Endocrinology team suppressing glycemic incidents
Patients entering a hospital normally anticipate getting well. But people who are dealing with diabetes face particular challenges that can be worsened, even during the delivery of expert medical care.
“There are a large number of factors that must be considered in the care of a patient with diabetes,” said Dr. Sasan Mirfakhraee, Assistant Professor of Internal Medicine who leads UT Southwestern’s inpatient diabetes program. “On average, we manage 40 to 60 patients each day on our service. Furthermore, our work does not end in the hospital, as we must come up with a diabetes plan that would be effective, convenient, and acceptable to our patients for when they ultimately leave.”
The inpatient diabetes program, at William P. Clements Jr. and Zale Lipshy University Hospitals, involves proactive care of diabetic patients undergoing chemotherapy, heart surgery, or treatments that call for steroid use, or organ transplant patients who are diabetic.
In many cases, the team’s 24/7 approach has reduced hyperglycemic and hypoglycemic episodes to about half the U.S. average. These events occur when there is a mismatch between blood sugar and insulin levels – blood sugars are either too high or too low. Because people with diabetes do not make and release enough insulin to keep blood glucose within a safe range, they may require either oral medications or injected insulin. In the hospital, insulin may need to be ordered and the dose personalized for each patient to keep blood sugar in a safe range.
Last year, U.S. News & World Report ranked UT Southwestern as the No. 1 hospital in Dallas-Fort Worth, and diabetes and endocrinology care was ranked No. 25 nationally for 2017-2018. In all, six UTSW clinical specialty areas were rated among the top 50 programs nationally for 2017-2018.
“Diabetic patients who are hospitalized are dealing with a new set of variables,” said Dr. Perry Bickel, Chief of the Division of Endocrinology and Associate Professor of Internal Medicine. “These can include stress, infections, diet changes, new medications, or inflammation related to their hospitalization. Even something as simple as having a meal delayed can trigger a hypoglycemic episode.”
The UTSW Diabetes Management Program depends on the combined efforts of endocrinologists, advanced practice providers, and a diabetes educator to thwart potential hypoglycemia and hyperglycemia in all hospital settings. The faculty physicians – Dr. Mirfakhraee, Dr. Maria Ramos-Roman, Associate Professor of Internal Medicine, and Drs. Sadia Ali and Jessica Abramowitz, Assistant Professors of Internal Medicine – share rotation duties to provide continuous supervision of care delivered by a team of advanced practice nurses and diabetes educators that includes Anitha Litty, Nisha Jacob, Natalie Kerlick, Ampili Jagan, Hilary Trevino, and Nancy Drobycki.
“Most hospitals only have ICU glycemic controls in place. We determined years ago that extra diabetes care needed to be provided for non-ICU patients as well, so UT Southwestern has the program throughout our hospitals,” Dr. Bickel said.
Although there are no national benchmarks, a large study published in Endocrine Practice in 2014 provided data on glycemic incidents at 635 hospitals involving more than 2.6 million patients.
The latest analytics report prepared by the Office of Health System Affairs showed lowered rates at UTSW across all glycemic categories over a 27-month span (January 2015 to the end of March 2017). It is notable that the UTSW was able to achieve significantly lower rates of both hypoglycemia and hyperglycemia in ICU and non-ICU settings at its University Hospitals.
“In the case of organ transplants, we see these patients quickly after surgery,” Dr. Mirfakhraee said. “Glycemic control provided by the diabetes team is an integral part to potentially preventing infections and improving wound healing.”
As part of an effective model of multidisciplinary care and information sharing, team members become familiar with each patient’s history.
“We try to ease their transition back to their homes and arrange for timely follow-up in our clinic. If our patients must return to the hospital for some reason, we don’t want that reason to be their diabetes,” Dr. Mirfakhraee said.
Dr. Bickel holds the Daniel W. Foster, M.D. Distinguished Chair in Internal Medicine.
About UT Southwestern Medical Center
UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty has received six Nobel Prizes, and includes 22 members of the National Academy of Sciences, 17 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The faculty of more than 2,700 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in about 80 specialties to more than 100,000 hospitalized patients, 600,000 emergency room cases, and oversee approximately 2.2 million outpatient visits a year.