Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm

Abstract

BACKGROUND:Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported.OBJECTIVE:Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control.DESIGN:Prospective observational.SETTING:400‐bed academic center.PATIENTS:Adult non‐critical care inpatients with diabetes or hyperglycemia and point‐of‐care (POC) glucose testing.INTERVENTIONS:Structured insulin orders, insulin management algorithm.MEASUREMENTS:Percent of insulin orders with basal insulin. Percent uncontrolled patient‐stays (day‐weighted mean glucose ≥180 mg/dL) and uncontrolled patient‐days (patient‐day mean glucose ≥180 mg/dL). Percent of monitored patient‐days and patient‐stays with hypoglycemia (glucose ≤60 mg/dL) and severe hypoglycemia (glucose ≤40 mg/dL).RESULTS:The percent sliding scale only insulin regimens decreased (72% versus 26% with structured insulin orders, P < 0.0001 chi square). The percent of uncontrolled patient‐days was 37.8% versus 33.9% versus 30.1% (P < 0.005) (TP1–Baseline; TP2–Structured insulin orders; TP3–Orders plus Algorithm). Expressed as relative risk with 95% confidence interval (RR with CI), the RR of an uncontrolled patient‐stay was reduced from baseline to 0.91 (CI 0.85–0.96) in TP2, and to 0.84 (CI 0.77–0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 POC values. The percent of patient‐days with hypoglycemia was 3.8%, 2.9%, and 2.6% in 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59‐0.78). Similar reductions were seen in risk for hypoglycemic patient‐stays.CONCLUSIONS:Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms. Journal of Hospital Medicine 2009;4:3–15. © 2009 Society of Hospital Medicine.

Management of hospitalized type 2 diabetes mellitus patients

“…[19] The most common risk factors are older age, change in nutritional intake (reduced oral intake, emesis, unexpected interruption of enteral or parenteral feedings), inappropriate administration of short-acting insulin's relation to meals and failure to adjust treatment when we reduce the infusion rate of intravenous dextrose or steroid therapy. [20,21] Hypoglycemia in hospitalized T2DM patients has been associated with poor outcomes and 2.8 days longer hospital stay. [22] However, other studies suggest that the increased mortality rate associated with hypoglycemia is only with spontaneous hypoglycemia rather than drug-associated hypoglycemia.…”

Prevention of Hospital Hypoglycemia by Algorithm Design: A Programming Pathway for Electronic Order Entry

“…A well designed order set facilitates individualization of patient care. Guidelines may be appended to or embedded within order sets, together with references to supportive medical literature (Donaldson et al 2006;Hermayer et al, 2009;Lee et al 2008;Maynard et al, 2009;Schnipper et al, 2010;Trujillo et al, 2008;Wexler et al, 2010). Protocols executed through order sets were thought to reduce medical errors, improve safety, and increase adherence to those guidelines that were supported by medical evidence.…”

“…Paper statements of guidelines adjunctive to computerized order entry were developed (Lee et al, 2008). The relative risk (RR) of an uncontrolled patient-stay was reduced from baseline to 0.91 in TP2, and to 0.84 (CI 0.77-0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 point-of-care glucose values (Maynard et al, 2009). The percent of patient-days with hypoglycemia was 3.8%, 2.9%, and 2.6% in the 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59-0.78).…”

The case for supporting inpatient glycemic control programs now: The evidence and beyond

“…64 Unfortunately, the opportunity that hospitalization presents to assess, educate, and intervene frequently is underused. 1,8,51,65 …”

“…Systems approaches to avoid the errors outlined above can minimize or even reverse the increased risk of hypoglycemia expected with tighter glycemic targets. 51 …”