AN INPATIENT DIABETES QI PROGRAM

Objective: The goal of this study was to establish a continuous qualit y improvement (CQI) program for diabetes which would identify patterns in the problems of care encountered by hospitalized patients with dia betes and improve the in-hospital process of diabetes care delivery. R esearch design and methods: The laboratory information system in an ac ute and tertiary care 1,000-bed urban teaching hospital provided us on a daily basis with a list of patients on the medical service having b lood glucose (BG) levels < 40 mg/dl or > 450 mg/dl and positive serum acetones. We performed concurrent implicit chart review when BG levels were hypoglycemic (< 40 mg/dl) or hyperglycemic (> 450 mg/dl on two o ccasions) or when diabetic ketoacidosis (DKA) was present (acetones we re > 1 +) using preset indicators for documentation and appropriate me dical management. Data were expressed as the ratio of number of cases in compliance with the indicator over total number of cases identified . A test for trend in proportions was used to assess compliance with t he indicators over time. Results: Documentation of nursing unit-based capillary blood glucose (CBGM) and insulin infusion monitoring improve d significantly over time (p < 0.001 for both). The medical management of hypoglycemia, hyperglycemia, and DKA improved (p = 0.1) over the t hree-year period. Identification of recurrent multidisciplinary proces s problems in the management of DKA, intravenous insulin infusion cons titution and delivery, CBGM determination in the setting of anemia, an d recognition of clinical settings conducive to the development of hyp o- and hyperglycemia were identified and addressed with standardizatio n in documentation, an insulin infusion protocol, administrative rules , and staff education. Conclusions: Efforts to standardize specific cl inical and documentation processes had a positive impact on the care o f hospitalized patients with diabetes and resulted in an institutional effort to improve inpatient diabetes care with a CQI team.