Basal-Bolus Insulin Protocols Enter the Computer Age

Abstract

Diabetes affects approximately one quarter of all hospitalized patients. Poor inpatient glycemic control has been associated with increased risk for multiple adverse events including surgical site infections, prolonged hospital length of stay, and mortality. Inpatient glycemic control protocols based on physiologic basal-bolus insulin regimens have been shown to improve glycemia and clinical outcomes and are recommended by the American Diabetes Association, the American Association of Clinical Endocrinologists, and the Society of Hospital Medicine for inpatient glycemic management of noncritically ill patients. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act will catalyze widespread computerized medication order entry implementation over the next few years. Here, we focus on the noncritical care setting and review the background on inpatient glycemic management as it pertains to computerized order entry, the translation and efficacy of computerizing glycemic control protocols, and the barriers to computerizing glycemic protocols.

Sliding Scale Insulin vs Basal-Bolus Insulin Therapy in Long-Term Care: A 21-Day Randomized Controlled Trial Comparing Efficacy, Safety and Feasibility

“…47 The introduction of B-BI computerized glycemic control protocols and its barriers will offer challenges in the future. 48 Finally, as 1 author stated regarding SSI "will the false idol finally fall?". 49…”

Glucose control in non‐critically ill inpatients with diabetes: towards closed‐loop

“…Larger feasibility and efficacy studies in inpatient needed Further assessment needed in various inpatient population Further development of sc -sc closed-loop system needed for use in general wards insulin sensitivity is needed [76,77]. Most systems allow the ordering of blood glucose monitoring and specifications of patient's dietary intake, in an attempt to mitigate against hypoglycaemic events in hospital.…”

“…These include accessing and ordering formulary-based basal, nutritional and correction insulin. The starting doses of insulin are commonly estimated via a weight-based insulin dose calculator, with correction scales offered when variability in insulin sensitivity is needed [76,77]. Most systems allow the ordering of blood glucose monitoring and specifications of patient's dietary intake, in an attempt to mitigate against hypoglycaemic events in hospital.…”

Slip sliding away: the need for continued discussion of the use of insulin sliding scale in hospitalized patients

“…This report should further energize the campaign to eliminate stand-alone RISS as an acceptable mode of insulin administration. Insulin order sets in hospitals that require consideration of basal, nutritional and correction needs, incorporating assessment of insulin sensitivity and nutritional contingencies, are now being used, demonstrate improved patient outcomes [9,13,14] and should be the standard of care. We now have the tools to employ physiologic insulin regimens so that we can reach the destination of improved in-hospital glycemic control without slip sliding away.…”