Background: Diabetes mellitus and hyperglycemia affect 25% to 40% of hospitalized patients and are associated with prolonged hospital stay, increased infections, and mortality. The 2026 American Diabetes Association (ADA) Standards of Care recommend insulin initiation for persistent hyperglycemia ≥180 mg/dL, with glycemic targets of 100-180 mg/dL for noncritically ill patients and 140-180 mg/dL for critically ill patients. The Centers for Medicare & Medicaid Services (CMS) tracks severe glucose excursions (≥300 mg/dL and ≤40 mg/dL) as electronic clinical quality measures (eCQMs) under the Hospital-Acquired Condition Reduction Program (HACRP). These thresholds represent the more extreme glycemic events that CMS tracks for regulatory reporting and payment penalties, distinguishing them from the broader ADA clinical classification. Effective this year, hospitals are required to track and report eCQMs related to hyperglycemia and hypoglycemia with financial penalties for non-compliance. Additionally, these metrics may become visible in CMS and other quality measurement systems to increase public transparency in regard to inpatient glucose control. Multiple studies have demonstrated that pharmacist interventions can improve glycemic control and reduce hypoglycemic events. The purpose of this study was to assess the impact of pharmacy involvement in glycemic monitoring within our facility’s inpatient population.
Methods: This single-center, retrospective, comparative study evaluated glucose levels in patients ≥18 years who were admitted to a community hospital. Glucose levels drawn during continuous insulin infusions were excluded. The pre-intervention group (December 1, 2024–February 28, 2025) was compared to the post-intervention group (December 1, 2025–February 28, 2026) following protocol implementation and pharmacist education. Patients were identified using automated electronic health record (EHR) alerts that flagged patients who met predefined glycemic criteria. Hyperglycemia alerts are generated when blood glucose exceeds 300 mg/dL on a single occurrence or exceeds 180 mg/dL on two occasions within 24 hours. Hypoglycemia alerts are generated for any blood glucose value <70 mg/dL. Pharmacists reviewed flagged patients' A1c, insulin regimens, glucose trends, nutritional status, renal function, and steroid use before providing recommendations to providers. Primary outcomes included the proportion of glucose measurements ≥300 mg/dL and ≤40 mg/dL. Secondary outcomes included intermediate ranges: ≥180 to <250 mg/dL, ≥250 to <300 mg/dL, and >40 to ≤70 mg/dL. The study was powered to detect a 10% relative reduction in severe hyperglycemia (≥300 mg/dL) at 80% power. Statistical significance was assessed using chi-square tests, with p < 0.05 considered significant.
Results: A total of 74,060 blood glucose measurements were analyzed in the pre-intervention period compared to 67,682 measurements in the post-intervention period. There was no statistically significant difference among baseline characteristics between the two groups. The proportion of severe hyperglycemic measurements (≥300 mg/dL) decreased significantly from 3.19% to 2.94% (ARR 0.25%; p = 0.007). The proportion of severe hypoglycemic measurements (≤40 mg/dL) showed no significant change (0.16% vs 0.15%; ARR 0.01%; p = 0.77). Significant reductions were observed in measurements ≥180 to <250 mg/dL (17.20% vs 14.84%; ARR 2.36%; p < 0.001) and ≥250 to <300 mg/dL (4.46% vs 3.80%; ARR 0.66%; p < 0.001). Level 1 hypoglycemia (>40 to ≤70 mg/dL) showed no difference (1.55% vs 1.66%; ARR −0.11%; p = 0.09).
Conclusions: Implementation of a glycemic monitoring protocol with pharmacist review was associated with significant reductions in severe and intermediate hyperglycemic levels without increasing the incidence of hypoglycemia. These findings support pharmacist involvement in improving glucose control in an inpatient setting. Future directions include the development and implementation of a pharmacist-driven glucose management protocol within our facility. Further evaluation would need to be done to assess patient-level outcomes such as length of stay, infection rates, and 30-day readmissions.
