title: Barriers to hyperglycemia control in hospitalized patients: a descriptive epidemiologic study.
abstract: OBJECTIVE
  To identify barriers that prevent appropriate control of hyperglycemia in a university teaching hospital and to document their frequency in patients hospitalized for cardiothoracic surgery.
  
  
  METHODS
  In this observational study, our inpatient diabetes team identified barriers to adequate glycemic control for diabetic patients in the cardiothoracic surgical intensive care unit between September 1, 2006, and January 3, 2007. Data were collected through chart review and patient and staff interviews. Blood glucose concentrations greater than 160 mg/dL prompted intervention, which involved speaking to the prescribing practitioner and making a treatment recommendation. Each intervention was reviewed by the diabetes nurses using the critical incident technique. The nurses determined which underlying barriers were responsible for the lack of glycemic control and had necessitated the intervention.
  
  
  RESULTS
  Of 105 patients, 6 (5.7%) demonstrated good glucose control (75% of their blood glucose measurements were 80-160 mg/dL) and did not require intervention, and 99 (94.3%) required intervention. Diabetes nurses intervened 202 times; each patient averaged 2.04 interventions during their hospital stay. Nurses coded 398 barriers to the 202 interventions; each intervention had between 1 and 5 barriers coded as the underlying reason(s) for the intervention. Thirty barriers to adequate glycemic control were identified. Eight barriers represented 74% of the barriers encountered. Therapeutic reluctance was the most common followed by inappropriate titration of medication, lack of basal insulin, lack of weekend staff trained in diabetes management, use of a sliding scale, inappropriate medications being prescribed, knowledge deficit of the weekend staff, and outpatient diabetes medications not being restarted.
  
  
  CONCLUSIONS
  We identified the most frequent barriers to adequate glycemic control in this group of patients and suggest how limited resources should be focused to improve glycemic control. Barrier incidence should be determined in other populations of diabetic patients.
authors.affiliation: Department of Internal Medicine, Hackensack University Medical Center, Hackensack, NJ 07601, USA. JGiangola@humed.com
authors.forename: Joseph
authors.initials: J
authors.lastname: Giangola
authors.forename: Kathe
authors.initials: K
authors.lastname: Olohan
authors.forename: Janet
authors.initials: J
authors.lastname: Longo
authors.forename: Jay M
authors.initials: JM
authors.lastname: Goldstein
authors.forename: Peter A
authors.initials: PA
authors.lastname: Gross
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003920:Diabetes Mellitus / Q000188:drug therapy*; D004334:Drug Administration Schedule; D016021:Epidemiologic Studies; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007297:Inpatients; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital / Q000592:standards; D010348:Patient Care Team / Q000592:standards; D011785:Quality Assurance, Health Care / Q000592:standards; D016896:Treatment Outcome
chemical_list: D007004:Hypoglycemic Agents