Introduction and How to Use the Glycemic Control Resource Room

Congratulations on your commitment to improving the care of your patients! This resource room is designed to enhance the efficiency and reliability of your quality improvement efforts in order to close the gap between best practices and what we do in caring for the inpatient with hyperglycemia. The resource room is an online version of the Glycemic Control Implementation Guide and is built on well-proven principles of quality improvement, personal experiences, and evidence-based medicine. A redesign in process, work flow, and information is needed In order to implement effective regimens and protocols that optimize glycemic control and minimize hypoglycemia in your institution.

Essential elements for reaching breakthrough levels of improvement in the care of the hyperglycemic inpatient include:

1. Institutional support for and prioritization of this initiative, expressed as a meaningful investment in time, equipment, informatics, and personnel in the effort.
2. A multidisciplinary team or steering committee that is focused on reaching glycemic targets and on many other aspects of the care of the inpatient with hyperglycemia and/or diabetes and that regularly reports to key medical staff committees.
3. Data collection and reliable metrics that, at a minimum, reflect glycemic control, hypoglycemia frequency, and insulin use patterns. These data should be transformed into reports that inform the team and frontline workers of progress and problem areas to address.
4. Specific aims, or goals, that are time defined, measurable, and achievable.
5. Standardized insulin order sets that promote the rational and evidence-based application of insulin in critical care and non? critical care settings.
6. Algorithms, policies, and protocols that are institution specific and that support the order sets and promote their safest and most effective use. These tools must not merely exist; they must be widely disseminated and used and, in some cases, be embedded in the order set. A high-reliability design should be used to enhance effective implementation. These algorithms, policies, and protocols should outline and guide the caregiver's approach to:
1. Calculating insulin dosages.
2. Recommended anticipatory physiologic insulin regimens for patients with different forms of nutritional intake.
3. Transitioning from infusion to subcutaneous insulin regimens.
4. Caring for patients in other special situations, including periprocedural patients, patients receiving high-dose steroids, patients on insulin pumps.
5. Obtaining and documenting appropriate glucose monitoring data and related testing such as HbA1C values; optimizing data collection and reporting strategies.
6. The recognition, prevention, and treatment of hypoglycemia.
7. The use of oral antidiabetes agents in the institution.
8. Providing optimum nutritional and dietary support.
9. Improving communications and handoffs in this population. Discharge planning, documentation, and follow-up of patients with diabetes, with special attention to patients with newly diagnosed hyperglycemia, as well as optimizing other important transitions in care (such as the perioperative period and the transition from the ICU to the ward).
10. The safe use of insulin and other related medications.
7. Comprehensive education and certification programs for health care providers and patients, reinforcing both general and institution-specific information, including education about the items listed under algorithms, policies, and protocols

How to Use the Glycemic Control Resource Room

The Glycemic Control Resource Room addresses each of these seven elements in some detail. Although it is designed to assist leaders who are starting from scratch, the resource room can also benefit teams that have already made considerable progress, as it is unlikely that any institution is performing optimally in all areas. For a portable version download the Implementation Guide. We recommend that all users initially review the Essential First Steps section and the Analyze Care Delivery Section which will help you assess your current status on all the elements explained in these sections. Completing these sections first will put you in a position to proceed with good institutional support and to intelligently prioritize areas for intervention and allocation of resources.

Although we attempted to present the information in a logical order, one that mirrors a real-life approach, you and your improvement teams should not feel obligated to pore over every detail of every section or to follow the sections in the exact order they are presented. In fact, you will find it difficult to stick to one particular sequential order, and activities presented in different sections often occur in parallel in real life. Your team should eventually assess and attempt to improve the full range of quality issues involving care of the inpatient with diabetes/hyperglycemia.

The resource room incorporates sections of all the essential elements described above to achieve breakthrough improvement. In addition, we highlight important topics and improvement tools such as run charts, process mapping, and methods to hold the gains and spread your improvement methods. Methods for demonstrating financial return on investment are also presented.

The resource room provides links to guidelines, key references, and examples of order sets, algorithms, protocols, and educational materials that can be invaluable to your team. One special word of caution is in order, however. We strongly discourage using these materials to build an order set or protocol that you try to implement without following the general improvement framework presented in the rest of the resource room. This framework calls for a multidisciplinary team effort, specific goals, reliable and practical metrics, and monitoring and learning from variation from your protocol. Ignoring these principles can lead to mediocre results and disillusionment.

Following these methods can enable you to demonstrate the value of quality improvement work to your medical center and insurers, both because of the outcomes obtained and because of the cost savings often inherent in higher-quality care. Demonstrating value in quality improvement and cost savings can lead to protected time for hospitalists and others to improve the quality and safety of the hospitalized patient.