Implementing a standardized workflow for early detection of steroid-induced hyperglycemia in allogeneic stem cell transplant recipients: A quality improvement project

• There are no standardized guidelines for monitoring hyperglycemia after starting glucocorticoids (GCs). • Postprandial blood glucose monitoring is a good alternative for earlier identification of steroid-induced hyperglycemia (SIH) based on the peak elevation of glucose after taking glucocorticoids. • This quality improvement project was implemented as part of a Doctor of Nursing Practice project for the University of Kansas School of Nursing to standardize glucose monitoring after the initiation of GCs for the treatment of acute or chronic graft versus host disease. • This project showed that daily postprandial blood glucose monitoring is superior for the earlier identification and treatment of SIH when compared to monitoring at routine clinic visits alone. Steroid-induced hyperglycemia (SIH) worsens overall outcomes in the allo-SCT population. Currently, there is no standardized workflow for monitoring SIH. To address this need, a quality improvement (QI) initiative was implemented, as part of a Doctor of Nursing Practice project for the University of Kansas School of Nursing, to standardize glucose monitoring after the initiation of glucocorticoids (CGs) for the treatment of acute or chronic graft-versus-host-disease (GVHD). This QI initiative aimed to decrease the median time to identification of SIH and the initiation of treatment in allo-SCT recipients on GCs for GVHD. The study took place at a large Midwestern blood and marrow transplant program. Patients diagnosed with acute or chronic GVHD and prescribed ≥0.5 mg/kg/day prednisone equivalent (PE) steroids were requested to monitor postprandial blood glucose values for 14 days. A control group (retrospective chart review) was used for comparison. Time to the identification of SIH was compared between the two groups, as well as the time to treatment of hyperglycemia. Over 9 weeks, 19 patients enrolled in the QI initiative. The control group consisted of 21 patients. The median PE steroid dose was 1 mg/kg/day in both groups (p=0.8100). Eighteen of the 19 patients (95%) had at least 1 blood glucose (BG) > 180 mg/dL and only 6 of 21 patients (29%) had at least 1 BG > 180 mg/dL (p<0.0001). The median time to a BG > 180 mg/dL was 1.5 days in the QI group and 7 days in the control group (p=0.0232). The median time to insulin was 2 days in the QI group and 10 days in the control group (p=0.0355). This project demonstrated that daily postprandial blood glucose monitoring is superior for the earlier identification and treatment of SIH when compared to monitoring at routine clinic visits alone.