Diabetes care in the hospital: Is there clinical inertia?

BACKGROUND: Effective control of hospital glucose improves outcomes, but little is known about hospital management of diabetes. OBJECTIVE: Assess hospital-based diabetes care delivery. DESIGN: Retrospective chart review. SETTING: Academic teaching hospital. PATIENTS: Inpatients with a discharge diagnosis of diabetes or hyperglycemia were selected from electronic records. A random sample (5%, n = 90) was selected for chart review. MEASUREMENTS: We determined the percentage of patients with diabetes or hyperglycemia documented in admission, daily progress, and discharge notes. We determined the proportion of cases with glucose levels documented in daily progress notes and with changes in hyperglycemia therapy recorded. The frequency of hypoglycemic and hyperglycemic events was also determined. RESULTS: A diabetes diagnosis was recorded at admission in 96% of patients with preexisting disease, but daily progress notes mentioned diabetes in only 62% of cases and 60% of discharge notes; just 20% of discharges indicated a plan for diabetes follow-up. Most patients (86%) had bedside glucose measurements ordered, but progress notes tracked values for only 53%, and only 52% had a documented assessment of glucose severity. Hypoglycemic events were rare (11% of patients had at least one bedside glucose < 70 mg/dL), but hyperglycemia was common (71% of cases had at least one bedside glucose > 200 mg/dL). Despite the frequency of hyperglycemia, only 34% of patients had their therapy changed. CONCLUSIONS: Practitioners were often aware of diabetes at admission, but the problem was often overlooked during hospitalization. The low rate of documentation and therapeutic change suggests the need for interventions to improve provider awareness and enhance inpatient diabetes care.