Challenges of inpatient diabetes care

“We’d rather have the blood sugar be 400 than 40!”

Over the years I have practiced in a variety of settings, from small town rural hospitals to large academic medical centers. I cannot recall how many times I have heard such a comment or a similar one. Resistance to aggressive inpatient diabetes management seems to be present everywhere.

Our diabetes team was once asked to see an inpatient with type 1 diabetes. She had been having severe hypoglycemia but was on sliding scale insulin only. Her situation was complicated by sepsis and acute renal failure. We started an IV insulin drip. However, overnight the hospitalist discontinued the drip. Instead, he ordered sliding scale insulin at doses we might use for a patient with insulin-resistant type 2 diabetes rather than insulin-sensitive type 1. Not surprisingly, the patient again had hypoglycemia.

We strongly urged for the insulin drip be reinitiated. The hospitalists declined. They wanted us to continue to manage the diabetes but with subcutaneous insulin only. We finally signed off the case in frustration.

Diabetes is common in the hospital. For every two inpatients with known diabetes, there is another with new hyperglycemia. Consensus statements have been written and glycemic targets suggested. More recent data suggests that perhaps we do not need to pursue as aggressive glycemic targets as had been previously recommended. Nevertheless, poor inpatient control is associated with prolonged length of stay, increased cost of hospitalization and higher rate of complications.

Insulin is a high-risk medication and a frequent source of medical errors. Some of the reasons include use of sliding scales, lack of basal insulin, reluctance to use IV insulin drip, infrequent blood glucose testing, confusion regarding timing of insulin related to food intake and lack of training or knowledge among hospital staff.

One means to reduce errors and improve safety is to use consistent protocols throughout the facility. A website I have found useful is the American Association of Clinical Endocrinologists Inpatient Glycemic Control Resource Center. However, clinical inertia can be difficult to overcome. There is often great reluctance to change practice.

I remember an inpatient diabetes committee meeting a number of years ago. We were attempting to develop protocols for the use of IV insulin drip and subcutaneous insulin. Suddenly, one of the physicians interrupted, “The nurses are too stupid to follow any protocol!” He said this in the presence of nursing staff. I was shocked. No one pointed out how inappropriate a statement that was. We never formalized diabetes protocols for that hospital. I eventually relocated to practice elsewhere.

Inpatient diabetes management is best achieved through a collaborative effort by a dedicated team of interested professionals. However, with attitudes such as I have described above, how can such a team succeed? I know that my experience is not unique. Nevertheless, endocrinologists and diabetologists must continue to advocate for excellence in diabetes care, even if it is unpopular or conflicts with the opinions of others.