Framing the Issue
- Diabetes is common in the hospital. The condition was a primary or secondary diagnosis in more than 5.3 million hospital discharges in 2010.
- The disease puts patients at higher risk of serious complications in the hospital. These include dangerous blood sugar levels, falls, infections and pressure ulcers.
- Medicare penalties for excess readmissions and high rates of health care-acquired conditions make blood sugar control a high priority for hospitals.
- Diabetes as a principal or secondary diagnosis can increase patient lengths of stay, which decreases hospital revenue. The mean length of stay for diabetic patients was 5.3 days in 2008, compared with 4.4 days for patients without the condition.
At any given time, one-third or more of patients in most hospitals have high blood sugar, typically caused by diabetes. These patients are at higher risk of serious complications: infections, falls, pressure ulcers and harmful or even deadly high or low blood sugar swings.
Medicare payment penalties for having high rates of health care-acquired conditions and for excess readmissions mean that hospitals must have systems in place to manage patients' blood sugar or run the risk not only of bad patient outcomes, but also financial losses.
"What hospitals should be doing is identifying diabetic patients when they come in and doing whatever they can to prevent that patient from getting any kind of hospital-acquired issue," says Hazel R. Seabrook, a managing director at Huron Consulting Group, Chicago.
But inpatient stays have to include more than blood sugar management. "Hospitals should also do appropriate discharge planning for diabetic patients so the patient gets discharged to the next care setting with the right education and the right follow-up care, so they've got that continuation of care outside the four walls of the hospital," Seabrook says.
At Scottsdale (Ariz.) Healthcare, inpatient glycemic control efforts start at admission. All patients' blood sugar levels are tested as part of their routine blood work, regardless of whether the patient is known to have diabetes. "Shame on us if a patient comes in, has all this blood work done and we don't screen them for diabetes," says Bobbi Presser, the system's service line director for diabetes and executive for clinical integration. "The undiagnosed patients who have lived with it for 10 years have no opportunity to make changes in order to prevent the complications that happen because of prolonged diabetes."
Since 2003, Scottsdale also has tested surgical patients, even those getting outpatient procedures, for abnormal blood sugar. If the level is too high, surgery is delayed until the patient's blood sugar is brought down to the normal range.
Before the protocol took effect, surgeons didn't want to be bothered about patients' blood sugars, Presser says. Now, they want to know patients' glucose levels because they understand that high blood sugar, known as hyperglycemia, hurts the immune system and increases infection risk.
The system created a Specialized Inpatient Diabetes Team that reviews lab results every day to identify patients whose blood sugar is abnormal because they're diabetic or they have stress diabetes — hyperglycemia induced by medication or their medical condition. When they find a patient with high blood sugar, they check the patient's medical record to see if it is being treated. If it's not, they have a talk with the doctor or nurse. Doctors also can request that the team, which consists of two nurse practitioners and a nurse specialist, consult on a patient's case and handle that patient's diabetes management.
"We're keeping blood sugar at normal levels so it does not impact the other reason why you happen to be in the hospital," Presser says. "The best any hospital can do is to make sure it's a nonissue for that patient."
Hospital staff teams up
More hospitals are developing teams that focus on inpatient diabetes management. Their makeup and duties vary, but they typically help to formulate blood sugar management protocols, serve as a staff resource, educate patients newly diagnosed with diabetes, and round on diabetic patients whose conditions warrant extra attention.
The Medical University of South Carolina in Charleston created its inpatient diabetes management service in 2004. The team, which includes an attending physician, an endocrine fellow, and NPs or physician assistants, typically is called to consult on patients whose blood sugar is particularly difficult to control, says Kathie Hermayer, M.D., director of the diabetes management service and chairwoman of the medical center's diabetes task force.
The service also has standing agreements with neurology and transplant, vascular, cardiothoracic, gastrointestinal, and bariatric surgery. These surgeons ask for consults for diabetic patients, and the team assumes blood sugar management for those patients.
At Saint Mary's Health Care in Grand Rapids, Mich., the inpatient glycemic control team comprises the physicians, NPs and other practitioners who run the hospital's outpatient diabetes and endocrine center, says Mary Harnish, R.N., clinical nurse leader who oversees the inpatient diabetes program. Because St. Mary's hospitalists and intensivists are well-versed in inpatient diabetes management, the team usually is called to consult only on difficult cases, at the request of an outpatient clinic patient, or on patients who use their own insulin pumps.
"What happens sometimes in other hospitals is they've mandated that everybody with diabetes be taken care of by the glycemic control team, and that really was stepping on the toes of hospitalists," Harnish says.
The trend toward blood sugar management teams partly is a response to the government's move in 2008 to stop reimbursing for the extra costs associated with health care-acquired conditions among Medicare patients. Many states and private insurers followed suit. Several of these conditions are related directly or indirectly to blood sugar control.
Before the Medicare payment change, some hospitals weren't focused on diabetes, Presser says. "Diabetes was just this orphan disease that impacted a whole lot of people. It was kind of the Rodney Dangerfield of diseases."
Now the Affordable Care Act is stepping up the pressure. Hospitals with health care-acquired condition rates in the highest quartile will see their Medicare payments cut 1 percent starting in 2015. The ACA's hospital value-based purchasing program is already under way. Among its measures is control of cardiac surgery patients' blood glucose at 6 a.m. the day after surgery.
"What CEOs need to understand is when diabetes is put in the background, patient length of stay goes down, their infection rate goes down," Presser says. "If it's uncontrolled, your length of stay is going way up and your complications are going to go way up."
Even in hospitals with special inpatient teams, not every diabetic patient can or should be seen by them. Uncomplicated diabetes care typically is handled by the physicians and the floor nurses. Protocols and order sets are instrumental in helping them to manage patients' blood sugar.
At Saint Mary's Health Care, a multidisciplinary diabetes operations team meets monthly to discuss diabetes across the care continuum. Using national care guidelines as a reference, the team develops the protocols and policies that drive day-to-day inpatient diabetes care, Harnish says.
About four years ago, Saint Mary's rolled out a new subcutaneous insulin regimen. "We put together an order set to make [physicians'] lives easier," Harnish says. The new regimen required collaboration with food service because Saint Mary's patients get meals on demand, and food intake impacts insulin dosing.
At Scottsdale, the inpatient diabetes team members try to get on any committee that's relevant to blood sugar control, Presser says. "That's where you try to break down the silos and do interdisciplinary work."
IT leads to 'phenomenal' results
Technology also plays a role in blood sugar control and patient safety. Nurses at Scottsdale use software that recommends doses for intensive care unit patients on a continuous IV insulin drip. Nurses have to check these patients' blood sugars every hour. Before the software, nurses had to use a complicated, 32-column grid to determine the right insulin dose.
Now nurses click on the tool's icon on their computer, enter the patient's account number, plug in the patient's blood sugar, and the tool calculates the correct dose and makes a recommendation. "This has been a lifesaver in terms of keeping the really sick patients who are on insulin in a safe place," Presser says.
Saint Mary's Health Care, recognized by the Joint Commission for advanced inpatient diabetes care, uses similar glucose-stabilizing software. Physicians write an order that directs the nurse to follow its recommendations. This takes any guesswork out of insulin dosing and saves physicians from constant phone calls to authorize adjustments. "We've had some phenomenal decreases in hypoglycemia and hyperglycemia," Harnish says.
The hospital also bought new blood glucose meters for bedside testing. Instead of a nurse transcribing the blood glucose level from the meter, the meter is docked and the reading automatically goes into the patient's electronic health record. "The investment was well worth it because there is no transcription-of-blood-glucose error," Harnish says.
Getting everyone up to speed
Doctor and staff education is critical to the success of inpatient diabetes programs. At Scottsdale, inpatient diabetes team members handle much of the staff education at the bedside. "Most of their time is spent educating the nurses and physicians because diabetes is so complex in terms of how you treat it, and it seems as though every three months [manufacturers are] coming out with some new drug," Presser says.
At Saint Mary's, nurses and patient care assistants go through a learning module on hypoglycemia — dangerously low blood sugar — in addition to having a protocol that allows nurses to handle the condition as an emergency and treat it immediately. The hospital also plans to educate the transport staff and housekeeping staff on the signs and symptoms of hypoglycemia, Harnish adds.
Diabetes patient education also must be part of the inpatient stay. Every diabetic patient at Saint Mary's fills out a diabetes education needs assessment. Staff nurses use the results to guide patient education. "I try to empower the nurses to provide that bedside education as they're providing care," Harnish says. "As the patient is being given insulin or a medication or their blood sugar is being checked, the nurse is doing ongoing education."
Hospital education usually focuses on what's known as diabetes survival skills, such as understanding the signs and symptoms of trouble, medications, blood glucose monitoring, nutrition and exercise.
"Patients are going to remember maybe 10 percent of what we teach them," Presser says. "We try to get them into outpatient education after [discharge] because in the hospital patients are sick and they're preoccupied with what they're really in for."
Hospitals increasingly are including discharge and care transitions planning as part of inpatient services for diabetic patients. The new Medicare payment penalty for excess 30-day readmissions is a driver of this trend. "An uncontrolled diabetic is always at high risk for readmission," Huron's Seabrook says.
Although the readmission penalties don't directly target diabetes, the disease affects the three conditions that are the focus: heart attack, heart failure and pneumonia. Diabetes is a major risk factor for heart attack and heart failure, so many patients discharged with those conditions also have diabetes. People with diabetes are three times more likely to die of pneumonia or influenza than those without the condition, according to the Centers for Disease Control and Prevention.
Seabrook recommends that hospitals not only make sure diabetic patients' follow-up appointments are made before discharge, but that they also get a quick phone call to remind them of their appointments.
The readmissions penalties mean hospitals should take into account the quality of post-acute care providers, says Laura Jacquin, a managing director at Huron. "It's not just 'Here's a list of post-acute care resources and providers,' but who does the hospital know that provides high quality care and understands how to care for a diabetic patient?"
Efforts to manage care for diabetics from admissions through discharge have costs, among them PA and NP salaries, staff time in committees, extra work for the nursing staff, educational materials and technology. But the expense is worth it in terms of preventing in-hospital complications and readmissions, says Hermayer of the Medical University of South Carolina, which also has Joint Commission recognition for advanced inpatient diabetes care.
"I don't know how many lawsuits we've saved the hospital from," she says. "We definitely have helped in terms of quality and standard of care."
— Geri Aston is a contributing writer for H&HN.
Diabetes' connection to Medicare HAC penalties
Beginning in fiscal 2015, hospitals with health care-acquired condition rates in the highest quartile will have their Medicare payments reduced by 1 percent for all DRGs. Several of these conditions are tied to diabetes management, including:
• Manifestations of poor glycemic control. These include hypoglycemic coma and diabetic ketoacidosis, a dangerous buildup of acids in the blood stream.
• Falls and trauma. Patients whose diabetes has caused nerve damage in their feet are at higher risk of falls. Also, diabetes ups the risk of hypoglycemia, which can cause confusion, vision problems and loss of consciousness.
• Surgical-site infections. Abnormally high blood sugar interferes with the immune system and increases infection risks.
• Pressure ulcers. Over time, diabetes damages blood flow, which increases pressure ulcer risk. Nerve damage means patients are less able to feel the pressure or notice pain from the ulcer.
Medicare dollars a factor
Diabetic patients are at higher risk for health care-acquired conditions, readmissions and longer lengths of stay than the general inpatient population. "If Medicare is penalizing [for complications and readmissions], there's a high probability that commercial payers will follow," says Laura Jacquin, a managing director at Huron Consulting Group.
Hospitals are creating teams dedicated to blood sugar management for the inpatient population. At a minimum, hospitals should have at least one clinician who is an expert on diabetes and can round on patients whose blood sugar is difficult to control, says Mary Harnish, R.N., Saint Mary's Health Care clinical nurse leader.
Protocols a necessity
Most patients' care can be controlled well by floor nurses and physicians, but protocols and order sets are necessary for them to succeed. "I can't minimize the impact our orders have had in ensuring that accurate care is done and the protocols are in place so it makes it easy for the doctors to do the right thing," says Bobbi Presser, Scottsdale Healthcare's service line director for diabetes.
Patient education priority
Education on diabetes survival skills is an essential part of the inpatient stay. Staff nurses usually can provide this education at the bedside, but patients newly diagnosed with diabetes and diabetic patients with access barriers or poor compliance might need extra attention from an expert. Patients who need more diabetes education and training should be referred to an outpatient program. •
Inpatient services must include post-discharge planning. Patients with diabetes should be discharged with a follow-up appointment already scheduled. "Hospitals need to make sure they've got good collaborative partnerships with post-acute care providers and [that] they can rely on them to provide quality care," says Jacquin.
How bariatric surgery might help
Most people think of bariatric surgery as a way for obese people to lose weight. Now word is spreading that it also can put diabetes into partial or even full remission.
"In the past year or so, more people are coming in saying, 'I've got diabetes and I want it taken care of and, by the way, I know I'm going to lose weight because of the surgery,' " says Paul Kemmeter, M.D., medical director of bariatric and metabolic surgery at Saint Mary's Health Care. "A few years ago people were coming in and saying, 'I want to lose weight and, oh, by the way, it would be nice if you could take care of my blood pressure and diabetes.' So I think the focus has changed."
The degree of remission varies depending on the type of procedure, diabetes severity, the length of time the patient has had diabetes, and the parameters used to define remission. A study of more than 4,400 patients at three integrated health systems found that 68 percent of patients who underwent gastric bypass had complete diabetes remission within five years. However, 35 percent of patients redeveloped diabetes, according to the study published in the January 2013 issue of Obesity Surgery.
Patients who don't go into complete remission usually see a lessening of their diabetes severity, Kemmeter says. People with insulin-dependent diabetes often are able to reduce their doses, and those on oral medications often go off them completely. "So, at the very least, if we can offer people better control of their diabetes, we've helped out considerably," he says.
Results are best for patients who have not had diabetes for a long time and whose diabetes doesn't require insulin. "The patients I'm really excited about are the ones who come in and say, 'I'm on three oral medicines, my blood sugar is still out of control, and my doctor says next time I go in and see him, I'm going to be put on insulin,' " Kemmeter says. "You know you're going to get them in control, and more than likely they're going to come off the medications."
Four types of operations are commonly offered in the United States — Roux-en-Y gastric bypass, biliopancreatic diversion with a duodenal switch, sleeve gastrectomy and adjustable gastric banding. Bariatric surgeries, on average, cost from $20,000 to $25,000, according to the National Institutes of Health.
NIH guidelines recommend bariatric surgery only for severely obese people: those with a body mass index of 40 or more or a BMI of 35 or more if they have an obesity-related health problem, such as diabetes. Most insurers cover patients who fall in or near the NIH criteria, established in 1991, Kemmeter says. Medicare covers some surgeries, including gastric bypass, but only in certified facilities and only for beneficiaries who have tried medical treatment unsuccessfully and who have BMIs of 35 or more and an obesity-related co-morbidity.
The NIH criteria were developed using data from the 1980s, when bariatric surgery was an open procedure and was of higher risk for patients, Kemmeter notes. Now most bariatric surgery is laparoscopic, and the mortality risk is much lower. He'd like the NIH to review its guidelines using current data.