Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: Results of a clinical trial

Abstract

BACKGROUND:Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non–intensive care unit (ICU) setting.OBJECTIVE:To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia.DESIGN:Before‐after trial.SETTING:Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists.PATIENTS:Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia.INTERVENTION:A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case‐based educational workshops and lectures to nurses, physicians, and PAs.MEASUREMENTS:Mean percent of glucose readings per patient between 60 and 180 mg/dL; percent patient‐days with hypoglycemia; insulin use patterns; and hospital length of stay.RESULTS:The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%‐18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% CI, 0.6–2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% CI, 2.0–9.9) and adjusted length of stay decreased by 25% (95% CI, 9%‐44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3.CONCLUSIONS:This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin ordering practices and glycemic control among non‐ICU medical patients. Journal of Hospital Medicine 2009;4:16–27. © 2009 Society of Hospital Medicine.

Clinical Inertia during Postoperative Management of Diabetes Mellitus: Relationship between Hyperglycemia and Insulin Therapy Intensification

“…23 Studies by others have shown that a combination of structured insulin orders combined with staff education to partially alleviates clinical inertia in the hospital. [24][25][26][27][28][29] Our facility implemented computerized order entry in 2007 that includes provisions to order basal, prandial, and correction insulin treatment that are accessible to all practitioners. However, despite all these efforts at our institution, clinical inertia remains evident among the inpatient surgical practices.…”

Failure to Control Hyperglycemia in NonCritically Ill Diabetes Patients despite Standard Glycemic Management in a Hospital Setting

“…Possible electronic implementation approaches are validated alerts and guidelines on the prescription of antidiabetic medication, especially insulin. 1,19,[27][28][29] In summary, our results show insufficient control of hyperglycemia in noncritically ill hospitalized patients with diabetes despite considerable glycemic management efforts. While the data indicate substantial glycemic management effort in the care of diabetes patients, it did not result in appropriate glycemic control according to recent guidelines.…”

Addressing hyperglycemia from hospital admission to discharge

“…One study 40 showed incremental benefits in BG control after switching from SSI to an insulin management algorithm, with a significant decrease in the amount of time BG was uncontrolled (BG4180 mg/ dL; 30% down from 38%, p50.005). The second study 62 showed a clear improvement in outcomes with a 10% improvement in patients achieving BG between 160 and 180 mg/dL, a 23% decrease in length of stay (112 vs. 86 h), and a decreased need for supplemental insulin (8% of patients down from 29%). Neither study aggressively titrated to low BG targets, thereby avoiding hypoglycemia, but both studies required tightly scheduled BG monitoring and insulin delivery, and strict algorithms for lowering BG.…”