Bedside Teaching

Hospitalist as Teacher:

Pearls for Teaching Inpatient Glycemic Control

The following teaching pearls are used by SHM members to teach inpatient glycemic control to residents and students. Submit your own to: glycemiccontrol@hospitalmedicine.org.

“Every diabetic patient presents opportunities for teaching, even when in control.  Like most, I give an informal teaching session on the order set and principles of glycemic control early in the year.  During daily rounds residents present glycemic control in the 24 hour events and then their plan on the active problem list.  Even with well controlled patients with residents making the correct adjustments, I often add variables and ask how they would adjust their plan.  For example 'the patient will be NPO for _____ procedure, or assume their morning sugar was actually ___, how would you adjust your plan?'  This opens up infinite teaching opportunities for every patient.  It is much more important to me that residents are recognizing poor control and making adjustments daily over micro-managing their specific approaches and dose adjustment amounts.  I offer what I would have done, but usually allow their choices to remain and we evaluate daily if it was effective.”
- Kendall Rogers, MD
Chief, Section of Hospital Medicine
University of New Mexico
Health Sciences Center

“At the beginning of the year, the interns go through a one-hour “boot camp” session on inpatient diabetes.  It’s run by residents in our program in small groups and goes through a series of cases that take them through why the inpatient setting is different than the outpatient setting, what the goals of care are, how to order insulin on the first day, how to adjust insulin, how to write discharge orders, etc.  When I’m on the wards, once we review the principles of management, I’ll take one of our patients with suboptimal control, make a chronological table on the board of all their glucose readings, nutritional intake, and insulin administration for the last 48 hours and have them diagnose the problem and suggest changes to the orders.  I find clinical inertia to be one of the biggest problems on the wards, and by increasing their comfort level with daily insulin adjustment, I find residents more willing to make necessary changes to the insulin regimen.”
-Jeffrey Schnipper, MD, MPH, FHM
Director of Clinical Research, Brigham and Women’s Hospitalist Service
Assistant Professor of Medicine, Harvard Medical School

“When I am attending on one of the resident teaching services, I usually give a talk on managing diabetes and hyperglycemia in the hospital. However, more importantly, I ask the residents to keep diabetes and hyperglycemia on the "active problem list" and to assess the patients' glycemic control on at least a daily basis. Bringing this into our daily rounds emphasizes that diabetes and hyperglycemia require constant management, and leads to many teaching opportunities about glycemic control goals and the best practice for achieving them.”
–David Wesorick, MD
Clinical Assistant Professor, Department of Internal Medicine
University of Michigan

“On the first day of I hand out a laminated pocket card to the team with the in-hospital
glycemic goals on it and the way to calculate the insulin dose based on the patient’s weight. There is a description of basal and bolus insulin dosing, and a review of the insulin choices available. On the back of the card is the ICU protocol and transition to SQ insulin, along with a bit of text on discharge planning. During the first week of the month I give a dedicated lecture to the team specifically focusing on the risks and benefits of tight glycemic control. We round twice daily: we see the pts in the morning and do a computer glucose review in the afternoon to make insulin adjustments. Finally, we try to have the discharged patients follow up within 1 week in with the internist or endocrinologist to assess the efficacy of the discharge regimen.“
-Mary Ann Emanuele, MD
Professor, Department of Medicine (Endocrinology)
Loyola University Stritch School of Medicine

“We try to make glycemic control part of a daily checklist of things to address in rounds (along with decubitus prevention, DVT prevention etc). We use our local algorithm for inpatient management of DM (featured in the Glycemic Control Workbook) as a teaching tool on an almost daily basis. A copy of it is also in the housestaff manual. It’s highly useful because it incorporates the glycemic target, methods for calculating insulin dose, guidance for the distribution of basal and nutritional insulins for each common type of nutritional status, and guidance for the transition for IV insulin infusion to a subcutaneous regimen. We also have found that case-based scenarios (such as those in the SHM Glycemic Control slide set in the Glycemic Control QI Resource Room) are a great way to get the point across on teaching rounds.”
-Greg Maynard, MD, MSc
Chief, Division of Hospital Medicine
Associate Clinical Professor of Medicine, Department of Medicine
University of California, San Diego

“When I am on the inpatient medicine wards, I dedicate one teaching session to inpatient management of hyperglycemia. Before this session I ask my team to read Susan Braithwaithe and Kristin Campbell’s article titled ‘Hospital Management of Hyperglycemia’ from Diabetes Care (we have made this paper available to them. along with other key inpatient medicine articles, in a reference file on the hospital intranet). The next day, I start out with basic discussions about oral meds, IV insulin and subcutaneous insulin (including basal/prandial/correction factor terminology) and then go through sample cases to decide on the most physiologic regimens. After they are convinced that around 50% basal and 50% prandial will give the most flexibility in the hospital and understand when they would want to include “hold” orders, I re-introduce our hospital’s subcutaneous protocol. I use the computer to navigate to where copies can be printed out and take them through the steps of using it. Finally, I demonstrate the on-line dose calculator that one of the pharmacists has created to show how simple the initial calculations and daily adjustments can be. They usually will bring up a few current cases that they are struggling with managing and we work through them. The next time they are on the ward service, they are usually performing at a much higher level with new questions so it is always fresh.”
-Cheryl W. O’Malley, MD
Associate Program Director
Banner Good Samaritan Medical Center
University of Arizona College of Medicine

“I do a case-based discussion with residents in two stages. First, I lead them through therapy for an outpatient with DM Type 1, including basal/bolus and insulin pumps – here we talk about carb counting, and pre-meal and correctional insulin. Next we go through an inpatient with DM Type 2 and ask what is different. Then we talk through the options for treatment, basal/bolus and insulin drips, leading them through some of the foundational evidence, including Van De Berge, DIGAMI, as well as outpatient evidence from UKPDS and DCCT. Finally I show them our protocol and resources to help them with dosing (an internal web-based tool). Then I find one of our diabetic patients and we jointly make a plan for their treatment. I have done this many times as I attend a lot. The students and residents love feeling knowledgeable and always respond when dealing with cases, either real or made up.”
-Kevin Larsen, MD, FACP
Assistant Professor Internal Medicine, U of MN
Associate Program Director, Internal Medicine Residency
Hennepin County Medical Center