The challenge: Maintaining the right levels of blood glucose in hospitalized patients with diabetes is notoriously tricky. This chronic condition, which affects 20 percent of the inpatients we see at Montefiore Einstein, is not typically what brings a patient to the hospital. For someone who requires emergency surgery or is experiencing heart failure, managing blood glucose is not the primary concern. But failing to do so can have a negative impact on a patient’s trajectory.

High levels of blood glucose (hyperglycemia) and low levels (hypoglycemia) both carry risks. “It’s a unique situation to have to manage patients with diabetes who are coming in with acute illnesses such as infections, sepsis, or organ dysfunction or failure, all of which can affect a patient’s blood glucose,” says Hanna Lee, MD, associate professor in the division of endocrinology and director of diabetes care for the Moses campus. “There is also a phenomenon called stress hyperglycemia, which can result from an acute medical condition.”

Insulin, the primary treatment, can be hard to order and dose properly. “Insulin can be confusing because there are several types, all of which act differently, and dosing is specific to each patient and changes based on the exact timing of their finger stick, which is how we check their blood glucose levels,” says Sarah Baron, MD, MS, associate professor in the division of hospital medicine and director of inpatient quality for the Department of Medicine. “It’s a time-sensitive, fluctuating situation.”

The solution: In 2019, Dr. Baron and an interdisciplinary team including endocrinology, nursing, pharmacy, information technology, and clinical disciplines across the hospital, embarked on a project to better manage blood glucose levels for inpatients with diabetes during their hospital stays. “The Institute of Medicine outlines six features of high-quality care,” Dr. Baron says. “It should be safe, timely, patient-centered, effective, efficient, and equitable. We saw this project as an opportunity to make an impact in all these domains.”

Dr. Baron, Dr. Lee and the inpatient endocrinology team identified a “sweet spot” (140-180 mg/dl) for blood glucose levels, based on national consensus guidelines. With this target in mind, the project team developed new insulin order sets and collaborated with IT to have them built into Epic.

Everybody made this change together. Any provider who uses this is contributing to better care for all our patients, because this is how we standardize care, using algorithms that have flexibility built in.

Sarah Baron, MD, MS, associate professor in the division of hospital medicine and director of inpatient quality for the Department of Medicine

Previously, if a finger stick revealed a patient’s blood glucose was too high, the nurse would have to contact the provider, who would place a new order for rapid-acting insulin. The new order sets provide guidance that allows nursing staff at the bedside to immediately adjust the amount of insulin given based on a patient’s finger stick results. This also prevents a patient from needing two injections if a higher dose is needed. 

“It’s finger stick-driven, variable and responsive insulin ordering. This eliminates the need for a call between a nurse and a provider, or an Epic chat, which takes up valuable time on both the nursing and the provider side,” says Dr. Baron. “You remove a whole chain of communication, and the patient gets what they need faster.”

The outcome: “The order sets have really increased nurses’ autonomy and made the process more efficient,” says Casilda Adames, NP, one of two nurse practitioners on the inpatient diabetes service at the Moses campus. “They allow nurses to have more confidence in making adjustments based on what they are seeing at the bedside.”

The results speak for themselves. In addition to improving the average blood glucose range to within national benchmarks, from a mean value of 184 to 164, the order sets also closed gaps. “Women used to have worse glucose control on average, and now we see values that are slightly better than men,” Dr. Baron explains. “It also improved equity based on racial differences, narrowing the gap between Black patients and white patients who had similar glucose control, and patients of Hispanic or Latinx descent. Everybody got better.”

The new standard-of-care: Another measure of success is how widely the order sets are used across Montefiore Einstein’s inpatient locations. Prescribers and nurses like using them, and as a result, the process is now embedded as a routine part of care across specialties.

“We've gotten great feedback from residents, clinicians, and nurses,” says Dr. Lee. “There is a lot less ambiguity about what to do if someone's glucose is high. The order sets empower team members, even if they are relatively new to managing blood glucose. They are independently able to take action and react to real life changes based on what they observe in patients.”

A true collaborative effort: “Everybody made this change together. Any provider who uses this is contributing to better care for all our patients, because this is how we standardize care, using algorithms that have flexibility built in,” says Dr. Baron. “Flexibility is key, but this type of electronic clinical decision support has been shown time and again to lead to better and more equitable care.”

“It’s a project that involved the whole hospital, and one that people feel especially good about,” says Adames. “It reminds you we’re working together for a common goal.”