In Brief This article reviews the use of subcutaneous insulin for hospitalized patients. Topics include the rationale for using insulin;scheduled insulin therapy to cover basal and nutritional needs; correction therapy; dose determination; establishment of timing of insulin action appropriate to the pattern of carbohydrate exposure; education of caregivers;and the design of hospital systems that will promote quality and help staff to manage complexity.

Hypoglycemia with intensive insulin therapy is independently associated with increased risk for respiratory complications and prolonged hospital and intensive care unit lengths of stay after cardiac surgery. In our study, hypoglycemia was not independently associated with increased risk of death.

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A 65-year-old male with diabetes and peripheral neuropathy (last glycosylated hemoglobin level 9.4 %) reported spontaneous development of a 14 × 9 cm, tense bulla on the medial aspect of his right lower extremity (Fig. 1). The lesion was non-inflammatory in appearance with a non-erythematous base and clear serous content. Nikolsky's sign was negative. There were no other bullous skin lesions. The patient had no prior history of dermatologic disorders and denied any recent trauma, acute edema, or change in medications. The massive bulla spontaneously ruptured and healed without complication. The distribution and appearance of the bulla led to a clinical diagnosis of bullosis diabeticorum, a rare but likely underdiagnosed condition in patients with diabetes. Lesions appear rapidly, primarily in an acral distribution in areas of otherwise normal-appearing skin, and range from a few centimeters to very large. The differential diagnosis includes friction bullae, bullae due to burns or edema, bullous fixed drug reaction, bullous pemphigoid, and epidermolysis bullosa acquisita. Bullae resolve spontaneously but can recur, and secondary infection after rupture is a concern. The etiology of bullae formation in diabetics is unknown, although theories include microangiopathy 1 and an enhanced vulnerability to trauma. 2

Health systems are utilizing insulin dosing algorithms (IDA) within the EMR to adjust IV insulin (IVI). EndoTool IV (ETIV) is IDA software for blood glucose (BG) management which evaluates BG values to recommend IV insulin/dextrose doses to adjust the BG level within a target range. ETIV was integrated with our EMR as part of a quality project to reduce hypoglycemia in IVI patients. The tool was started in two of our ICUs that treat our DKA admissions. Dashboards capture BG values defined as hypoglycemia BG less than 70 mg/dL, severe hypoglycemia BG less than 40 mg/dL, and length of hospital stay for diabetic ketoacidosis (DKA LOS). Dosing modalities were available for hyperglycemia, HHS or DKA; 90% of ordering providers selected the hyperglycemia mode. We report results on the first 437 patient runs. The population was 60 % type 2 DM, 16 % type 1 and the remainder unknown. Average BG at IVI start was 221.5 mg/dL with an average time to goal of 4.7 hours. This translated to an average time on IVI of 15.5 hours for the group studied. Adoption of ETIV was associated with an approximate 5-fold reduction in hypoglycemic BG values, elimination of observed severe hypoglycemic BG values and a reduction in length of stay for DKA LOS. We conclude that ETIV is effective in reducing hypoglycemic events in persons treated with IVI and may reduce DKA LOS. Hospital systems considering a quality improvement project to reduce inpatient hypoglycemia for IVI should consider adopting an IDA. Disclosure J.Aloi: Research Support; Abbott Diabetes, Medtronic. C.E.Price: None. C.O.Usoh: None. K.Dunn: None.