Improving Diabetes Care in the Hospital Using Guideline-Directed Orders

Abstract

Improving glycemic control for inpatients with diabetes remains a formidable challenge. While the use of inadequate and nonphysiological insulin regimens is widespread, there are many potential barriers to improving physician and nursing hospital practices in this area. This article describes an integrated program that utilizes subcuta-neous and intravenous insulin order forms incorporating guidelines that encourage more appropriate insulin therapy in the hospital. This approach has resulted in a significant decrease in one factor associated with suboptimal insulin use for inpatients: reliance on sliding-scale short-acting insulin alone for blood glucose control.

Management of Diabetes and Hyperglycemia in Hospitals

“…The concentrated infusion is piggybacked into a dedicated running intravenous line. Highly concentrated solutions may be reserved for patients requiring volume restriction; otherwise, solutions as dilute as 1 unit insulin per 10 ml normal saline may be used (306,307). When the more dilute solutions are used, at least 50 ml of the insulin-containing solution should be allowed to run through the tubing before use (308).…”

“…Many institutions use insulin infusion algorithms that can be implemented by nursing staff (2,189,194,197,200,280,298,301,304,307,314). Algorithms should incorporate the concept that maintenance requirements differ between patients and change over the course of treatment.…”

“…A mathematical algorithm can be reduced to tabular form, in which each column indicates different insulin infusion rates necessary to maintain target range control and shows appropriate infusions rates necessary for correction at given blood glucose levels, accompanied by a rule for shifting between columns (see online appendix 2 [available at http:// care.diabetesjournals.org]) (314). It is prudent to provide inservice teaching of pharmacy, nursing, and physician staff on the use of insulin drip protocols (307). Transition from intravenous to subcutaneous insulin therapy.…”

“…In evaluation of institutional performance, variability of treatment strategies among providers may itself be interpreted as a risk factor for unsafe practices, and "standardization to excellence" may be interpreted as a surrogate for patient safety (322,383). In the care of diabetes, implementation of standardized order sets for scheduled and correction-dose insulin may reduce reliance on sliding scale management (307). A team approach is needed to establish hospital pathways.…”

Glucose Management by Registered Nurses for Adult Patients Hospitalized in Medical Wards: Structured Guidelines (Protocol) and Working Process

“…12 One of the main recommendations from these studies is to focus on the increasing need for standardization of care in such patients to control glucose levels and manage care according to guidelines. 1,3,13,14 Despite the significance of this issue and the prevalence of the condition in medical wards, few studies have addressed the management of patients who receive subcutaneous insulin according to structured protocols. A retrospective study 15 conducted at the Mayo Clinic medical center in the United States between 2001 and 2004 examined treatment of hyperglycemia in patients who were diagnosed with diabetes or hyperglycemia and hospitalized in non-ICU wards.…”