title: IMPROVING GLYCEMIC CONTROL SAFELY IN CRITICAL CARE PATIENTS: A COLLABORATIVE SYSTEMS APPROACH IN NINE HOSPITALS.
abstract: OBJECTIVE
  Safely improve glycemic control in the critical care units of nine hospitals.
  
  
  METHODS
  Critical care adult inpatients from nine hospitals with ≥4 point-of-care blood glucose (BG) readings over ≥2 days were targeted by collaborative improvement efforts to reduce hyper- and hypoglycemia. Balanced glucometric goals for each hospital were set targeting improvement from baseline or goals deemed desirable from Society of Hospital Medicine (SHM) benchmarking data. Collaborative interventions included standardized insulin infusion protocols, hypoglycemia prevention bundles, audit and feedback, education, and measure-vention (coupling measurement of patients "off protocol" with concurrent interventions to correct suboptimal care).
  
  
  RESULTS
  All sites improved glycemic control. Six reached prespecified levels of improvement of the day-weighted mean BG. The day-weighted mean BG for the cohort decreased by 7.7 mg/dL (95% confidence interval [CI], 7.0 mg/dL to 8.4 mg/dL) to 151.3 mg/dL. Six of nine sites showed improvement in the percent intensive care unit (ICU) days with severe hyperglycemia (any BG >299 mg/dL). ICU severe hyperglycemic days declined from 8.6 to 7.2% for the cohort (relative risk, 0.84; 95% CI, 0.80 to 0.88). Patient days with any BG <70 mg/dL were reduced by 0.4% (95% CI, 0.06% to 0.6%), from 4.5 to 4.1%, for a small but statistically significant reduction in hypoglycemia. Seven of nine sites showed improvement.
  
  
  CONCLUSIONS
  Multihospital improvements in ICU glycemic control, severe hyperglycemia, and hypoglycemia are feasible. Balanced goals for glycemic control and hypoglycemia in the ICU using SHM benchmarks and metrics enhanced successful improvement efforts with good staff acceptance and sustainability.
  
  
  BACKGROUND
  BG = blood glucose CMI = case-mix index CY = calendar year DKA = diabetic ketoacidosis EMR = electronic medical record GBMF = Gordon and Betty Moore Foundation ICU = intensive care unit IIP = insulin infusion protocol SHM = Society of z Hospital Medicine.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Maynard
authors.forename: Janet
authors.initials: J
authors.lastname: Holdych
authors.forename: Heather
authors.initials: H
authors.lastname: Kendall
authors.forename: Karen
authors.initials: K
authors.lastname: Harrison
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Montgomery
authors.forename: Kristen
authors.initials: K
authors.lastname: Kulasa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000378:metabolism*; D002140:California; D003299:Cooperative Behavior; D003422:Critical Care; D005260:Female; D006761:Hospitals; D006801:Humans; D006943:Hyperglycemia / Q000097:blood* / Q000517:prevention & control*; D007003:Hypoglycemia / Q000097:blood* / Q000517:prevention & control*; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects; D007332:Insulin Infusion Systems; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems / Q000592:standards*; D058996:Quality Improvement
chemical_list: D001786:Blood Glucose; D007328:Insulin