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Diabetes is undertreated among inpatients, especially acute care patients, sometimes with devastating results. "Blood glucose levels are too often not treated as intensively as other medical conditions among floor patients," said Almut G. Winterstein, Ph.D., assistant professor of pharmacy health care administration at the University of Florida College of Pharmacy. "If hospitals made a more aggressive effort, it could save quite a significant number of lives."
Such efforts could include hiring clinical pharmacists who are certified in diabetes care, said Winterstein. "There is a push now for hospitals to hire pharmacists trained in the administration of the anticoagulation drugs warfarin and heparin," she said. "That is because over- or underdosing those two drugs is so dangerous. Insulin is analogous."
That study's conclusions were reinforced recently in a joint position paper by the American Association of Clinical Endocrinologists (AACE); the American College of Endocrinology (ACE), which is the scientific and educational arm of AACE; the American Diabetes Association (ADA); and 10 other professional organizations. It listed existing barriers for proper treatment of diabetes patients and patients who may become diabetic while hospitalized. They include: insufficient knowledge among healthcare professionals, including pharmacists, about how to manage blood glucose; poor tracking of glycemic control in hospitals; a need for more intensive nursing care; and fear that aggressive insulin therapy puts patients at high risk for hypoglycemia.
The position paper also outlined specific recommendations to overcome these barriers, including:
Health-system pharmacists, especially clinical pharmacists, should address each of those problems and help implement solutions, said ASHP's Mohassel. "When practicing in this type of setting, all pharmacists have the responsibility to educate themselves about diabetes," she said. "In turn, the education of nurses and other staff about the importance of glycemic control becomes a vital role."
Blood glucose levels do not have to be extremely high for hyperglycemia to be dangerous. Winterstein, who has studied the management of diabetes in hospital settings for nearly a decade, said that even blood glucose levels consistently as high as 150 mg/dl can be dangerous, resulting in sepsis. She pointed to a seminal report in the Nov. 8, 2001, issue of the New England Journal of Medicine that found that "intensive insulin therapy to maintain blood glucose at or below 110 mg/dl reduces morbidity and mortality among critically ill patients in the surgical intensive care unit."