Meet the Glucose Monitoring Team

CSMC takes new approach to managing inpatient hyperglycemia

By Odelia Cooper, M.D., and Philip Barnett, M.D., Ph.D.

Your patient with osteomyelitis is admitted to 7 SE and has a glucose of 200 mg/dl. You add an insulin sliding scale, but the sugars remain in the 200s during the hospital stay.

Q. Is that OK?
A. No.

Q. Should you aim for tighter glucose control?
A. Yes.

Q. Who do you call?
A. The Glucose Monitoring Team.

The team is part of a new approach for managing inpatient hyperglycemia at Cedars-Sinai.

The target populations for this protocol test of change are established diabetics, previously undiagnosed diabetics and those with "stress hyperglycemia."

Studies suggest that hyperglycemia is associated with worse outcomes, and sliding scale insulin alone is insufficient to control hyperglycemia. Therefore, the 2009 American Diabetes Association guidelines recommend the use of insulin to address the basal and nutritional glycemic needs of patients. The association also supports a multidisciplinary team approach in managing inpatient hyperglycemia to reduce significant morbidity and mortality, reduce hospital length of stay and contain cost.

This is how the Glucose Monitoring Team was born. The team is composed of an attending endocrinologist, endocrine fellow, certified diabetes educator and a nutritionist.

The pilot protocol has started on 7 SE to assess the safety and efficacy of subcutaneous insulin treatment of hyperglycemia in non-ICU patients. If a patient's glucose is above 150 mg/dL, the admitting physician will be offered the services of the team by the patient's nurse. The team will use bedtime glargine for basal insulin needs and lispro for bolus insulin at mealtimes.

Novel features of this pilot are:

  • Basal/bolus subcutaneous insulin regimen
  • Carbohydrate counting and correction factors, based on carbohydrates consumed and pre-meal glucose check to calculate prandial (bolus) insulin requirements
  • Administration of "prandial insulin" after the meal
  • All other diabetes medications discontinued

Glycemic targets are less than 140 mg/dL for fasting and under 180 mg/dL for random sugars.

The team will monitor glucose levels and trends and adjust the insulin doses daily to meet the glycemic goals as well as for changes in nutritional status. A certified diabetes educator and nutritionist will see the patient regularly. Upon discharge, the Glucose Monitoring team will provide guidance in follow-up care if requested. Through this protocol, the team hopes to supplement the care of your patients.

For any questions, please contact Dr. Phillip Barnett at (310) 423-3870.

To view a PDF of the protocol, click here.