Why Now is the Time to Prioritize Inpatient Glycemic Management

Updated on November 8, 2020
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By Jordan Messler

More than seven million COVID-19 cases have been recorded in the United States, with over 400,000 of those individuals requiring hospitalization. Unfortunately, it’s safe to assume another spike in cases and hospitalizations are forthcoming this winter, with many states already seeing an increase. To better treat COVID-19 patients today and prepare for future cases, physicians need to use what we’ve learned over the past six months. Doing so could be the difference between life and death. 

What kind of changes do health systems need to make? Take blood sugar levels, for instance. As we’ve learned, individuals living with diabetes aren’t more susceptible to contracting COVID-19, but they have worse outcomes. In fact, a recent study showed that mortality rates for hospitalized COVID-19 patients with diabetes were four times greater than those without. Even more surprising was that mortality rates were seven times higher for people without diabetes who then experience high blood sugar during their hospital stay. 

Proper glycemic control has been linked to improved outcomes across various conditions. Based on early studies, the same seems to be true for COVID-19. And even though glycemic care may not have been top of mind for clinicians in March, studies continue to show it’s a critical aspect of care. This concept becomes even more important as governing bodies issue new treatment guidelines.

How Treatment Can Alter Blood Sugars

In early September, the WHO issued treatment guidelines calling for corticosteroids to become the standard of care for patients with critical COVID-19 cases. Dexamethasone has received much interest after the RECOVERY study showed the mortality reduction in COVID-19 patients that required oxygen. The importance of steroids in the management of COVID-19 drew more attention recently when it was administered to the President during his stay at Walter Reed National Military Medical Center.

The discovery of dexamethasone’s ability to help patients fight COVID-19 has provided hope as we hope for other treatments, and ultimately a global vaccine. It also shines a light on how much has changed over the past six months from a treatment perspective. And not applying and prioritizing these learnings to current treatments could create trouble for patients and providers alike. 

While dexamethasone supports critically ill patients, like other steroids, it raises blood sugars, even in patients who do not have diabetes. Moreover, critically ill patients may also require artificial nutrition during hospitalization – another factor that alters blood sugar. Given what we know about mortality rates for people who unexpectedly experience high blood sugar, this is potentially very dangerous. 

Enhancing Care Moving Forward 

In a perfect setting, providers are able to consider every single symptom and possible treatment option. With a once-in-lifetime pandemic, though, providers were forced to triage care and focus on a myriad of symptoms before blood sugar – and that makes sense. 

When a patient is having trouble breathing with declining oxygen levels, doctors are going to explore respiratory issues and prioritize if a ventilator is needed or not. Doctors, nurses and other first responders faced the impossible task of caring for patients with a disease they knew very little about. 

But as we learn more, we can improve the quality of care and wellbeing of patients with enhanced care based on evidence. We now have the advantage against the disease of knowing what we didn’t know in the early months of 2020. So much information on the relationship between COVID-19 and glycemic characteristics have surfaced since March. 

And it’s time for this evidenced-based approach to extend beyond COVID, too. We have a vast array of information on the adverse relationship between glycemic management and other medical conditions, from heart attacks to sepsis. While providers will always attend to the primary condition first, monitoring blood glucose and keeping a patient in range should be a very close second. Since up to 40% of patients in the hospital setting have challenges with glucose management, it’s an issue that deserves much more attention. 

Now is the time for hospital leaders to focus on treating glycemic management as aggressively as other symptoms and prioritizing treatment as a key component of care. Doing so has the potential to reduce the mortality rate for patients with and without diabetes. 

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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