The decision to transfer a patient to the intensive care unit (ICU) from a general care setting is complex and based not only on clinical findings and patient wishes but also on the understanding that ICU resources are limited and costly.1 Adding to the decision‐making complexity is the knowledge that patients who transfer to an ICU from a general medical unit comprise the highest mortality group of ICU patients, with the mortality rate directly proportional to both the time spent on the general medical unit1, 2 and the number of physiologic abnormalities before ICU admission.3, 4

Prior studies have shown that cardiac arrest and unplanned (unexpected) transfers to the ICU are preceded by a period of physiologic instability reflected in the vital signs.510 However, vital signs alone may not accurately indicate clinical condition. For example, a person may be able to maintain normal blood pressure and heart rate despite severe illness or may have abnormal vital signs at baseline, which may be the case for an otherwise healthy young woman who has baseline low systolic blood pressure. Also, noncritical conditions commonly seen in hospitalized medical or surgical patients, such as anxiety or pain, may increase the respiratory rate or heart rate. Conversely, certain common medications, such as ‐blockers, may mask or blunt the normal physiologic response to illness. Overall, the prevalence of abnormal physiologic variables is high among hospitalized adult patients irrespective of the presence of serious adverse events.11 This prevalence may be a reason why 2 recent studies of inpatient medical emergency teams (METs) or rapid response teams (RRTs), which generally rely on vital signs for activation, failed to show a decrease in adult mortality rates.12, 13

Given the complexity of interpreting single vital sign readings, we evaluated a simple and clinically intuitive variable, the shock index (SI) (heart rate/systolic blood pressure, a noninvasive indication of left ventricular function),14 as a potential marker of the need for intensive care. Allgwer and Burri14 first developed the SI in studies of patients with acute blood loss, intraabdominal bleeding, fat emboli, and severe infections. They observed that a healthy adult had a mean SI of 0.54 (standard deviation [SD], 0.021), while an index of 1.0 indicated threatened shock and indices greater than 1.5 were seen in volume‐deficient shock.

We hypothesized that an elevated SI is a differentiating factor between a patient who had an unplanned ICU transfer and a general medical patient who did not require this higher level of care. To our knowledge, the SI has not been studied for this application previously.

Patients and Methods

Results

A total of 50 pairs of matching cases and controls was included in this study. Table 1 lists the source of admission, demographic characteristics, and numbers of deaths for cases and controls. There were no statistically significant differences in admission source, age, sex, ethnicity, admission care unit, or Charlson Comorbidity Index. Mean length of stay was 14.8 days (SD, 9.7 days) for the cases and 5.7 days (SD, 6.3 days; P < 0.001) for the controls. Admission diagnoses were classified on the basis of the organ system of involvement (Table 2). In 30 of 50 cases, the admission diagnosis and the reason for ICU transfer were related.

We reviewed the vital signs and shock indices for the 24 hours before ICU transfer for each case and over the entire hospitalization for each control, to determine the worst set (the lowest systolic blood pressure and the highest heart rate, respiratory rate, and SI). The cases had 1 to 22 complete sets of vitals for the 24 hours before ICU transfer; the median number of sets was 3 and the mean was 4. The controls had 1 to 12 complete sets for the 24 hours before the worst SI: the median was 3 sets and the mean was 3. In 26 of 50 controls, the worst SI occurred within the first 24 hours after admission. There was a significant difference between the median values of the worst shock indices of the cases and the controls (0.87 vs. 0.72; P < 0.005).

Table 3 shows the different values of the SI and the corresponding odds ratio of unplanned ICU transfer for cases compared with controls. The difference was significant at an SI of 0.85 and greater, indicating a strong association with unplanned ICU transfer.

We also found that the patients who transferred to the ICU had a greater number of inpatient deaths (9 cases vs. 1 control; P = 0.008), which would be expected, but there was no difference in 30‐day or 6‐month mortality rate (Table 1). One patient died after 30 days and while still hospitalized.

Comparison between the temporal trend of vital signs and the SI of the cases for the 24 hours before ICU transfer is shown in Figure 1. This graph shows the median of all the worst values (minimum systolic blood pressure and maximum SI, heart rate, and respiratory rate) over the four 6‐hour time periods (24 hours) preceding ICU transfer. Of note, the change in vital signs is subtle even while the SI increased to more than 0.8 as the patients clinically worsened before transfer.

Figure 1

Discussion

In our comparison of the SI of 50 patients who required unplanned (unexpected) transfer to the ICU with the SI of 50 matched controls who did not require this higher level of care, we found that a SI of 0.85 or greater was significantly associated with unplanned transfer to the ICU. The cases had a significantly higher worst SI than the controls, and they also had a significantly longer hospital stay and higher inpatient mortality rate, as would be expected for a sicker patient population. These findings are important given that the SI may be useful for assessing illness severity, for helping determine the need for transfer to the ICU, or for activating METs or RRTs.

A major problem with providing optimal care for hospitalized general medical patients is the inherent difficulty in determining illness severity and clinical decline, especially when the decline occurs gradually. Existing consensus recommendations for ICU admission include both specific diagnoses and arbitrary objective criteria based on abnormal vital signs and laboratory values.27 Also, individual institutions may have their own ICU admission requirements, which may differ from these or RRT criteria. Although vital signs are important as a snapshot of basic physiologic function, a number of noncritical conditions may lead to abnormal vital signs, and not all abnormal vital signs are associated with an adverse clinical event. By relying solely on vital signs, clinicians may not recognize critical illness and therefore not transfer a patient to the ICU or may inappropriately transfer a patient who does not need ICU‐level care.

Markers of illness severity other than vital signs, such as the Acute Physiology and Chronic Health Evaluation (APACHE) score, have been shown to predict the death of ICU patients17, 18 but have been rarely studied outside the ICU setting.19 Also, calculating the APACHE score is cumbersome, and there is no cutoff score that defines when a patient should be transferred to the ICU. Subbe et al.,20 in their study to identify critically ill patients, found that introduction of a physiological scoring system (including MET or RRT activation scores) would have identified only a small number of additional patients as critically ill. Another common marker of illness severity, the 4 criteria of the systemic inflammatory response syndrome (temperature <36C or >38C; heart rate >90 beats per minute; respiratory rate >20 breaths per minute or PCO₂ <32 mm Hg; and white blood cell count >12,000/L or <4000/L or with more than 10% band cells)21 may be too sensitive to use as a decision aid, since even a healthy person running after a bus could have 2 of the 4 criteria.22 Likewise, surgical patients may have transient leukocytosis due to a stress response independent of an infection.23

The SI may be more accurate than vital signs alone to determine illness severity and who is at risk for an unplanned transfer to the ICU. Birkhahn et al.24 concluded that the SI may be more useful in early hemorrhage than either heart rate or systolic blood pressure alone. Rady et al.25 showed that the SI used in the emergency department can identify critical illness with apparently stable vital signs, where an elevation of the SI above 0.9 was associated with an illness that was treated immediately with admission to the hospital and intensive therapy on admission. However, it is unclear whether the SI can be used to monitor ongoing treatment, because a previous study showed that the SI may be of limited value in the assessment of systemic oxygen transport and response to therapy in clinical septic shock.26 Of note, the SI is mostly independent of the effects of pain or anxiety, which cause a concurrent rise in heart rate and systolic blood pressure. Because the heart's left ventricular work is unchanged or may increase from the underlying catecholamine surge, the SI will be unchanged or may actually decrease.

Our study adds to the medical literature the findings that: (1) the SI may be useful as an indicator of illness severity and a triage tool in patients with no trauma but with various medical conditions, and (2) the SI showed a strong association with unplanned ICU transfer.

The main strength of our study is its case‐control design with matched controls. Also, by comparing groups from the same patient care unit, we sought to minimize the selection bias that can be inherent in case‐control studies. Limitations include the retrospective, nonrandomized study design and the fact that there may have been variations in vital sign measurements by the multiple caregivers. However, the vital signs were taken according to standard hospital practice and reflect real‐world conditions. Although generalizability may be somewhat limited because of our homogeneous patient population, our patients had a wide range of various medical illnesses, so our study should be applicable to other hospital settings, both academic and community‐based.

One of the main weaknesses of our study is that the results were not adjusted for the burden of comorbid conditions, although there were no statistically significant differences in the number of comorbid conditions among the cases and the controls (P = 0.96). Also, we did not directly compare the SI with vital signs alone to determine superiority.

The SI may be an important objective measure to help clinicians decide when patients need treatment that is more aggressive, assistance from a MET or an RRT, or a preemptive, rather than unplanned, transfer to an ICU. Although it is unlikely that a single measure will allow accurate triage of all medical or surgical patients, the SI may be a useful adjunct to clinical judgment and other objective measures in determining illness severity and clinical decline. Further prospective studies are needed to compare the role of the SI specifically with MET or RRT activation criteria, to clarify the role of comorbid conditions in unplanned transfers to the ICU, to validate the cut point for the SI in various disease states, and to assess its utility in patients with septic shock. Depending on these results, it may be beneficial to incorporate the SI into the electronic medical record as an automatic alert to identify patients at risk for ICU transfer.

Conclusions

The SI is an easily calculated composite index of heart rate and systolic blood pressure. An elevated SI of 0.85 can identify patients who are at risk for unplanned transfer to the ICU from general patient care units. Future studies will determine whether the SI is more accurate than simple vital signs as an indicator of clinical decline. If so, it may be useful as a trigger to activate METs or RRTs for treatment.

The decision to transfer a patient to the intensive care unit (ICU) from a general care setting is complex and based not only on clinical findings and patient wishes but also on the understanding that ICU resources are limited and costly.1 Adding to the decision‐making complexity is the knowledge that patients who transfer to an ICU from a general medical unit comprise the highest mortality group of ICU patients, with the mortality rate directly proportional to both the time spent on the general medical unit1, 2 and the number of physiologic abnormalities before ICU admission.3, 4

Prior studies have shown that cardiac arrest and unplanned (unexpected) transfers to the ICU are preceded by a period of physiologic instability reflected in the vital signs.510 However, vital signs alone may not accurately indicate clinical condition. For example, a person may be able to maintain normal blood pressure and heart rate despite severe illness or may have abnormal vital signs at baseline, which may be the case for an otherwise healthy young woman who has baseline low systolic blood pressure. Also, noncritical conditions commonly seen in hospitalized medical or surgical patients, such as anxiety or pain, may increase the respiratory rate or heart rate. Conversely, certain common medications, such as ‐blockers, may mask or blunt the normal physiologic response to illness. Overall, the prevalence of abnormal physiologic variables is high among hospitalized adult patients irrespective of the presence of serious adverse events.11 This prevalence may be a reason why 2 recent studies of inpatient medical emergency teams (METs) or rapid response teams (RRTs), which generally rely on vital signs for activation, failed to show a decrease in adult mortality rates.12, 13

Given the complexity of interpreting single vital sign readings, we evaluated a simple and clinically intuitive variable, the shock index (SI) (heart rate/systolic blood pressure, a noninvasive indication of left ventricular function),14 as a potential marker of the need for intensive care. Allgwer and Burri14 first developed the SI in studies of patients with acute blood loss, intraabdominal bleeding, fat emboli, and severe infections. They observed that a healthy adult had a mean SI of 0.54 (standard deviation [SD], 0.021), while an index of 1.0 indicated threatened shock and indices greater than 1.5 were seen in volume‐deficient shock.

We hypothesized that an elevated SI is a differentiating factor between a patient who had an unplanned ICU transfer and a general medical patient who did not require this higher level of care. To our knowledge, the SI has not been studied for this application previously.

Patients and Methods

Results

A total of 50 pairs of matching cases and controls was included in this study. Table 1 lists the source of admission, demographic characteristics, and numbers of deaths for cases and controls. There were no statistically significant differences in admission source, age, sex, ethnicity, admission care unit, or Charlson Comorbidity Index. Mean length of stay was 14.8 days (SD, 9.7 days) for the cases and 5.7 days (SD, 6.3 days; P < 0.001) for the controls. Admission diagnoses were classified on the basis of the organ system of involvement (Table 2). In 30 of 50 cases, the admission diagnosis and the reason for ICU transfer were related.

We reviewed the vital signs and shock indices for the 24 hours before ICU transfer for each case and over the entire hospitalization for each control, to determine the worst set (the lowest systolic blood pressure and the highest heart rate, respiratory rate, and SI). The cases had 1 to 22 complete sets of vitals for the 24 hours before ICU transfer; the median number of sets was 3 and the mean was 4. The controls had 1 to 12 complete sets for the 24 hours before the worst SI: the median was 3 sets and the mean was 3. In 26 of 50 controls, the worst SI occurred within the first 24 hours after admission. There was a significant difference between the median values of the worst shock indices of the cases and the controls (0.87 vs. 0.72; P < 0.005).

Table 3 shows the different values of the SI and the corresponding odds ratio of unplanned ICU transfer for cases compared with controls. The difference was significant at an SI of 0.85 and greater, indicating a strong association with unplanned ICU transfer.

We also found that the patients who transferred to the ICU had a greater number of inpatient deaths (9 cases vs. 1 control; P = 0.008), which would be expected, but there was no difference in 30‐day or 6‐month mortality rate (Table 1). One patient died after 30 days and while still hospitalized.

Comparison between the temporal trend of vital signs and the SI of the cases for the 24 hours before ICU transfer is shown in Figure 1. This graph shows the median of all the worst values (minimum systolic blood pressure and maximum SI, heart rate, and respiratory rate) over the four 6‐hour time periods (24 hours) preceding ICU transfer. Of note, the change in vital signs is subtle even while the SI increased to more than 0.8 as the patients clinically worsened before transfer.

Figure 1

Discussion

In our comparison of the SI of 50 patients who required unplanned (unexpected) transfer to the ICU with the SI of 50 matched controls who did not require this higher level of care, we found that a SI of 0.85 or greater was significantly associated with unplanned transfer to the ICU. The cases had a significantly higher worst SI than the controls, and they also had a significantly longer hospital stay and higher inpatient mortality rate, as would be expected for a sicker patient population. These findings are important given that the SI may be useful for assessing illness severity, for helping determine the need for transfer to the ICU, or for activating METs or RRTs.

A major problem with providing optimal care for hospitalized general medical patients is the inherent difficulty in determining illness severity and clinical decline, especially when the decline occurs gradually. Existing consensus recommendations for ICU admission include both specific diagnoses and arbitrary objective criteria based on abnormal vital signs and laboratory values.27 Also, individual institutions may have their own ICU admission requirements, which may differ from these or RRT criteria. Although vital signs are important as a snapshot of basic physiologic function, a number of noncritical conditions may lead to abnormal vital signs, and not all abnormal vital signs are associated with an adverse clinical event. By relying solely on vital signs, clinicians may not recognize critical illness and therefore not transfer a patient to the ICU or may inappropriately transfer a patient who does not need ICU‐level care.

Markers of illness severity other than vital signs, such as the Acute Physiology and Chronic Health Evaluation (APACHE) score, have been shown to predict the death of ICU patients17, 18 but have been rarely studied outside the ICU setting.19 Also, calculating the APACHE score is cumbersome, and there is no cutoff score that defines when a patient should be transferred to the ICU. Subbe et al.,20 in their study to identify critically ill patients, found that introduction of a physiological scoring system (including MET or RRT activation scores) would have identified only a small number of additional patients as critically ill. Another common marker of illness severity, the 4 criteria of the systemic inflammatory response syndrome (temperature <36C or >38C; heart rate >90 beats per minute; respiratory rate >20 breaths per minute or PCO₂ <32 mm Hg; and white blood cell count >12,000/L or <4000/L or with more than 10% band cells)21 may be too sensitive to use as a decision aid, since even a healthy person running after a bus could have 2 of the 4 criteria.22 Likewise, surgical patients may have transient leukocytosis due to a stress response independent of an infection.23

The SI may be more accurate than vital signs alone to determine illness severity and who is at risk for an unplanned transfer to the ICU. Birkhahn et al.24 concluded that the SI may be more useful in early hemorrhage than either heart rate or systolic blood pressure alone. Rady et al.25 showed that the SI used in the emergency department can identify critical illness with apparently stable vital signs, where an elevation of the SI above 0.9 was associated with an illness that was treated immediately with admission to the hospital and intensive therapy on admission. However, it is unclear whether the SI can be used to monitor ongoing treatment, because a previous study showed that the SI may be of limited value in the assessment of systemic oxygen transport and response to therapy in clinical septic shock.26 Of note, the SI is mostly independent of the effects of pain or anxiety, which cause a concurrent rise in heart rate and systolic blood pressure. Because the heart's left ventricular work is unchanged or may increase from the underlying catecholamine surge, the SI will be unchanged or may actually decrease.

Our study adds to the medical literature the findings that: (1) the SI may be useful as an indicator of illness severity and a triage tool in patients with no trauma but with various medical conditions, and (2) the SI showed a strong association with unplanned ICU transfer.

The main strength of our study is its case‐control design with matched controls. Also, by comparing groups from the same patient care unit, we sought to minimize the selection bias that can be inherent in case‐control studies. Limitations include the retrospective, nonrandomized study design and the fact that there may have been variations in vital sign measurements by the multiple caregivers. However, the vital signs were taken according to standard hospital practice and reflect real‐world conditions. Although generalizability may be somewhat limited because of our homogeneous patient population, our patients had a wide range of various medical illnesses, so our study should be applicable to other hospital settings, both academic and community‐based.

One of the main weaknesses of our study is that the results were not adjusted for the burden of comorbid conditions, although there were no statistically significant differences in the number of comorbid conditions among the cases and the controls (P = 0.96). Also, we did not directly compare the SI with vital signs alone to determine superiority.

The SI may be an important objective measure to help clinicians decide when patients need treatment that is more aggressive, assistance from a MET or an RRT, or a preemptive, rather than unplanned, transfer to an ICU. Although it is unlikely that a single measure will allow accurate triage of all medical or surgical patients, the SI may be a useful adjunct to clinical judgment and other objective measures in determining illness severity and clinical decline. Further prospective studies are needed to compare the role of the SI specifically with MET or RRT activation criteria, to clarify the role of comorbid conditions in unplanned transfers to the ICU, to validate the cut point for the SI in various disease states, and to assess its utility in patients with septic shock. Depending on these results, it may be beneficial to incorporate the SI into the electronic medical record as an automatic alert to identify patients at risk for ICU transfer.

Conclusions

The SI is an easily calculated composite index of heart rate and systolic blood pressure. An elevated SI of 0.85 can identify patients who are at risk for unplanned transfer to the ICU from general patient care units. Future studies will determine whether the SI is more accurate than simple vital signs as an indicator of clinical decline. If so, it may be useful as a trigger to activate METs or RRTs for treatment.

The decision to transfer a patient to the intensive care unit (ICU) from a general care setting is complex and based not only on clinical findings and patient wishes but also on the understanding that ICU resources are limited and costly.1 Adding to the decision‐making complexity is the knowledge that patients who transfer to an ICU from a general medical unit comprise the highest mortality group of ICU patients, with the mortality rate directly proportional to both the time spent on the general medical unit1, 2 and the number of physiologic abnormalities before ICU admission.3, 4

Prior studies have shown that cardiac arrest and unplanned (unexpected) transfers to the ICU are preceded by a period of physiologic instability reflected in the vital signs.510 However, vital signs alone may not accurately indicate clinical condition. For example, a person may be able to maintain normal blood pressure and heart rate despite severe illness or may have abnormal vital signs at baseline, which may be the case for an otherwise healthy young woman who has baseline low systolic blood pressure. Also, noncritical conditions commonly seen in hospitalized medical or surgical patients, such as anxiety or pain, may increase the respiratory rate or heart rate. Conversely, certain common medications, such as ‐blockers, may mask or blunt the normal physiologic response to illness. Overall, the prevalence of abnormal physiologic variables is high among hospitalized adult patients irrespective of the presence of serious adverse events.11 This prevalence may be a reason why 2 recent studies of inpatient medical emergency teams (METs) or rapid response teams (RRTs), which generally rely on vital signs for activation, failed to show a decrease in adult mortality rates.12, 13

Given the complexity of interpreting single vital sign readings, we evaluated a simple and clinically intuitive variable, the shock index (SI) (heart rate/systolic blood pressure, a noninvasive indication of left ventricular function),14 as a potential marker of the need for intensive care. Allgwer and Burri14 first developed the SI in studies of patients with acute blood loss, intraabdominal bleeding, fat emboli, and severe infections. They observed that a healthy adult had a mean SI of 0.54 (standard deviation [SD], 0.021), while an index of 1.0 indicated threatened shock and indices greater than 1.5 were seen in volume‐deficient shock.

We hypothesized that an elevated SI is a differentiating factor between a patient who had an unplanned ICU transfer and a general medical patient who did not require this higher level of care. To our knowledge, the SI has not been studied for this application previously.

Patients and Methods

Results

A total of 50 pairs of matching cases and controls was included in this study. Table 1 lists the source of admission, demographic characteristics, and numbers of deaths for cases and controls. There were no statistically significant differences in admission source, age, sex, ethnicity, admission care unit, or Charlson Comorbidity Index. Mean length of stay was 14.8 days (SD, 9.7 days) for the cases and 5.7 days (SD, 6.3 days; P < 0.001) for the controls. Admission diagnoses were classified on the basis of the organ system of involvement (Table 2). In 30 of 50 cases, the admission diagnosis and the reason for ICU transfer were related.

We reviewed the vital signs and shock indices for the 24 hours before ICU transfer for each case and over the entire hospitalization for each control, to determine the worst set (the lowest systolic blood pressure and the highest heart rate, respiratory rate, and SI). The cases had 1 to 22 complete sets of vitals for the 24 hours before ICU transfer; the median number of sets was 3 and the mean was 4. The controls had 1 to 12 complete sets for the 24 hours before the worst SI: the median was 3 sets and the mean was 3. In 26 of 50 controls, the worst SI occurred within the first 24 hours after admission. There was a significant difference between the median values of the worst shock indices of the cases and the controls (0.87 vs. 0.72; P < 0.005).

Table 3 shows the different values of the SI and the corresponding odds ratio of unplanned ICU transfer for cases compared with controls. The difference was significant at an SI of 0.85 and greater, indicating a strong association with unplanned ICU transfer.

We also found that the patients who transferred to the ICU had a greater number of inpatient deaths (9 cases vs. 1 control; P = 0.008), which would be expected, but there was no difference in 30‐day or 6‐month mortality rate (Table 1). One patient died after 30 days and while still hospitalized.

Comparison between the temporal trend of vital signs and the SI of the cases for the 24 hours before ICU transfer is shown in Figure 1. This graph shows the median of all the worst values (minimum systolic blood pressure and maximum SI, heart rate, and respiratory rate) over the four 6‐hour time periods (24 hours) preceding ICU transfer. Of note, the change in vital signs is subtle even while the SI increased to more than 0.8 as the patients clinically worsened before transfer.

Figure 1

Discussion

In our comparison of the SI of 50 patients who required unplanned (unexpected) transfer to the ICU with the SI of 50 matched controls who did not require this higher level of care, we found that a SI of 0.85 or greater was significantly associated with unplanned transfer to the ICU. The cases had a significantly higher worst SI than the controls, and they also had a significantly longer hospital stay and higher inpatient mortality rate, as would be expected for a sicker patient population. These findings are important given that the SI may be useful for assessing illness severity, for helping determine the need for transfer to the ICU, or for activating METs or RRTs.

A major problem with providing optimal care for hospitalized general medical patients is the inherent difficulty in determining illness severity and clinical decline, especially when the decline occurs gradually. Existing consensus recommendations for ICU admission include both specific diagnoses and arbitrary objective criteria based on abnormal vital signs and laboratory values.27 Also, individual institutions may have their own ICU admission requirements, which may differ from these or RRT criteria. Although vital signs are important as a snapshot of basic physiologic function, a number of noncritical conditions may lead to abnormal vital signs, and not all abnormal vital signs are associated with an adverse clinical event. By relying solely on vital signs, clinicians may not recognize critical illness and therefore not transfer a patient to the ICU or may inappropriately transfer a patient who does not need ICU‐level care.

Markers of illness severity other than vital signs, such as the Acute Physiology and Chronic Health Evaluation (APACHE) score, have been shown to predict the death of ICU patients17, 18 but have been rarely studied outside the ICU setting.19 Also, calculating the APACHE score is cumbersome, and there is no cutoff score that defines when a patient should be transferred to the ICU. Subbe et al.,20 in their study to identify critically ill patients, found that introduction of a physiological scoring system (including MET or RRT activation scores) would have identified only a small number of additional patients as critically ill. Another common marker of illness severity, the 4 criteria of the systemic inflammatory response syndrome (temperature <36C or >38C; heart rate >90 beats per minute; respiratory rate >20 breaths per minute or PCO₂ <32 mm Hg; and white blood cell count >12,000/L or <4000/L or with more than 10% band cells)21 may be too sensitive to use as a decision aid, since even a healthy person running after a bus could have 2 of the 4 criteria.22 Likewise, surgical patients may have transient leukocytosis due to a stress response independent of an infection.23

The SI may be more accurate than vital signs alone to determine illness severity and who is at risk for an unplanned transfer to the ICU. Birkhahn et al.24 concluded that the SI may be more useful in early hemorrhage than either heart rate or systolic blood pressure alone. Rady et al.25 showed that the SI used in the emergency department can identify critical illness with apparently stable vital signs, where an elevation of the SI above 0.9 was associated with an illness that was treated immediately with admission to the hospital and intensive therapy on admission. However, it is unclear whether the SI can be used to monitor ongoing treatment, because a previous study showed that the SI may be of limited value in the assessment of systemic oxygen transport and response to therapy in clinical septic shock.26 Of note, the SI is mostly independent of the effects of pain or anxiety, which cause a concurrent rise in heart rate and systolic blood pressure. Because the heart's left ventricular work is unchanged or may increase from the underlying catecholamine surge, the SI will be unchanged or may actually decrease.

Our study adds to the medical literature the findings that: (1) the SI may be useful as an indicator of illness severity and a triage tool in patients with no trauma but with various medical conditions, and (2) the SI showed a strong association with unplanned ICU transfer.

The main strength of our study is its case‐control design with matched controls. Also, by comparing groups from the same patient care unit, we sought to minimize the selection bias that can be inherent in case‐control studies. Limitations include the retrospective, nonrandomized study design and the fact that there may have been variations in vital sign measurements by the multiple caregivers. However, the vital signs were taken according to standard hospital practice and reflect real‐world conditions. Although generalizability may be somewhat limited because of our homogeneous patient population, our patients had a wide range of various medical illnesses, so our study should be applicable to other hospital settings, both academic and community‐based.

One of the main weaknesses of our study is that the results were not adjusted for the burden of comorbid conditions, although there were no statistically significant differences in the number of comorbid conditions among the cases and the controls (P = 0.96). Also, we did not directly compare the SI with vital signs alone to determine superiority.

The SI may be an important objective measure to help clinicians decide when patients need treatment that is more aggressive, assistance from a MET or an RRT, or a preemptive, rather than unplanned, transfer to an ICU. Although it is unlikely that a single measure will allow accurate triage of all medical or surgical patients, the SI may be a useful adjunct to clinical judgment and other objective measures in determining illness severity and clinical decline. Further prospective studies are needed to compare the role of the SI specifically with MET or RRT activation criteria, to clarify the role of comorbid conditions in unplanned transfers to the ICU, to validate the cut point for the SI in various disease states, and to assess its utility in patients with septic shock. Depending on these results, it may be beneficial to incorporate the SI into the electronic medical record as an automatic alert to identify patients at risk for ICU transfer.

Conclusions

The SI is an easily calculated composite index of heart rate and systolic blood pressure. An elevated SI of 0.85 can identify patients who are at risk for unplanned transfer to the ICU from general patient care units. Future studies will determine whether the SI is more accurate than simple vital signs as an indicator of clinical decline. If so, it may be useful as a trigger to activate METs or RRTs for treatment.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of 150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of 150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of 150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

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Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

Hyperglycemia due to diabetes or stress is prevalent in the intensive care unit (ICU) and general ward setting. Umpierrez et al.1 reported hyperglycemia in 38% of hospitalized ward patients with 26% having a known history of diabetes. While patients with hyperglycemia admitted to the ICU are primarily treated with infusion insulin, those on the general wards usually receive a subcutaneous regimen of insulin. How best to transition patients from infusion insulin to a subcutaneous regimen remains elusive and under evaluated.

A recent observational pilot study of 24 surgical and 17 cardiac/medical intensive care patients at our university‐based hospital found that glycemic control significantly deteriorated when patients with diabetes transitioned from infusion insulin to subcutaneous insulin. A total of 21 critical care patients with a history of diabetes failed to receive basal insulin prior to discontinuation of the drip and developed uncontrolled hyperglycemia (mean glucose Day 1 of 216 mg/dL and Day 2 of 197 mg/dL). Patients without a history of diabetes did well post transition with a mean glucose of 142 mg/dL Day 1 and 133 mg/dL Day 2. A similar study by Czosnowski et al.2 demonstrated a significant increase in blood glucose from 123 26 mg/dL to 168 50 mg/dL upon discontinuation of infusion insulin.

This failed transition is disappointing, especially in view of the existence of a reliable subcutaneous (SC) insulin order set at our institution, but not surprising, as this is an inherently complex process. The severity of illness, the amount and mode of nutritional intake, geographic location, and provider team may all be in flux at the time of this transition. A few centers have demonstrated that a much improved transition is possible,36 however many of these solutions involve technology or incremental personnel that may not be available or the descriptions may lack sufficient detail to implement theses strategies with confidence elsewhere.

Therefore, we designed and piloted a protocol, coordinated by a multidisciplinary team, to transition patients from infusion insulin to SC insulin. The successful implementation of this protocol could serve as a blueprint to other institutions without the need for additional technology or personnel.

Methods

Inclusion/Exclusion Criteria

All patients on continuous insulin infusion admitted to the SICU or the MICU/CCU between May 2008 and September 2008 were evaluated for the study (Figure 1). Patients were excluded from analysis if they were on the infusion for less than 24 hours, had a liver transplant, were discharged within 48 hours of transition, were made comfort care or transitioned to an insulin pump. All other patients were included in the final analysis.

Figure 1

Results

A total of 210 episodes of infusion insulin in ICU patients were evaluated for the study from May of 2008 to September 2008 (Figure 1). Ninety‐six of these episodes were excluded, most commonly due to time on infusion insulin <24 hours or transition to comfort care. The remaining 114 infusions were eligible to use the protocol. Because the protocol recommends insulin therapy based on a diagnosis of diabetes, patients were further divided into these subcategories. Of these 114 transitions, the protocol was followed 66 times (58%).

Patients With Diabetes

(Table 1: Patient Demographics; Table 2: Insulin Use and Glycemic Control; Figure 2: Transition Graph).

Figure 2

Table 1.Patient Demographics

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 29 Patients*	Protocol NOT Followed, n = 33 Patients		Protocol Followed, n = 30 Patients	Protocol NOT Followed, n = 9 Patients
Abbreviations: BMI, body mass index; SD, standard deviation; TPN, total parenteral nutrition. * One patient followed the protocol requiring basal insulin solely because they were on high dose steroids. They did not have a medical history of diabetes or an A1c 6%. Full Nutrition: Patient is eating >50% of their meals, on goal tube feeds, or on TPN. Too small of cell size to conduct chi‐square analysis.
Average age, years, mean SD	57.7 12.1	57.8 12.3	0.681	56.5 18.1	62.4 15.5	0.532
Male patients	21 (72%)	21 (63%)	0.58	20 (66%)	7 (77%)	0.691
BMI	30.7 7.2	28.6 6.8	0.180	27 5.4	25.2 3	0.081
History of diabetes*	18 (64%)	25 (86%)	0.07	0	0
Mean Hgb A1c (%)	6.61.2	7.3 1.8	0.136	5.6 0.3	5.4 0.4	0.095
Full nutrition	26 (79%)	24 (61%)	0.131	23 (70%)	9 (100%)
On hemodialysis	5 (17%)	9 (27%)	0.380	3 (10%)	0
On >60 mg prednisone or equivalent per day	7 (24%)	10 (30%)	0.632	0	0

Table 2.Insulin Use and Glycemic Control

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 33 transitions	Protocol NOT followed, n = 39 transitions		Protocol Followed, n = 33 transitions	Protocol NOT Followed, n = 9 transitions
Abbreviations: BG, blood glucose; LOS, length of stay; n/a, not applicable. * Too small of cell size to conduct chi‐square analysis.
Average infusion rate, hours	3.96 3.15	3.74 3.64	0.1597	2.34 1.5	4.78 1.6	<0.001
Average BG on infusion insulin (mg/dL)	122.5 27.5	122.5 31.8	0.844	115.1 22.7	127.5 27.2	0.006
Average basal dose (units) given	34.5 14.4	14.4 15.3	<0.001	0	32.7	<0.001
Hours before () or after (+) infusion stopped basal insulin given	1.13 0.9	11.6 9.3	<0.001	n/a	0.33	*
Average BG 6 hours post transition (mg/dL)	143.7 39.4	182 62.5	0.019	150.2 54.9	142.1 34.1	0.624
Average BG 0 to 24 hours post transition (mg/dL)	167.98 50.24	211.02 81.01	<0.001	150.24 54.9	150.12 32.4	0.600
Total insulin used from 0 to 24 hours (units)	65 32.2	26.7 25.4	<0.001	3.2 4.1	51.3 30.3	<0.001
Average BG 25 to 48 hours post transition (mg/dL)	176.1 55.25	218.2 88.54	<0.001	153 35.3	154.4 46.7	0.711
Total insulin used from 25 to 48 hours (units)	60.5 35.4	28.1 24.4	<0.001	2.8 3.8	44.9 34	<0.001
# of patients with severe hypoglycemia (<40 mg/dL)	1 (3%)	1 (2.6%)	*	0	1	*
# of patients with hypoglycemia (4170 mg/dL)	3 (9%)	2 (5.1%)	*	1	0	*
% of BG values in goal range (80180 mg/dL) (# in range/total #)	60.2% (153/254)	38.2% (104/272)	0.004	80.1% (173/216)	75.4% (49/65)	0.83
# of patients with severe hyperglycemia (>300 mg/dL)	5 (15.2%)	19 (48.7%)	0.002	1 (3%)	1 (11.1%)	*
LOS from transition (days)	14.6 11.3	14 11.4	0.836	25.3 24.4	13.6 7.5	0.168

A total of 62 individual patients accounted for 72 separate transitions in patients with diabetes based on past medical history or an A1c 6% (n = 14). Of these 72 transitions, 33 (46%) adhered to the protocol while the remaining 39 (54%) transitions varied from the protocol at the treatment team's discretion. Despite similar insulin infusion rates and mean glucose values pretransition, patients with diabetes following the protocol had better glycemic control at both 24 hours and 48 hours after transition than those patients transitioned without the protocol. Day 1 mean blood glucose was 168 mg/dL vs. 211 mg/dL (P = <0.001) and day 2 mean blood glucose was 176 mg/dL vs. 218 mg/dL (P = <0.001) in protocol vs. nonprotocol patients with diabetes respectively (Figure 2).

There was a severe hypoglycemic event (40 mg/dL) in 1 patient with diabetes following the protocol and 1 patient not following the protocol within 48 hours of transition. Both events were secondary to nutritional‐insulin mismatch with emesis after insulin in one case and tube feeds being held in the second case. These findings were consistent with our prior examination of hypoglycemia cases.13 Severe hyperglycemia (glucose 300mg/dL) occurred in 5 (15 %) patients following the protocol vs. 19 (49%) patients not following protocol (P = 0.002.) Patients with diabetes following the protocol received significantly more insulin in the first 24 hours (mean of 65 units vs. 27 units, P 0.001) and 24 to 48 hours after transition (mean of 61 units vs. 28 units, p0.001) than those not following protocol.

An alternate method used at our institution and others14, 15 to calculate TDD is based on the patient's weight and body habitus. When we compared the projected TDD based on weight with the TDD using the transition protocol, we found that the weight based method was much less aggressive. For patients following the protocol, the weight based method projected a mean TDD of 46.3 16.9 units whereas the protocol projected a mean TDD of 65 33.2 units (P = 0.001).

Patients with diabetes following protocol received basal insulin an average of 1.13 hours prior to discontinuing the insulin infusion versus 11.6 hours after for those not following protocol.

Three patients with diabetes following the protocol and 3 patients with diabetes not following the protocol were restarted on infusion insulin within 72 hours of transition.

LOS from final transition to discharge was similar between protocol vs. nonprotocol patients (14.6 vs. 14 days, P = 0.836).

Figure 3 demonstrates that when used correctly, the protocol provides an extended period of glycemic control up to 12 days post transition. Patients transitioned per protocol had a day‐weighted mean glucose of 155 mg/dL vs. 184 mg/dL (P = 0.043) in patients not following protocol. There was only 1 glucose value less than 40 mg/dL between days 2 to 12 in the protocol group.

Figure 3

Discussion

This study demonstrates the utility of hospitalist‐pharmacist collaboration in the creation and implementation of a safe and effective transition protocol for patients on infusion insulin. The protocol identifies patients appropriate for transition to a basal/nutritional insulin regimen versus those who will do well with premeal correctional insulin alone. Daily mean glucose was improved post transition for diabetic patients following the protocol compared to those not following the protocol without an increase in hypoglycemic events.

We found an equal number of insulin infusion restarts within 72 hours of transition and a similar LOS in protocol vs. nonprotocol patients with diabetes. The LOS was increased for patients without diabetes. This may be due to worse outcomes noted in patients with stress hyperglycemia in other studies.1, 16

The use of the higher multiplier for patients on minimal nutrition led to confusion among many protocol users. The protocol has since been modified to start by averaging the infusion rate over the prior 6 hours and then multiplying by 20 for all patients. This essentially calculates 80% of projected insulin requirements for the next 24 hours based on the patient's current needs. This calculation is then given as 50% basal and 50% nutritional for those on full nutrition vs. 100% basal for those on minimal nutrition. This protocol change has no impact on the amount of insulin received by the patient, but is more intuitive to providers. Instead of calculating the TDD as the projected requirement when full nutrition is obtained, the TDD is now calculated based on current insulin needs, and then doubled when patients who are receiving minimal nutrition advance to full nutrition.

Our study is limited by the lack of a true randomized control group. In lieu of this, we used our patients who did not follow protocol as our control. While not truly randomized, this group is comparable based on their age, gender mix, infusion rate, mean A1c, and projected TDD. This group was also similar to our preprotocol group mentioned in the Introduction.

Additional study limitations include the small number of nondiabetic patients not following the protocol (n = 9). We noted higher infusion rates in nondiabetics not following protocol versus those following protocol, which may have driven the primary team to give basal insulin. It is possible that these 9 patients were not yet ready to transition from infusion insulin or had other stressors not measured in our study. Unfortunately their small population size limits more extensive analysis.

The protocol was followed only 50% of the time for a variety of reasons. Patients who transitioned at night or on weekends were monitored by covering pharmacists and physicians who may not have been familiar with the protocol. Many physicians and nurses remain fearful of hypoglycemia and the outcomes of our study were not yet available for education. Some reported difficulty fully understanding how to use the protocol and why a higher multiplier was used for patients who were on minimal nutrition.

Efforts to improve adherence to the protocol are ongoing with some success, aided by the data demonstrating the safety and efficacy of the transition protocol.

Conclusion

By collaborating with ICU pharmacists we were able to design and implement a protocol that successfully and safely transitioned patients from infusion insulin to subcutaneous insulin. Patients following the protocol had a higher percentage of glucose values within the goal glucose range of 80 mg/dL to 180 mg/dL. In the future, we hope to automate the calculation of TDD and directly recommend a basal/bolus regimen for the clinical provider.

Hyperglycemia due to diabetes or stress is prevalent in the intensive care unit (ICU) and general ward setting. Umpierrez et al.1 reported hyperglycemia in 38% of hospitalized ward patients with 26% having a known history of diabetes. While patients with hyperglycemia admitted to the ICU are primarily treated with infusion insulin, those on the general wards usually receive a subcutaneous regimen of insulin. How best to transition patients from infusion insulin to a subcutaneous regimen remains elusive and under evaluated.

A recent observational pilot study of 24 surgical and 17 cardiac/medical intensive care patients at our university‐based hospital found that glycemic control significantly deteriorated when patients with diabetes transitioned from infusion insulin to subcutaneous insulin. A total of 21 critical care patients with a history of diabetes failed to receive basal insulin prior to discontinuation of the drip and developed uncontrolled hyperglycemia (mean glucose Day 1 of 216 mg/dL and Day 2 of 197 mg/dL). Patients without a history of diabetes did well post transition with a mean glucose of 142 mg/dL Day 1 and 133 mg/dL Day 2. A similar study by Czosnowski et al.2 demonstrated a significant increase in blood glucose from 123 26 mg/dL to 168 50 mg/dL upon discontinuation of infusion insulin.

This failed transition is disappointing, especially in view of the existence of a reliable subcutaneous (SC) insulin order set at our institution, but not surprising, as this is an inherently complex process. The severity of illness, the amount and mode of nutritional intake, geographic location, and provider team may all be in flux at the time of this transition. A few centers have demonstrated that a much improved transition is possible,36 however many of these solutions involve technology or incremental personnel that may not be available or the descriptions may lack sufficient detail to implement theses strategies with confidence elsewhere.

Therefore, we designed and piloted a protocol, coordinated by a multidisciplinary team, to transition patients from infusion insulin to SC insulin. The successful implementation of this protocol could serve as a blueprint to other institutions without the need for additional technology or personnel.

Methods

Inclusion/Exclusion Criteria

All patients on continuous insulin infusion admitted to the SICU or the MICU/CCU between May 2008 and September 2008 were evaluated for the study (Figure 1). Patients were excluded from analysis if they were on the infusion for less than 24 hours, had a liver transplant, were discharged within 48 hours of transition, were made comfort care or transitioned to an insulin pump. All other patients were included in the final analysis.

Figure 1

Results

A total of 210 episodes of infusion insulin in ICU patients were evaluated for the study from May of 2008 to September 2008 (Figure 1). Ninety‐six of these episodes were excluded, most commonly due to time on infusion insulin <24 hours or transition to comfort care. The remaining 114 infusions were eligible to use the protocol. Because the protocol recommends insulin therapy based on a diagnosis of diabetes, patients were further divided into these subcategories. Of these 114 transitions, the protocol was followed 66 times (58%).

Patients With Diabetes

(Table 1: Patient Demographics; Table 2: Insulin Use and Glycemic Control; Figure 2: Transition Graph).

Figure 2

Table 1.Patient Demographics

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 29 Patients*	Protocol NOT Followed, n = 33 Patients		Protocol Followed, n = 30 Patients	Protocol NOT Followed, n = 9 Patients
Abbreviations: BMI, body mass index; SD, standard deviation; TPN, total parenteral nutrition. * One patient followed the protocol requiring basal insulin solely because they were on high dose steroids. They did not have a medical history of diabetes or an A1c 6%. Full Nutrition: Patient is eating >50% of their meals, on goal tube feeds, or on TPN. Too small of cell size to conduct chi‐square analysis.
Average age, years, mean SD	57.7 12.1	57.8 12.3	0.681	56.5 18.1	62.4 15.5	0.532
Male patients	21 (72%)	21 (63%)	0.58	20 (66%)	7 (77%)	0.691
BMI	30.7 7.2	28.6 6.8	0.180	27 5.4	25.2 3	0.081
History of diabetes*	18 (64%)	25 (86%)	0.07	0	0
Mean Hgb A1c (%)	6.61.2	7.3 1.8	0.136	5.6 0.3	5.4 0.4	0.095
Full nutrition	26 (79%)	24 (61%)	0.131	23 (70%)	9 (100%)
On hemodialysis	5 (17%)	9 (27%)	0.380	3 (10%)	0
On >60 mg prednisone or equivalent per day	7 (24%)	10 (30%)	0.632	0	0

Table 2.Insulin Use and Glycemic Control

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 33 transitions	Protocol NOT followed, n = 39 transitions		Protocol Followed, n = 33 transitions	Protocol NOT Followed, n = 9 transitions
Abbreviations: BG, blood glucose; LOS, length of stay; n/a, not applicable. * Too small of cell size to conduct chi‐square analysis.
Average infusion rate, hours	3.96 3.15	3.74 3.64	0.1597	2.34 1.5	4.78 1.6	<0.001
Average BG on infusion insulin (mg/dL)	122.5 27.5	122.5 31.8	0.844	115.1 22.7	127.5 27.2	0.006
Average basal dose (units) given	34.5 14.4	14.4 15.3	<0.001	0	32.7	<0.001
Hours before () or after (+) infusion stopped basal insulin given	1.13 0.9	11.6 9.3	<0.001	n/a	0.33	*
Average BG 6 hours post transition (mg/dL)	143.7 39.4	182 62.5	0.019	150.2 54.9	142.1 34.1	0.624
Average BG 0 to 24 hours post transition (mg/dL)	167.98 50.24	211.02 81.01	<0.001	150.24 54.9	150.12 32.4	0.600
Total insulin used from 0 to 24 hours (units)	65 32.2	26.7 25.4	<0.001	3.2 4.1	51.3 30.3	<0.001
Average BG 25 to 48 hours post transition (mg/dL)	176.1 55.25	218.2 88.54	<0.001	153 35.3	154.4 46.7	0.711
Total insulin used from 25 to 48 hours (units)	60.5 35.4	28.1 24.4	<0.001	2.8 3.8	44.9 34	<0.001
# of patients with severe hypoglycemia (<40 mg/dL)	1 (3%)	1 (2.6%)	*	0	1	*
# of patients with hypoglycemia (4170 mg/dL)	3 (9%)	2 (5.1%)	*	1	0	*
% of BG values in goal range (80180 mg/dL) (# in range/total #)	60.2% (153/254)	38.2% (104/272)	0.004	80.1% (173/216)	75.4% (49/65)	0.83
# of patients with severe hyperglycemia (>300 mg/dL)	5 (15.2%)	19 (48.7%)	0.002	1 (3%)	1 (11.1%)	*
LOS from transition (days)	14.6 11.3	14 11.4	0.836	25.3 24.4	13.6 7.5	0.168

A total of 62 individual patients accounted for 72 separate transitions in patients with diabetes based on past medical history or an A1c 6% (n = 14). Of these 72 transitions, 33 (46%) adhered to the protocol while the remaining 39 (54%) transitions varied from the protocol at the treatment team's discretion. Despite similar insulin infusion rates and mean glucose values pretransition, patients with diabetes following the protocol had better glycemic control at both 24 hours and 48 hours after transition than those patients transitioned without the protocol. Day 1 mean blood glucose was 168 mg/dL vs. 211 mg/dL (P = <0.001) and day 2 mean blood glucose was 176 mg/dL vs. 218 mg/dL (P = <0.001) in protocol vs. nonprotocol patients with diabetes respectively (Figure 2).

There was a severe hypoglycemic event (40 mg/dL) in 1 patient with diabetes following the protocol and 1 patient not following the protocol within 48 hours of transition. Both events were secondary to nutritional‐insulin mismatch with emesis after insulin in one case and tube feeds being held in the second case. These findings were consistent with our prior examination of hypoglycemia cases.13 Severe hyperglycemia (glucose 300mg/dL) occurred in 5 (15 %) patients following the protocol vs. 19 (49%) patients not following protocol (P = 0.002.) Patients with diabetes following the protocol received significantly more insulin in the first 24 hours (mean of 65 units vs. 27 units, P 0.001) and 24 to 48 hours after transition (mean of 61 units vs. 28 units, p0.001) than those not following protocol.

An alternate method used at our institution and others14, 15 to calculate TDD is based on the patient's weight and body habitus. When we compared the projected TDD based on weight with the TDD using the transition protocol, we found that the weight based method was much less aggressive. For patients following the protocol, the weight based method projected a mean TDD of 46.3 16.9 units whereas the protocol projected a mean TDD of 65 33.2 units (P = 0.001).

Patients with diabetes following protocol received basal insulin an average of 1.13 hours prior to discontinuing the insulin infusion versus 11.6 hours after for those not following protocol.

Three patients with diabetes following the protocol and 3 patients with diabetes not following the protocol were restarted on infusion insulin within 72 hours of transition.

LOS from final transition to discharge was similar between protocol vs. nonprotocol patients (14.6 vs. 14 days, P = 0.836).

Figure 3 demonstrates that when used correctly, the protocol provides an extended period of glycemic control up to 12 days post transition. Patients transitioned per protocol had a day‐weighted mean glucose of 155 mg/dL vs. 184 mg/dL (P = 0.043) in patients not following protocol. There was only 1 glucose value less than 40 mg/dL between days 2 to 12 in the protocol group.

Figure 3

Discussion

This study demonstrates the utility of hospitalist‐pharmacist collaboration in the creation and implementation of a safe and effective transition protocol for patients on infusion insulin. The protocol identifies patients appropriate for transition to a basal/nutritional insulin regimen versus those who will do well with premeal correctional insulin alone. Daily mean glucose was improved post transition for diabetic patients following the protocol compared to those not following the protocol without an increase in hypoglycemic events.

We found an equal number of insulin infusion restarts within 72 hours of transition and a similar LOS in protocol vs. nonprotocol patients with diabetes. The LOS was increased for patients without diabetes. This may be due to worse outcomes noted in patients with stress hyperglycemia in other studies.1, 16

The use of the higher multiplier for patients on minimal nutrition led to confusion among many protocol users. The protocol has since been modified to start by averaging the infusion rate over the prior 6 hours and then multiplying by 20 for all patients. This essentially calculates 80% of projected insulin requirements for the next 24 hours based on the patient's current needs. This calculation is then given as 50% basal and 50% nutritional for those on full nutrition vs. 100% basal for those on minimal nutrition. This protocol change has no impact on the amount of insulin received by the patient, but is more intuitive to providers. Instead of calculating the TDD as the projected requirement when full nutrition is obtained, the TDD is now calculated based on current insulin needs, and then doubled when patients who are receiving minimal nutrition advance to full nutrition.

Our study is limited by the lack of a true randomized control group. In lieu of this, we used our patients who did not follow protocol as our control. While not truly randomized, this group is comparable based on their age, gender mix, infusion rate, mean A1c, and projected TDD. This group was also similar to our preprotocol group mentioned in the Introduction.

Additional study limitations include the small number of nondiabetic patients not following the protocol (n = 9). We noted higher infusion rates in nondiabetics not following protocol versus those following protocol, which may have driven the primary team to give basal insulin. It is possible that these 9 patients were not yet ready to transition from infusion insulin or had other stressors not measured in our study. Unfortunately their small population size limits more extensive analysis.

The protocol was followed only 50% of the time for a variety of reasons. Patients who transitioned at night or on weekends were monitored by covering pharmacists and physicians who may not have been familiar with the protocol. Many physicians and nurses remain fearful of hypoglycemia and the outcomes of our study were not yet available for education. Some reported difficulty fully understanding how to use the protocol and why a higher multiplier was used for patients who were on minimal nutrition.

Efforts to improve adherence to the protocol are ongoing with some success, aided by the data demonstrating the safety and efficacy of the transition protocol.

Conclusion

By collaborating with ICU pharmacists we were able to design and implement a protocol that successfully and safely transitioned patients from infusion insulin to subcutaneous insulin. Patients following the protocol had a higher percentage of glucose values within the goal glucose range of 80 mg/dL to 180 mg/dL. In the future, we hope to automate the calculation of TDD and directly recommend a basal/bolus regimen for the clinical provider.

Hyperglycemia due to diabetes or stress is prevalent in the intensive care unit (ICU) and general ward setting. Umpierrez et al.1 reported hyperglycemia in 38% of hospitalized ward patients with 26% having a known history of diabetes. While patients with hyperglycemia admitted to the ICU are primarily treated with infusion insulin, those on the general wards usually receive a subcutaneous regimen of insulin. How best to transition patients from infusion insulin to a subcutaneous regimen remains elusive and under evaluated.

A recent observational pilot study of 24 surgical and 17 cardiac/medical intensive care patients at our university‐based hospital found that glycemic control significantly deteriorated when patients with diabetes transitioned from infusion insulin to subcutaneous insulin. A total of 21 critical care patients with a history of diabetes failed to receive basal insulin prior to discontinuation of the drip and developed uncontrolled hyperglycemia (mean glucose Day 1 of 216 mg/dL and Day 2 of 197 mg/dL). Patients without a history of diabetes did well post transition with a mean glucose of 142 mg/dL Day 1 and 133 mg/dL Day 2. A similar study by Czosnowski et al.2 demonstrated a significant increase in blood glucose from 123 26 mg/dL to 168 50 mg/dL upon discontinuation of infusion insulin.

This failed transition is disappointing, especially in view of the existence of a reliable subcutaneous (SC) insulin order set at our institution, but not surprising, as this is an inherently complex process. The severity of illness, the amount and mode of nutritional intake, geographic location, and provider team may all be in flux at the time of this transition. A few centers have demonstrated that a much improved transition is possible,36 however many of these solutions involve technology or incremental personnel that may not be available or the descriptions may lack sufficient detail to implement theses strategies with confidence elsewhere.

Therefore, we designed and piloted a protocol, coordinated by a multidisciplinary team, to transition patients from infusion insulin to SC insulin. The successful implementation of this protocol could serve as a blueprint to other institutions without the need for additional technology or personnel.

Methods

Inclusion/Exclusion Criteria

All patients on continuous insulin infusion admitted to the SICU or the MICU/CCU between May 2008 and September 2008 were evaluated for the study (Figure 1). Patients were excluded from analysis if they were on the infusion for less than 24 hours, had a liver transplant, were discharged within 48 hours of transition, were made comfort care or transitioned to an insulin pump. All other patients were included in the final analysis.

Figure 1

Results

A total of 210 episodes of infusion insulin in ICU patients were evaluated for the study from May of 2008 to September 2008 (Figure 1). Ninety‐six of these episodes were excluded, most commonly due to time on infusion insulin <24 hours or transition to comfort care. The remaining 114 infusions were eligible to use the protocol. Because the protocol recommends insulin therapy based on a diagnosis of diabetes, patients were further divided into these subcategories. Of these 114 transitions, the protocol was followed 66 times (58%).

Patients With Diabetes

(Table 1: Patient Demographics; Table 2: Insulin Use and Glycemic Control; Figure 2: Transition Graph).

Figure 2

Table 1.Patient Demographics

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 29 Patients*	Protocol NOT Followed, n = 33 Patients		Protocol Followed, n = 30 Patients	Protocol NOT Followed, n = 9 Patients
Abbreviations: BMI, body mass index; SD, standard deviation; TPN, total parenteral nutrition. * One patient followed the protocol requiring basal insulin solely because they were on high dose steroids. They did not have a medical history of diabetes or an A1c 6%. Full Nutrition: Patient is eating >50% of their meals, on goal tube feeds, or on TPN. Too small of cell size to conduct chi‐square analysis.
Average age, years, mean SD	57.7 12.1	57.8 12.3	0.681	56.5 18.1	62.4 15.5	0.532
Male patients	21 (72%)	21 (63%)	0.58	20 (66%)	7 (77%)	0.691
BMI	30.7 7.2	28.6 6.8	0.180	27 5.4	25.2 3	0.081
History of diabetes*	18 (64%)	25 (86%)	0.07	0	0
Mean Hgb A1c (%)	6.61.2	7.3 1.8	0.136	5.6 0.3	5.4 0.4	0.095
Full nutrition	26 (79%)	24 (61%)	0.131	23 (70%)	9 (100%)
On hemodialysis	5 (17%)	9 (27%)	0.380	3 (10%)	0
On >60 mg prednisone or equivalent per day	7 (24%)	10 (30%)	0.632	0	0

Table 2.Insulin Use and Glycemic Control

	Patients With Diabetes		P Value	Patients Without Diabetes		P Value
	Protocol Followed, n = 33 transitions	Protocol NOT followed, n = 39 transitions		Protocol Followed, n = 33 transitions	Protocol NOT Followed, n = 9 transitions
Abbreviations: BG, blood glucose; LOS, length of stay; n/a, not applicable. * Too small of cell size to conduct chi‐square analysis.
Average infusion rate, hours	3.96 3.15	3.74 3.64	0.1597	2.34 1.5	4.78 1.6	<0.001
Average BG on infusion insulin (mg/dL)	122.5 27.5	122.5 31.8	0.844	115.1 22.7	127.5 27.2	0.006
Average basal dose (units) given	34.5 14.4	14.4 15.3	<0.001	0	32.7	<0.001
Hours before () or after (+) infusion stopped basal insulin given	1.13 0.9	11.6 9.3	<0.001	n/a	0.33	*
Average BG 6 hours post transition (mg/dL)	143.7 39.4	182 62.5	0.019	150.2 54.9	142.1 34.1	0.624
Average BG 0 to 24 hours post transition (mg/dL)	167.98 50.24	211.02 81.01	<0.001	150.24 54.9	150.12 32.4	0.600
Total insulin used from 0 to 24 hours (units)	65 32.2	26.7 25.4	<0.001	3.2 4.1	51.3 30.3	<0.001
Average BG 25 to 48 hours post transition (mg/dL)	176.1 55.25	218.2 88.54	<0.001	153 35.3	154.4 46.7	0.711
Total insulin used from 25 to 48 hours (units)	60.5 35.4	28.1 24.4	<0.001	2.8 3.8	44.9 34	<0.001
# of patients with severe hypoglycemia (<40 mg/dL)	1 (3%)	1 (2.6%)	*	0	1	*
# of patients with hypoglycemia (4170 mg/dL)	3 (9%)	2 (5.1%)	*	1	0	*
% of BG values in goal range (80180 mg/dL) (# in range/total #)	60.2% (153/254)	38.2% (104/272)	0.004	80.1% (173/216)	75.4% (49/65)	0.83
# of patients with severe hyperglycemia (>300 mg/dL)	5 (15.2%)	19 (48.7%)	0.002	1 (3%)	1 (11.1%)	*
LOS from transition (days)	14.6 11.3	14 11.4	0.836	25.3 24.4	13.6 7.5	0.168

A total of 62 individual patients accounted for 72 separate transitions in patients with diabetes based on past medical history or an A1c 6% (n = 14). Of these 72 transitions, 33 (46%) adhered to the protocol while the remaining 39 (54%) transitions varied from the protocol at the treatment team's discretion. Despite similar insulin infusion rates and mean glucose values pretransition, patients with diabetes following the protocol had better glycemic control at both 24 hours and 48 hours after transition than those patients transitioned without the protocol. Day 1 mean blood glucose was 168 mg/dL vs. 211 mg/dL (P = <0.001) and day 2 mean blood glucose was 176 mg/dL vs. 218 mg/dL (P = <0.001) in protocol vs. nonprotocol patients with diabetes respectively (Figure 2).

There was a severe hypoglycemic event (40 mg/dL) in 1 patient with diabetes following the protocol and 1 patient not following the protocol within 48 hours of transition. Both events were secondary to nutritional‐insulin mismatch with emesis after insulin in one case and tube feeds being held in the second case. These findings were consistent with our prior examination of hypoglycemia cases.13 Severe hyperglycemia (glucose 300mg/dL) occurred in 5 (15 %) patients following the protocol vs. 19 (49%) patients not following protocol (P = 0.002.) Patients with diabetes following the protocol received significantly more insulin in the first 24 hours (mean of 65 units vs. 27 units, P 0.001) and 24 to 48 hours after transition (mean of 61 units vs. 28 units, p0.001) than those not following protocol.

An alternate method used at our institution and others14, 15 to calculate TDD is based on the patient's weight and body habitus. When we compared the projected TDD based on weight with the TDD using the transition protocol, we found that the weight based method was much less aggressive. For patients following the protocol, the weight based method projected a mean TDD of 46.3 16.9 units whereas the protocol projected a mean TDD of 65 33.2 units (P = 0.001).

Patients with diabetes following protocol received basal insulin an average of 1.13 hours prior to discontinuing the insulin infusion versus 11.6 hours after for those not following protocol.

Three patients with diabetes following the protocol and 3 patients with diabetes not following the protocol were restarted on infusion insulin within 72 hours of transition.

LOS from final transition to discharge was similar between protocol vs. nonprotocol patients (14.6 vs. 14 days, P = 0.836).

Figure 3 demonstrates that when used correctly, the protocol provides an extended period of glycemic control up to 12 days post transition. Patients transitioned per protocol had a day‐weighted mean glucose of 155 mg/dL vs. 184 mg/dL (P = 0.043) in patients not following protocol. There was only 1 glucose value less than 40 mg/dL between days 2 to 12 in the protocol group.

Figure 3

Discussion

This study demonstrates the utility of hospitalist‐pharmacist collaboration in the creation and implementation of a safe and effective transition protocol for patients on infusion insulin. The protocol identifies patients appropriate for transition to a basal/nutritional insulin regimen versus those who will do well with premeal correctional insulin alone. Daily mean glucose was improved post transition for diabetic patients following the protocol compared to those not following the protocol without an increase in hypoglycemic events.

We found an equal number of insulin infusion restarts within 72 hours of transition and a similar LOS in protocol vs. nonprotocol patients with diabetes. The LOS was increased for patients without diabetes. This may be due to worse outcomes noted in patients with stress hyperglycemia in other studies.1, 16

The use of the higher multiplier for patients on minimal nutrition led to confusion among many protocol users. The protocol has since been modified to start by averaging the infusion rate over the prior 6 hours and then multiplying by 20 for all patients. This essentially calculates 80% of projected insulin requirements for the next 24 hours based on the patient's current needs. This calculation is then given as 50% basal and 50% nutritional for those on full nutrition vs. 100% basal for those on minimal nutrition. This protocol change has no impact on the amount of insulin received by the patient, but is more intuitive to providers. Instead of calculating the TDD as the projected requirement when full nutrition is obtained, the TDD is now calculated based on current insulin needs, and then doubled when patients who are receiving minimal nutrition advance to full nutrition.

Our study is limited by the lack of a true randomized control group. In lieu of this, we used our patients who did not follow protocol as our control. While not truly randomized, this group is comparable based on their age, gender mix, infusion rate, mean A1c, and projected TDD. This group was also similar to our preprotocol group mentioned in the Introduction.

Additional study limitations include the small number of nondiabetic patients not following the protocol (n = 9). We noted higher infusion rates in nondiabetics not following protocol versus those following protocol, which may have driven the primary team to give basal insulin. It is possible that these 9 patients were not yet ready to transition from infusion insulin or had other stressors not measured in our study. Unfortunately their small population size limits more extensive analysis.

The protocol was followed only 50% of the time for a variety of reasons. Patients who transitioned at night or on weekends were monitored by covering pharmacists and physicians who may not have been familiar with the protocol. Many physicians and nurses remain fearful of hypoglycemia and the outcomes of our study were not yet available for education. Some reported difficulty fully understanding how to use the protocol and why a higher multiplier was used for patients who were on minimal nutrition.

Efforts to improve adherence to the protocol are ongoing with some success, aided by the data demonstrating the safety and efficacy of the transition protocol.

Conclusion

By collaborating with ICU pharmacists we were able to design and implement a protocol that successfully and safely transitioned patients from infusion insulin to subcutaneous insulin. Patients following the protocol had a higher percentage of glucose values within the goal glucose range of 80 mg/dL to 180 mg/dL. In the future, we hope to automate the calculation of TDD and directly recommend a basal/bolus regimen for the clinical provider.