Question from Maria Gomes MD (AACE Member):
I use insulin-glucose infusions extensively in the care of diabetic patients in hospital settings. I notice that when moving patients from the intensive care unit to the telemetry unit in our hospital, it is not uncommon that the nurses make mistakes in handling the infusion, which works so well in the ICU setting. I think the problem is the poor training of the nurses, and I am sometimes frustrated because it is hard to teach them how to best handle the infusions.

Answer from Richard Hellman, MD, FACP, FACE:
You have correctly focused on what is an all too common problem in hospitals today. In a study by Peter Pronovost, a study that collected data from more than 100 hospitals in 3 different countries, it was reported that only 58% of the supervisors felt that their trainees had adequate knowledge and had adequate education and supervision. In order to promote safety in all clinical settings, it is key that we closely examine the education program of those who care for our patients. The solution, in this case, would be to provide more robust educational formats to both initially train the nurses, evaluate their knowledge in this area, and provide refresher courses in order to help them use these algorithms correctly.

Question from Howard Rosen MD, FACE:
I have often seen hypoglycemia develop in the hospital setting because patients receive insulin and then are transported by the transportation department to another part of the hospital and become hypoglycemic in another part of the hospital. What is the best way to deal with this problem?

Answer from Richard Hellman, MD, FACP, FACE:
Unfortunately the problem you have brought up is extremely common. Dr. David Bates, a leading patient-safety expert in Boston, has stated that the example you gave represents one of the most common causes of hypoglycemia in hospital settings. Another related problem is when, after insulin is given, a meal is either delayed or sent by mistake to some other room. In both cases there is an imbalance between insulin and the meal, and hypoglycemia results. In order to promote a culture of safety within the clinical unit, it is necessary that people discuss how to best coordinate their responsibilities. Everyone needs to communication better with each other if these common problems are to be eliminated. In dedicated diabetes units, these problems can and have been completely eliminated merely by better communication and education of all of the people involved in patient care.

Question from Kent Ishihara, MD (AACE Member):
As a practicing endocrinologist, I find that I often need information on new drugs, about which we have little joint experience because they were just approved by the FDA, but the FDA does not provide that initially. How can we improve this?

Answer from Richard Hellman, MD, FACP, FACE:
This is a very important problem which highlights the shortcomings of the present method of drug approval in the United States. There is good evidence to show that the risk-benefit ratio of drugs varies widely with different comorbid or demographic groups. Often, because of changes in drug metabolism because of age or comorbid conditions, the drug dosage, usefulness, and safety may be different. One option, used in some countries, is to have a “limited roll-out”, that is, a drug is approved conditionally but is identified as a new drug so people understand that there is limited data, and it may have different recommendations attached to it just because of the newness. Other suggestions that have been made include developing a robust drug registry so that professional medical societies can rapidly evaluate the drug’s performance regarding quality and safety among different subgroups. This approach is being developed by the American College of Cardiology and might well be something our society may consider, either alone or in conjunction with other organizations.

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