Virtual Glucose Management System

Robert Rushakoff reviews patient glucose levelsWhen patients are hospitalized, their outpatient diabetes medications are frequently stopped out of concern for drug interactions and changes in diet for test and procedures that may result in hypoglycemia. This can lead to large fluctuations in a patient’s glucose level in a hospital.

Without restarting the patient’s home medications, busy clinicians are often left without a clear answer on how to manage glucose control in the hospital. UCSF’s answer? An innovative virtual glucose management service (vGMS) for hospitalized patients with diabetes.

The system, which was developed by UCSF diabetes specialists, combines an automated daily report of all patients experiencing high or low glucose levels, with individual reviews by a trained diabetes specialist via the electronic medical record (EMR). These are integrated into each patient’s record, along with a program that customizes ideal insulin levels based on whether the patient has eaten, or other factors. Together, these enable providers who are not diabetes specialists to immediately assess the correct amount of insulin to provide.

“With this new system, there has been a 39 percent decrease in patients on the daily high-glucose hospital report,” said lead author Robert Rushakoff, MD, MS, professor of medicine at UCSF and medical director for inpatient diabetes at UCSF Medical Center. “The vGMS and similar inpatient-services leveraging technology may also become economically important for cost savings, as medicine moves toward bundled care.”

Diabetes (hyperglycemia) causes blood glucose (sugar) levels to rise higher than normal. More than 29 million Americans, or about 9.3 percent of the population, are living with diabetes, and an estimated 86 million are living with prediabetes, a serious health condition that increases the risk of diabetes, according to the U.S. Centers for Disease Control and Prevention. About a third of hospitalized patients have diabetes, which is associated with increased risks for complications, length of stay, costs of care and mortality. Blood glucose levels in inpatients often exceed recommended targets due to low priority given to glycemic control, suboptimal regimens chosen for simplicity over effectiveness and difficulty titrating insulin in acutely ill patients. Diabetes treatment also can cause hypoglycemia, or low blood sugar levels, which is linked to mortality, increased likelihood of readmission and longer hospital stays.

Diabetes specialists and inpatient diabetes teams performing formal consultations can reduce length of stay and improve glycemic control and clinical outcomes, but these are time and resource intensive.

vGMS Simplifies Diabetes Management Process

Rather than rely on manual contact of clinical teams individually, the research team of diabetes specialists developed an electronic method to convey recommendations via a new glucose management note. The automated glucose reports, clinician review and clinical notes combined to create the vGMS.

The vGMS system generates an automated daily report by 5:30 each morning of all inpatients with uncontrolled blood glucose. The report is then reviewed remotely by a diabetes specialist, along with an insulin/glucose chart, via the EMR. Together, these elements contain sufficient information about the patient’s insulin regimen to make appropriate recommendations without interviewing the patient.

The vGMS template includes drop-down boxes with specific recommendations based on whether the patient was eating or receiving glucocorticoids or enteral feedings, followed by suggested insulin doses. The note, which is available for clinician review by 6:30 a.m. daily, also includes a disclaimer that it is solely a recommendation, and advises the treating team to take into account the patient’s current clinical condition and obtain a formal endocrinology consultation if necessary.

As a result, the proportion of hyperglycemic patients decreased 39 percent, from 6.6 per 100 patient-days in the pre-vGMS period to 4.0 in the vGMS period. The hypoglycemic proportion in the vGMS period was 36 percent lower than in the pre-vGMS period. Overall, 40 severe hypoglycemic events occurred during the pre-vGMS period and only 15 during the vGMS period.