About the Author(s)
Recent Developments
Patient Safety in Hospital Settings: Blood Glucose Level Monitoring
Nomomi Yagi


Abstract:
Hyperglycemia in hospitalized patients with or without the history of diabetes has detrimental effects resulting in increased morbidity and mortality. A number of professional associations have published empirically developed guidelines to treat inpatient hyperglycemia.

Keywords: diabetes, clinical practice guidelines, patient safety
Published: 16 August 2012
Cite as: Yagi N. Patient Safety in Hospital Settings: Blood Glucose Level Monitoring.
Bull Health L Policy. 2012;1(1): e9.

Introduction

Following acute illness, surgery, and trauma, patients often experience hyperglycemia, an excess amount of sugars in the blood.
1 Prolonged hyperglycemia triggers a cascade of cellular events which can ultimately lead to an increased risk of infection, impaired wound healing, multi-organ failure, prolonged ventilation and hospitalization, as well as death.2 Observational studies have reported the prevalence of hyperglycemia as 41 percent of critically ill patients with acute coronary syndrome, 44 percent of patients with heart failure, and 80 percent of patients after cardiac surgery.3 Identifying and intercepting hyperglycemia as soon as possible is crucial to ensure the best outcomes because in most cases it cannot be predicted or prevented.4

Issue: Safe Management of Hyperglycmia
Clinical Guidelines
To date, numerous randomized-control and observational studies have been conducted to assess the relationship between inpatient hyperglycemia and clinical outcomes.5 Based on the empirical evidence, the first treatment guideline for inpatient glycemic control was published in 2004 by the American College of Endocrinology (ACE), American Association of Clinical Endocrinologists (AACE), and American Diabetes Association (ADA).6 The latest of such efforts is the publication of the consensus statement by AACE and ADA in 2009.7 In the 2009 clinical guidelines, numerous studies were reviewed to assess the optimal glucose target range. However, there was no consensus among studies as to whether aggressive glucose control was beneficial.8 Inconsistent measurement and reporting of blood glucose values were thought to be among the reasons for the lack of concensus.9

Methods of Blood Glucose Measurement

The safe management of hyperglycemia is dependent on the accuracy and reliability of glucose monitoring technology. Clinicians depend on these measurements to make treatment decisions.
10 Currently, point of care (POC) is the most commonly used method for blood glucose monitoring and is completed with a handheld finger-stick glucometer.11 However, there are numerous limiting factors associated with POC.12 It is labor intensive because samples must be taken every 1-4 hours; it cannot be interpolated because patients could be hyper or hypoglycemic between readings; it does not provide the direction of glucose trend (if it is decreasing or increasing at the moment of readings); and it is not capable of predicting glucose values.13 In fact, a recent study shows that 49 percent of hyperglycemia and 39 percent of hypoglycemia were missed in patients by the POC within a ±20 minute window.14

Continuous glucose monitoring (CGM) devices address these POC issues. CGM is capable of obtaining blood glucose levels at set time intervals, eliminating the need of interpolation.
15 While some CGM devices are commercially available, many modalities are still under development.16 Using one of the commercially available CGMs, researchers from the University of Toledo Medical Center in Ohio developed a neural network modeling (NNM) system that incorporates various factors such as vital signs, medications, and nutritional intake for real-time prediction of blood glucose level.17 This research model could predict real-time glucose at a “clinically acceptable” level.18

Future Guidelines
The newest AACE/ADA consensus statement discussed the limitation of POC monitoring and briefly mentioned CGM.19 At the time it was released in 2009, the AACE/ADA taskforce questioned CGM’s practical usage due to the lack of reliability and inhibiting cost, citing the first treatment guidelines published in 2004 and 2006 as its basis.20 However, studies conducted since 2009 suggest that CGM devices may be helpful in monitoring hypoglycemic events in acute care settings.21 In order to exploit CGM capability to its fullest, the technology needs to be tested adequately in acute care settings to validate the accuracy and reliability.22

Conclusion
The accuracy of blood glucose measurement holds the key to successful management of inpatient hyperglycemia. CGM holds many advantages over POC, and its evolution will most likely influence the direction of future hyperglycemia monitoring.

Competing Interests:
None reported
Acknowledgments: None reported

Author(s)
Nozomi Yagi is a first year student in the joint master degree program in Health Law at the University of California, San Diego-California Western School of Law. Ms. Yagi received her undergraduate degree in Biomedical Engineering from the University of California, Irvine.

References (Bluebook)
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Stress Hyperglycemia, 373 Lancet 1798, 1804 (2009).
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American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control, 15 Endocrine Prac. 1, 3 (2009).
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Development of a Neural Network Model for Predicting Glucose Levels in a Surgical Critical Care Setting, 4 Patient Safety in Surgery 1, 1 (2010).
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supra note 5, at 8.
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22. Id.

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