A1c TestingTeam G, Chart ReviewSAMUEL LAI

1/2015

Goals + Methods

GOALS

Promote cost-consciousness in our inpatient ward teams

Specifically, reducing unnecessary repeat lab testing

Methods

Chart review of the 15 patients admitted to Team G

Reviewing if and when A1c was ordered

Evaluating appropriate use of A1c testing given current guidelines

Guidelines

When is A1c testing warranted?

No inpatient guidelines, but the following are outpatient guidelines

Fasting glucose > 100 mg/dL, Random Glucose > 200 mg/dL with symptoms

Comorbidities of HTN, HLD

Diabetic with no A1c within 3 months (including those with no previous records)

When is it not warranted?

No history of DM II, HTN, HLD

A1c charted within the last 3 months

Initial Evaluation

Out of 15 patients

6 patients with A1c checked

5 patients during this admission

1 patient within the last 3 months

Appropriate?

Of the 6 patients, all 6 were appropriate usages of A1c

2 pts admitted for diabetes related illnesses (DKA)

All 6 had risk factors for diabetes, including HTN, HLD or BMI > 25

The Table

Patient’s History A1c History Appropriate?

33 y/o DM I, ESRD, CRPS admitted for DKA

Last A1c was 10.7 on 10/28A1c checked, 12.1 on 1/22

Yes, last A1c was > 3 months ago in a diabetic patient

54 y/o IDDM, HFrEF, Obesity, HLD admitted for R ankle fracture

Last A1c = none in chart (Transfer)A1c checked, 9.6 on 1/1

Yes, no known A1c in patient with IDDM

58 y/o schizophrenia, IDDM, admitted for auditory

hallucinations

Last A1c = none in chart (Transfer)A1c checked, 8.9 on 1/21

Yes, no known A1c in patient with IDDM

44 y/o DM II, HIV admitted for pneumonia

Last A1c = 5.8 on 9/2014A1c checked, 6.6 on 1/22

Yes, DM II patient with last A1c > 3 months ago

32 y/o DM II admitted for DKA Last A1c = none in chartA1c checked, 6.8 on 1/16

Yes, DKA patient with no A1c listed in our charts

69 y/o HTN, Afib, Hx of ICH, admitted for sepsis from UTI

Last A1c = 4.9 on 12/31No A1c checked on this admission

Yes, no repeat A1c as last one was 3 months ago, normal

Discussion

Should we test more?

Other patients were:

35 y/o = DM II, 3 DM meds, no A1c in our files

55 y/o = morbidly obese, FSG in > 150s, cirrhotic patient

43 y/o = IDDM, osteomyelitis 2/2 ulcer, no A1c in our files

84 y/o = DM II, fractured hip, daily glucose in 200s, no A1c in our files

32 y/o = morbidly obese, HTN, no A1c in our files

All of these patients meet criteria for A1c testing

Previous Study

Done by Samantha Harris in 2012

Showed similar findings as above for 15 patients on Team D

Patient Pertinent History

A1c / date performed

Appropriate vs. Inappropriate

1)History of diabetes, presented with cellulitis

8.3%

1/23/12

Appropriate

Did not recheck during hospitalization

2)No history of diabetes, presented with SOB from COPD

6.0%

2/1/12

? Ordered by Gottschalk PCP

Did not recheck during hospitalization

3)Admitted for DKA, and sepsis from pyelonephritis

14.7%

2/14/12

Appropriate

No prior A1c on file, no prior admission.

4)Admitted for PNA, AMS and meningitis, with impaired fasting glucose levels 110-180

6.2%

2/12/12

Appropriate

5)History of diabetes, admitted with AMS from metastatic cancer

7.6%

2/12/12

Appropriate

No prior A1c on file, Starting steroids.

6)History of diabetes, hyperglycemia, admitted for AMS

9.4%

2/15/12

Appropriate

No prior A1c of file.

Problems/Concerns

Do we not check enough?

As noted in previous slide, multiple reasons to check

However, would it have changed management?

Did patients have transfer labs with A1c on them?

Did we forego checking as patient had out of system PCP?

Small sample size

Patients on steroids, active infection, may not need A1c