Background: Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown. Methods: This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated. Results: Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 ( P = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; P < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; P = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period. Conclusions: In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.

Background: Insulin pen injectors (“pens”) are intended to facilitate a patient’s self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs. Methods: Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions. Results: 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year. Conclusions: In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.

Background: The American Diabetes Association (ADA) recommends measuring A1C in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1C measurements in hospitalized patients. Methods: We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1C in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1C, (2) more rapid turnaround of A1C results, and (3) an EHR glucose-management tab and insulin order set that included A1C. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1C measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis. Results: Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1C measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention. Conclusions: We demonstrate a novel approach in improving A1C in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.

Background Studies have shown the predictive value of hemoglobin A1c (HbA1c) on inpatient glycemic control, and its value for discharge planning. There is little data on HbA1c testing adherence to American Diabetes Association (ADA) guidelines among inpatient providers, and anecdotal evidence suggests that most inpatient providers do not have a standardized approach to HbA1c measurement. The Lean Six Sigma method is a management system that originated in the automobile industry and has become widely used in healthcare to improve the efficiency of processes. The objective of this study was to determine the impact utilizing Lean Six Sigma methodology to increase frequency of HbA1c measurements among hospitalized patients with a known history of diabetes, in line with ADA guidelines. Methods This was a quality improvement study performed in a 240-bed community hospital, evaluating inpatients (≥16 years) consecutively admitted with a diagnosis of diabetes (ICD-10 code E8-E13 and O24) between January 2016-June 2021. Patients were excluded if they had a HbA1c in the health system electronic health record (EHR) in the prior 3 months. The Lean Six Sigma approach was utilized to define the problem and implement solutions. The intervention bundle delivered between November 2017 and February 2018 included 1) provider and nursing education on the utility of HbA1c in patient care, 2) change in laboratory protocols for more rapid turnaround of HbA1c, 3) modifications to the EHR including a glucose management tab and insulin order set that included HbA1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Demographic characteristics were calculated. Frequency of HbA1c lab sent while inpatient was compared pre- (Jan 2016-Nov 2017) and post-intervention (March 2018-June 2021) using chi-square analysis. Results 17,869 patients were included (7,332 pre- and 10,537 post-intervention). Demographics did not differ between pre and post intervention periods (mean age [range]: 78.1 [16-106] years, sex: 52.3% male, race: 52.1% White, 25.1% Black). Only 53.5% of patients who met criteria had a HbA1c measured during hospitalization before intervention. This frequency increased to 70.2% postintervention. The improvement in the frequency of HbA1c measurement was sustained more than two years following the initial interventions and continued to improve over time. Conclusion This novel approach was successful in improving adherence to guideline-based measurement of HbA1c in hospitalized patients. This is the first quality improvement project in a community hospital utilizing the Lean Six Sigma process for this purpose and may represent a valuable methodology for community hospitals to improve inpatient diabetes care. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.