An Evidence-Based Protocol for the Assessment and Management of Glucocorticoid-Induced Hyperglycemia.

Abstract

Glucocorticoid-induced hyperglycemia (GCIH) has been associated with negative patient outcomes. Oncology inpatients are particularly affected by GCIH, as they are prescribed highdose glucocorticoids (GC) during their hospitalization. Yet, organizational data highlights variability in treatment, suboptimal glycemic control, and a gap in the timeliness of therapy. The purpose of this Doctor of Nursing Practice (DNP) project was to improve GCIH assessment and management for oncology inpatients receiving GCs. The Iowa model was used as the guiding framework for translating evidence into clinical decision-making for this project. An evidence-based protocol that included a Best Practice Advisory (BPA) within the electronic medical record and a standardized algorithm was developed and implemented. The goal was to immediately initiate blood glucose monitoring (BGM) and sliding scale insulin (SSI) therapy in concurrence with a GC order to promptly detect and treat GCIH, thereby reducing uncontrolled hyperglycemia rates. Average length of stay (ALOS) days were also evaluated to assess for any correlations with Diabetes Team consults and uncontrolled hyperglycemia rates. The sample group within a four-month period comprised of 49 patients with hematologic malignancies who were prescribed GCs. The results revealed an improvement in BGM orders, Diabetes Team consults that met criteria, total uncontrolled hyperglycemia episodes, and hypoglycemic events. There was a decrease in SSI orders and an overall increase in ALOS by six days. A trend in more prolonged hospitalizations was noted in patients with uncontrolled hyperglycemia. The data was not strong enough to produce conclusions for both process and impact evaluations. It is possible that a Hawthorne effect occurred as a result of a recurrent discussion of this project at multiple meetings. It is challenging to infer a direct correlation of ALOS with Diabetes Team consults due to many potential influential factors. Improvement in GCIH detection and management resulted in a reduction of uncontrolled hyperglycemic episodes. Further benefits associated with GCIH management need to be explored with larger samples. Limitations included sample size and time, patient right to refusal of care, staffing considerations, variance in clinical judgment and preferences for administrative autonomy, and factors impacting ALOS and hyperglycemia.