Transforming Inpatient Glycemic Management: A System-Wide Approach to Reducing Hyperglycemia and Hypoglycemia

Diabetes affects >37 million U.S. adults and poses major inpatient challenges. Up to 25% of noncritically ill hospitalized patients have diabetes, and many develop stress hyperglycemia. Hyperglycemia and hypoglycemia lead to complications, extended hospital stays, readmissions, and mortality. Our Northern California academic medical center launched a system-wide quality improvement initiative to optimize inpatient glycemic management.

Key interventions included establishing an inpatient glycemic team consisting of endocrinologists and advanced practice nurses, implementing standardized insulin order sets with decision support tools, developing glycemic dashboards, and introducing an intensive care unit pharmacist-comanaged insulin protocol. Education emphasized the importance of evidence-based insulin use and workflow efficiency, including the synchronization of point-of-care (POC) glucose testing, meal delivery, and insulin administration. POC glucose data from acute care inpatients were analyzed over 7 years grouped into early (2017-2019), transition (2020-2021), and mature (2022-2024) phases of the quality improvement program. Glucometrics included percent patient-days with day-weighted mean (DWM) glucose >180 mg/dL, percent days with glucose ≥300 mg/dL, and percent days with hypoglycemia <70 mg/dL and severe hypoglycemia <54 mg/dL, assessed biannually. Logistic regression analysis was used to assess differences between phases.

Hyperglycemia declined significantly: percent patient-days with DWM glucose >180 mg/dL fell from 35.2% to 31.0% (P < 0.001). Percent days with glucose ≥300 mg/dL decreased from 11.3% to 8.4%, hypoglycemia <70 mg/dL dropped from 3.5% to 2.9%, and severe hypoglycemia <54 mg/dL dropped from 1.1% to 0.8%.

A quality improvement strategy incorporating standardized protocols and education sustainably improved glycemic control and safety across a large academic medical center.