Objectives: Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state. Design: Pre-post study. Setting: Large academic medical center in the United States. Patients: Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014. Interventions: High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration. Measurements and Main Results: Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123). Conclusions: Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.
Objective: Examine the impact of vaccination status on hospital cost and course for patients admitted with COVID-19 infection. Design: Retrospective cohort study characterizing vaccinated and unvaccinated individuals hospitalized for COVID-19 between April 2021 to January 2022. Setting: Large academic medical center. Methods: Patients were included if they were greater than 18 years old, fully vaccinated or unvaccinated against COVID-19, and admitted for COVID-19 infection. Patients: 437 consecutively admitted patients for COVID-19 infection met inclusion criteria. Of these, 79 were excluded for unknown or partial vaccination status, transfer from an outside hospital, or multiple COVID-19 related admissions. Results: Overall, 279 (77.9%) unvaccinated patients compared to 79 (22.1%) vaccinated patients were hospitalized with a diagnosis of COVID-19. Average length of stay was significantly lower in the vaccinated group (6.47 days versus 8.92 days, P = 0.03). Vaccinated patients experienced a 70.6% lower risk of ICU admission (OR = 0.29, 95% CI 0.12–0.71, P = 0.006). The unadjusted cost of hospitalization was not found to be statistically significant ($119,630 versus $191,146, P = 0.06). After adjusting for age and comorbidities, vaccinated patients experienced a 26% lower cost of hospitalization compared to unvaccinated patients (P = 0.004). Unvaccinated patients incurred a significantly higher cost of hospitalization per day ($29,425 vs $13,845 P < 0.0001). Unvaccinated patients (n = 118, 42.9%) were more likely than vaccinated patients (n = 16, 20.3%) to require high-flow oxygen or mechanical ventilation (OR = 2.95, 95% CI 1.62–5.38, P = 0.0004). Conclusion: Vaccinated patients experienced a lower cost of hospitalization after adjusting for age and comorbidities and shorter length of stay compared to unvaccinated patients admitted for COVID-19.
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Introduction: Insulin infusion therapy (IIT) is commonly used in the hospital setting to manage diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Clinical evidence suggests that both hypoglycemia and glycemic variability experienced while on insulin infusions negatively impacts patient outcomes. To address these concerns our institutional DKA protocol was revised to include evidence-based targets for glycemic control and to emphasize wide safety thresholds via use of an online infusion rate calculator embedded within the electronic medical record. Extensive, targeted outreach efforts were also employed to increase staff education about the new protocol. The aim of this study was to characterize the impact of a conservative-correction DKA protocol on the prevalence of hypoglycemic events, glycemic variability, and hospital length of stay. Methods: This single-center, retrospective cohort study incorporated a before-after design and included all adult patients admitted with a DKA or HHS diagnosis and initiated on a continuous insulin infusion. Outcome data was collected on 100 subjects in the pre-protocol group (October 2010 -October 2012) and 38 subjects in the post-protocol group (March 2013 -July 2013). The primary endpoint was hospital length of stay (LOS) in hours. Other endpoints included mean absolute glucose change (mg/dL/hr), hypoglycemia (blood glucose < 70 mg/dL), severe hypoglycemia (blood glucose < 40 mg/dL), and ICU LOS. Sample size was determined assuming a 25% reduction in hospital LOS with an alpha of 0.05 and power of 80%. Descriptive statistics, Fischer's exact test, and the paired student t-test were used. Results: A total of 138 subjects with 3187 blood glucose readings were evaluated. Seventy-five (54.3%) of these subjects required admission to the ICU. There was a significant reduction in the risk of hypoglycemia (35% vs. 2.6%) and severe hypoglycemia (4% vs. 0%) when compared to the pre-protocol group. The average number of extreme glucose variability episodes, defined as mean absolute glucose change > 100 mg/dL/hr, were also notably decreased after protocol implementation (3.2 per patient vs. 1.7 per patient). Hospital and ICU length of stay were reduced by 20% and 27% respectively, suggesting that a conservative-correction approach does not delay ketosis resolution or time to discharge. Conclusions: This preliminary data support the hypothesis that a conservative-correction approach to DKA management is safe and effective in minimizing the risk of hypoglycemia and glycemic variability without impacting hospital length of stay.
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