Early subspecialist involvement led to reduced infections among inpatients with diabetes

Early identification and management of inpatients with diabetes by subspecialist teams decreased hyperglycemia and hospital-acquired infections, a study found.

Researchers studied an early intervention model of care in which an inpatient diabetes team electronically identified patients with hyperglycemia and aimed to provide bedside management within 24 hours of admission, compared with usual care with a referral-based consultation service. The Australian trial was conducted on eight wards among 1,002 consecutive inpatients with diabetes or new hyperglycemia (5,447 patient-days). After a 10-week baseline period in which all clusters received usual care, clusters were randomized to early intervention or usual care for 12 weeks. Results were published March 28 by Diabetes Care.

With early intervention, more patients received subspecialist diabetes management (92% vs. 15%, P<0.001) and new insulin treatment (57% vs. 34%, P=0.001). A primary outcome of the study was the number of adverse glycemic days, defined as patient-days when glucose levels went below 4 mmol/L (72 mg/dL) or above 15 mmol/L (270 mg/dL). At the cluster level, incidence of such days decreased by 24% from 243 to 186 per 1,000 patient-days in the intervention arm (P<0.001), with no change in the control arm.

At the individual level, the adjusted number of adverse glycemic days per person decreased from a mean of 1.4 to 1.0 days (−28% change; 95% CI, −45 to −11%; P=0.001) in the intervention arm, with no significant change in the control arm. The patient-day mean glucose level decreased from 9.4 mmol/L to 9.0 mmol/L (169 mg/dL to 162 mg/dL, P=0.003) in the intervention arm, while remaining stable in the control arm.

The proportions of patient-days with a mean blood glucose level greater than 10 mmol/L (180 mg/dL) and 15 mmol/L (270 mg/dL) decreased by 14% and 55%, respectively, in the intervention arm, with no change in the control arm. The proportion of good diabetes days, defined as patient-days with no blood glucose level measurement below 4 mmol/L (72 mg/dL) and no more than one blood glucose level measurement above 11 mmol/L (198 mg/dL), increased in the intervention arm (from 70% to 74%; P=0.020). There was no change of note in the control arm (65% to 66%; P=0.61).

Incidence of hypoglycemia did not change in either treatment arm. The proportion of individuals with hospital-acquired infections decreased (6.4% to 2.4%; P=0.035) in the intervention arm but did not change significantly in the control arm (8.6% to 7.0%; P=0.61). Early diabetes management conferred a lower risk for hospital-acquired infection (adjusted odds ratio, 0.20; 95% CI, 0.07 to 0.58; P=0.003). The number needed to treat to prevent one hospital-acquired infection was 25.

Potential limitations include “relatively few clusters and some differences in patient characteristics between clusters as a result of hospital structure with nonsymmetrical specialist medical and surgical wards,” the authors said. The study used a mixed-effects model, which accounted for clustering and adjusted for baseline patient characteristics, but residual confounding was still possible.

The results provide evidence that early intervention models of diabetes care in the hospital improve glycemia and patient outcomes, according to the study authors. “With the increasing prevalence of diabetes and complexity of hospital care, hospital clinicians should concentrate on early identification and management to improve the care of people with diabetes,” they wrote.