practice registered nurse at The Hospital of Central Connecticut in New Britain, Connecticut.

There are two primary elements of caring for patients with diabetes in the hospital setting, she says. "When a diabetic patient is admitted to the hospital, they are primarily treated with insulin, which is the safest modality and has the least amount of side effects. We can get blood sugar control of the patient and maintain it throughout the hospitalization. When they are under control, patients can recover quicker and have less of a risk for infection. For most patients, we want to keep their blood sugar between 100 and 180 milligrams per deciliter throughout the hospitalization. We also want to ensure that our diabetic patients have adequate diabetes education to manage their diabetes when they are back home. We provide chronic disease management education."

Diabetes management is a challenge in the inpatient setting, Kubacka says. "Resources such as endocrinology are often limited at hospitals, so it is often a challenge getting our patients under control within the hospital setting. With insulin, you must give the right amount. If we don't give the right amount, you either have blood sugar that is too high or too low, both of which can lead to adverse outcomes."

In the hospital setting, there are adverse outcomes for patients with diabetes who have low blood sugar and high blood sugar, she says. "The adverse outcomes of low blood sugar include hypoglycemia, which can make the patient feel shaky and dizzy. In severe cases where the patient's blood sugar goes below 40, they can have altered mental status or hypoglycemic coma. Those patients have a longer length of stay at the hospital. Low blood sugar is the biggest concern for hospital staff. The adverse outcomes of high blood sugar—above 180 during hospitalization—include bacterial infections. Among COVID-19 patients, those who had uncontrolled high blood sugar while hospitalized have had higher mortality rates."

Managing hospitalized diabetic patients

Expert resources for patients with diabetes are often lacking in many hospitals across the country, and technology can fill the gap, Kubacka says. "We have a shortage of endocrinologists. We have a shortage of nurses who specialize in diabetes to help support team members in managing diabetic patients in hospitals. With a shortage of expert resources, we must look at things like technology to improve glycemic care. That is something that we implemented within Hartford HealthCare to assist our staff in calculating insulin doses by using Food and Drug Administration-cleared computerized algorithms."

The Hospital of Central Connecticut has launched three primary initiatives to improve glycemic care, she says.

• "There has been a lot of work in order set design. Within the electronic health record, we provide guidance to our physicians, nurse practitioners, and physician assistants in how to prescribe insulin. So, although endocrinology may not be their specialty, information on how to prescribe for a patient is at their fingertips."
•  "We have ensured through our nutrition services that diabetic patients are getting the correct diet. We ensure that we have a process, so the nurse knows when a meal is delivered, and the nurse can check the patient's blood sugar before the meal and administer insulin in a timely manner. We have put processes in place and support the staff as best as we can."
•  "We have an endocrine council that meets monthly, and I serve on that council. We look at any adverse event that occurs in the hospital and do root cause analysis on those events to see if there is anything within our processes that we can do differently to prevent adverse outcomes in the future."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.