Glucometrics – the system-wide analysis of inpatient glucose data – should be of fundamental interest for hospital administrators striving to improve the outcomes of their patients.
Why is this data so important? Proper glycemic control has been linked to improved outcomes and decreased length of stay time and time again across a myriad of conditions – whether it’s someone recuperating from a heart attack, battling pneumonia, or recovering from surgery.
The U.S. health system lacks standards and processes to track this data, and the coronavirus pandemic is bringing that weakness into full focus. While there are bright spots among a number of health systems that have taken it upon themselves to track and measure glucometrics, they are the outliers.
Pre-pandemic studies revealed that one in every three US hospitals didn’t have the technology systems to measure glycemic outcomes. Of those that did, nearly 60% didn’t have processes to extract or analyze data collected. As this once-in-a-century pandemic beset hospitals across the country and world, the lack of attention paid to inpatient glucose management has had a costly impact.
A recent study revealed that hospitalized COVID-19 patients with diabetes have a mortality rate four times greater than those without. Furthermore, mortality rates were seven times higher for people without diabetes, who experienced high blood sugar during their hospital stay.
On average, somewhere between 30% and 40% of hospital patients have diabetes or experience hyperglycemia, making glycemic management an issue that touches every department. With such a broad impact and clear association with poor outcomes, it might be difficult to understand why providers have not yet addressed it. The lack of standard metrics and benchmarks is one major reason.
Standardizing Glycemic Data KPIs and Benchmarks
Many hospitals track the percent of blood glucose checks done at their facilities that are high or low. Other health systems track high or low readings against patient days and some even track against patient stays. These metrics can look wildly different and therefore be interpreted (or misinterpreted) in many different ways.
This points to two key related problems: the lack of pre-defined and well-understood KPIs and the related problem of no industry benchmarks for these KPIs.
For example, say an ICU patient is receiving 20 blood glucose (BG) checks per day, a fairly standard regimen for someone on an IV insulin drip. If that person’s stay lasted five days they’d receive a total of 100 BG checks, meaning that if one check was severely low it would equate to 1% of checks. But if you’re counting days, one out of five days with severely low blood glucose would be a patient-day metric of 20%. And if you use a patient-stay metric, you are now at 100%. Wow, from 1% to 100%, same patient, same BGs. I think your administration would pay more attention if they knew 100% of patients experience hypoglycemia versus being told 1% of readings are low. That 1% should be reinterpreted as well, as it could easily be 10,000 hypoglycemia BGs per year in a large health system.
Without a specific set of standards, hospitals will continue to measure, analyze, treat, and discuss glycemic management in different ways. It’s easy to see why glucometrics could cause confusion, why standard metrics are essential, how they could significantly impact the quality and cost of care across the U.S. health system, and how technology could help. However, with COVID-19 as a potential long-term reality, it’s not the only challenge facing glycemic management.
While many hospitals have some of this data available, it’s often siloed in different systems, owned by different units or personnel roles, and often only viewable at a patient level. This inability to aggregate hospital-wide or unit-wide data prevents meaningful analysis and insight into overall patient care.
Impact on Care Beyond Glucometrics
Think back to the example of people in the ICU who should be getting up to 20 checks per day, or better yet, hourly checks on blood sugar levels. Or even consider non-ICU settings, where checks are less frequent but still happen four to five times a day and usually coincide with meals. In the era of COVID-19, shortages of personal protective equipment (PPE) and the risk of providers’ exposure are challenges that can impact the frequency of these checks.
Add limited blood glucose data on top of the lack of standards or benchmarks and the picture gets really murky. With the fact that this impacts up to 40% of hospital patients and is associated with high mortality rates for patients with COVID and other conditions, the picture is even worse.
Many hospitals are taking it upon themselves to overcome these challenges. For example, some are bundling care by having nurses split duties to ensure they get the blood glucose data they need to provide optimal care. In this situation, nurses conserve PPE by having one nurse check blood sugar levels in patient rooms while another inputs data and draws the insulin outside the room.
The fact that the FDA is temporarily allowing Continuous Glucose Monitoring (CGM) systems to be used in hospital settings is a much more sustainable solution. This technology enables providers to remotely monitor and track blood glucose levels continuously throughout the day. It helps meet the standard of care without exposing staff and utilizing excess PPE. Linking insulin dosing software to these systems to analyze the vast amount of blood glucose measurement data available and deliver personalized insulin doses has been an even more powerful development. In the ICU, providers can even use this software to adjust an IV insulin’s drip rate outside the patient’s room.
While these solutions cannot replace human interaction, they are examples of how technology can help reduce the burden and exposure to front line workers. However, until the U.S. health system can standardize data collection, best practices for care, and the technology needed to support both, glucometrics will continue to be the missing data set in the fight against COVID-19.
About Jordan Messler
Jordan Messler, MD, SFHM, FACP is the Executive Director, Clinical Practice with Glytec. He trained in internal medicine at Emory University in Atlanta, and subsequently served as an academic hospitalist at Emory University for several years after residency. He is the former medical director for the Morton Plant Hospitalist group in Clearwater, Florida (serving BayCare Health), where he continues to work as a hospitalist. He is the current physician editor for the Society of Hospital Medicine’s (SHM) blog, The Hospital Leader. In addition, he previously chaired SHM’s Quality and Patient Safety Committee and has been active in several of their national mentoring programs, including Project BOOST and Glycemic Control. He has talked at national conferences on a variety of topics such as teamwork in the hospital, quality and patient safety, the history of hospitals, and mentoring quality improvement projects.