By Jordan Messler
Since the start of the coronavirus pandemic, government agencies warned that individuals living with diabetes are at an increased risk of severe illness from COVID-19. Scientific reports, like the analysis my organization Glytec published in April, have measured the outcomes of hospitalized COVID-19 patients with diabetes or patients experiencing hyperglycemia throughout their stay. The results indicate that poor glucose management is related to worse outcomes.
Our April research showed mortality rates for hospitalized COVID-19 patients with diabetes were four times greater than those without diabetes. What was more striking, however, was that mortality rates were seven times higher for people without diabetes who then experienced hyperglycemia during their hospital stay.
These findings pushed our team and trusted clinical partners to dig even deeper and investigate outcomes based on whether patients achieved glycemic control or not during their hospital stay. We analyzed this “opportunity window” for hospitalized COVID-19 patients with diabetes or hyperglycemia. In December 2020, we published the first study to address this critical question. The results suggested a higher risk of mortality for patients that did not achieve target blood glucose levels soon after admission, within the expected opportunity window for achieving glycemic goals by the first 48 to 72 hours of a patient’s stay.
Defining the Opportunity Window
The peer-reviewed research, published in Diabetes Care, the journal of the American Diabetes Association, analyzed pooled data from 91 hospitals in 12 states accessed through the Glytec national database. The study ran from March 1 to May 8, 2020. After omitting patients admitted for less than 24 hours, children under the age of 18 and active admissions, we analyzed data from 1,601 patients.
Patients were categorized according to achieved mean glucose category in mg/dL during days 2–3 in non-ICU patients or on day 2 in ICU patients.
The results showed that more than half of patients in both the ICU (56%) and non-ICU (53%) did not achieve target blood glucose levels within the first two or three days. Those patients that remained with severe hyperglycemia after 48 to 72 hours had a sevenfold mortality risk. The study found that achieving target blood glucose within the first two days of admission was associated with reduced mortality.
Putting the Data to Use Today and in a Post-Pandemic World
As we surpass a full year of the global pandemic, these critical findings armed hospitals with actionable insights to improve patient outcomes that weren’t available in March 2020. While frontline workers manage countless priorities, they need to understand the importance that timely blood glucose management plays in treating hospitalized patients with COVID-19.
And while the vaccine roll-out continues to bring hope and promise to hospitals, patients and citizens across the globe, there is still plenty we can learn about treating this virus that can influence care delivery and help save lives. The impact of glycemic management is one of the critical factors providers can better understand.
As we look towards the future, health systems still need to remember that for many conditions beyond COVID-19, like sepsis, coronary disease, pneumonia, stroke and the critically ill, hyperglycemia on admission is a marker for worse outcomes. Time and again, research showsthat good glycemic management during the hospital stay leads to better outcomes.
Adhering to glycemic management best practices can help streamline processes and workflows, decrease time to target range and improve patient outcomes.
So, what are these clinical best practices?
The Essential Steps for Achieving Glycemic Control
The most effective way to manage glycemic levels for any hospitalized patient is with efficient monitoring and personalized insulin doses based on blood glucose readings and other critical factors.
However, our analysis shows that more than 90% of doctors, practitioners and nurses today rely on one-size-fits-all insulin protocols and pocket cards to determine appropriate insulin doses for hospitalized patients.
Not only are these simplistic approaches outdated, error-prone and difficult to scale, but they’re discouraged by organizations like the American Diabetes Association, the American Association of Clinical Endocrinologists, and other leading authoritative bodies and researchers.
Most experts today will provide the following standard recommendations for patients that need insulin therapy:
- Insulin should be used for most hospitalized patients with hyperglycemia
- Continuous intravenous insulin infusion should be utilized to treat persistent hyperglycemia for critically ill patients
- Intravenous insulin infusions should be administered based on validated written or computerized protocols that allow for predefined adjustments in the infusion rate, account for glycemic fluctuations and achieve low rates of hypoglycemia
- Use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged
- A basal insulin or a basal plus bolus correction insulin regimen with mealtime adjustments as warranted is preferred to treat noncritically ill hospitalized patients
- Health systems should transition patients to subcutaneous insulin schedules using institutional protocols before discontinuing intravenous insulin infusions
These recommendations just scratch the surface of advanced glycemic treatments, but they’re a step in the right direction. While change is always difficult, the coronavirus pandemic further illuminated how vital glycemic management is for hospitalized patients. In order to meet glycemic goals during opportunity window for today’s COVID-19 patients and hospitalized patients in a post-pandemic world, we must focus on adopting these standards of care at every health system across the globe.
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.
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