Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital

Differences in hospital glycemic control and insulin requirements in patients recovering from critical illness and those without prior critical illness

Introduction

Hospital patients recovering from critical illness on general floors often receive insulin therapy based on protocols designed for patients admitted directly to general floors. The objective of this study is to compare glycemic control and insulin dosing in patients recovering from critical illness and those without prior critical illness.

Methods

Medical record review of blood glucose measurements and insulin dosing in 25 patients under general ward care while transitioning from the intensive care unit (transition group) and 25 patients admitted directly to the floor (direct floor group).

Results

Average blood glucose did not differ significantly between groups (transition group 9.49 mmol/L, direct floor group 9.6 mmol/L; P = 0.83). Significant differences in insulin requirements were observed between groups with average daily doses of 55.9 units in patients transitioning from the intensive care unit (ICU) versus 25.6 units in the direct floor group (P = 0.004).

Conclusions

Patients recovering from critical illness required significantly larger doses of insulin than those patients admitted directly to the floor. Managing insulin therapy in patients transitioning from the ICU may require greater insulin doses.

Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial

OBJECTIVE

To determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia.

METHODS

We conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital's computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL.

RESULTS

Between April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose <40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58).

CONCLUSION

The use of an order set built into a hospital's CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program.

Hyperglycemia management using insulin in the acute care setting: therapies and strategies for care in the non-critically ill patient

BACKGROUND

Hyperglycemia is prevalent in hospitalized non-critically ill patients and is associated with higher morbidity and mortality. Poor glycemic control is related to elevated costs due to longer hospital stays and higher rates of complications.

OBJECTIVE

To review current literature evaluating treatment strategies for management of hyperglycemia in the non-critically ill hospitalized patient and to discuss the role of pharmacists in glycemia management.

DATA SOURCES

A literature review (January 2000-January 2010) was conducted via PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. MeSH terms for diabetes were used along with stress hyperglycemia, insulin therapy, and insulin analogs in combination with non-critically ill, hospitalized, acute care, or inpatient.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources were reviewed for inclusion. Clinical trial reports, practice guidelines, and reviews involving insulin therapies and/or quality improvement initiatives for hyperglycemia in the acute care setting were evaluated. A total of 133 citations were reviewed and an additional 11 citations were identified from reference lists.

DATA SYNTHESIS

The association between hyperglycemia and increased mortality is recognized in the acute care setting among critically ill patients; however, data to support glycemia management in non-critically ill patients continue to be established. National consensus guidelines support strategies for glycemia control that focus on insulin therapy and treatment-driven protocols. These initiatives can result in quality improvement when led by multidisciplinary teams, including pharmacists. Literature supports a pharmacist role in glucose monitoring and insulin dosing.

CONCLUSIONS

Management of hyperglycemia is a critical component of acute care. Insulin treatment regimens and protocols for non-critically ill patients in the acute care setting are evolving with recognition of ideal glucose targets to prevent adverse outcomes. Glycemia management can be complex and presents opportunities for pharmacist involvement.

The nuts and bolts of subcutaneous insulin therapy in non-critical care hospital settings

In non-critical care settings, patients with hyperglycemia experience increased morbidity and mortality. Despite an increased recognition of the importance of treating inpatient hyperglycemia, many patients are still not adequately controlled. Insulin offers flexibility to address varying glucose levels and therefore is the preferred therapy to achieve recommended targets and manage hyperglycemia. Traditional sliding-scale insulin regimens often ineffectively control blood glucose levels as they are unable to mimic physiologic insulin secretion. Basal-bolus insulin regimens are recognized as a more effective way to correct hyperglycemia in non-critical care settings and a systematic glycemic control program is necessary to address hyperglycemia while minimizing hypoglycemia. Critical components of these programs include addressing barriers to glycemic control, understanding varying needs of different types of patients, and developing standardized subcutaneous insulin orders to achieve target glucose levels. This article provides strategies for using insulin in non-critical care settings to facilitate glycemic control.

Incretin-based therapies: review of the outpatient literature with implications for use in the hospital and after discharge

A large percentage of critically ill adult inpatients have type 2 diabetes, which may be undiagnosed or uncontrolled during hospitalization. Hyperglycemia complicates the therapeutic management of inpatients and leads to adverse outcomes, and intensive glycemic control with insulin reduces morbidity and mortality. Insulin therapy, however, is labor-intensive and time-consuming. More important, long-standing protocols such as the sliding scale do not provide adequate glucose control. Although more research is needed to determine the best methods for treating hyperglycemia in-hospital, the importance of achieving better glycemic control while reducing the risk of hypoglycemia has been demonstrated. Post-discharge diabetes care is equally important, as it is essential in improving long-term outcomes after a hospital stay. Hospital care providers can play an important role in effective antihyperglycemic regimens in patients with diabetes prior to discharge. Post-discharge management is a formidable challenge because of the availability of an array of oral antidiabetes agents, including metformin, sulfonylureas, and thiazolidinediones, each with distinct therapeutic and adverse event profiles. Incretin-based therapies offer a potentially useful option for post-discharge therapy, and possibly for inpatient diabetes treatment. Incretins are effective, safe, and well-tolerated; they are easier for patients to use compared with insulin injections (eg, continual glucose monitoring is not required); and they may provide long-term improvement of cardiovascular parameters and beta-cell function. This review examines the challenges to achieving glycemic control in the hospital setting and summarizes clinical data on the efficacy and safety of incretin-based therapies in their use in the hospital and after discharge.

Development of computer-based training to enhance resident physician management of inpatient diabetes

BACKGROUND

Treating hyperglycemia promotes better outcomes among inpatients. Knowledge deficits about management of inpatient diabetes are prevalent among resident physicians, which may affect the care of a substantial number of these patients.

METHODS

A computer-based training (CBT) curriculum on inpatient diabetes and hyperglycemia was developed and implemented for use by resident physicians and focuses on several aspects of the management of inpatient diabetes and hyperglycemia: (1) review of importance of inpatient glucose control, (2) overview of institution-specific data, (3) triaging and initial admission actions for diabetes or hyperglycemia, (4) overview of pharmacologic management, (5) insulin-dosing calculations and ordering simulations, (6) review of existing policies and procedures, and (7) discharge planning. The curriculum was first provided as a series of lectures, then formatted and placed on the institutional intranet as a CBT program.

RESULTS

Residents began using the inpatient CBT in September 2008. By August 2009, a total of 29 residents had participated in CBT: 8 in family medicine, 12 in internal medicine, and 9 in general surgery. Most of the 29 residents confirmed that module content met stated objectives, considered the information valuable to their inpatient practices, and believed that the quality of the online modules met expectations. The majority reported that the modules took just the right amount of time to complete (typically 30 min each).

CONCLUSIONS

Improvement in inpatient diabetes care requires continuous educational efforts. The CBT format and curriculum content were well accepted by the resident physicians. Ongoing assessment must determine whether resident practice patterns are influenced by such training.

Inpatient glucose control: a glycemic survey of 126 U.S. hospitals

BACKGROUND

Despite increased awareness of the value of treating inpatient hyperglycemia, little is known about glucose control in U.S. hospitals.

METHODS

The Remote Automated Laboratory System-Plus (RALS-Plus Medical Automation Systems, Charlottesville, VA) was used to extract inpatient point-of-care bedside glucose (POC-BG) tests from 126 hospitals for the period January to December 2007. Patient-day-weighted mean POC-BG and hypoglycemia/hyperglycemia rates were calculated for intensive care unit (ICU) and non-ICU areas. The relationship of POC-BG levels with hospital characteristics was determined.

RESULTS

A total of 12,559,305 POC-BG measurements were analyzed: 2,935,167 from the ICU and 9,624,138 from the non-ICU. Patient-day-weighted mean POC-BG was 165 mg/dL for ICU and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% for ICU and 31.7% for non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was low at 10.1% for ICU and 3.5% for non-ICU. For ICU and non-ICU there was a significant relationship between number of beds and patient-day-weighted mean POC-BG levels, with larger hospitals (> or = 400 beds) having lower patient-day weighted mean POC-BG per patient day than smaller hospitals (<200 beds, P < 0.001). Rural hospitals had higher POC-BG levels compared to urban and academic hospitals (P < 0.05), and hospitals in the West had the lowest values.

CONCLUSIONS

POC-BG data captured through automated data management software can support hospital efforts to monitor the status of inpatient glycemic control. From these data, hospital hyperglycemia is common, hypoglycemia prevalence is low, and POC-BG levels vary by hospital characteristics. Increased hospital participation in data collection and reporting may facilitate the creation of a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.

Long-term improvements in insulin prescribing habits and glycaemic control in medical inpatients associated with the introduction of a standardized educational approach

BACKGROUND

We carried out an educational strategy to increase physician adherence to 8 recommendations for inpatient evaluation and management of diabetes endorsed by the American Diabetes Association.

METHODS

We evaluated physician attitude, barriers and facilitators to incorporate the proposed recommendations into clinical practice. We analyzed the impact of the educational strategy on process-of-care and outcome variables in 138 patients with type 2 diabetes discharged from the internal medicine department before the intervention, at 3-month and at 9-month after the intervention.

RESULTS

After the educational intervention there was a high motivation of physicians to adhere to the proposed recommendations. The intervention caused a significant reduction of insulin administered by sliding scale (50% vs. 7% vs. 3%, P=0.000), and in the median pre-discharge glycaemic values (185 mg/dL vs. 153 mg/dL vs. 161 mg/dL, P=0.005), in the three periods, respectively. The use basal-bolus-correction insulin dosage increased in postintervention periods (17% vs. 85% vs. 99%, P=0.004). Hypoglycaemia (glycaemia <60 mg/dL) episodes were similar among the three periods (0.30% vs. 0.70% vs. 1.07%, P=0.10). The intervention required improvements to promote haemoglobin(A1c) ordering on admission and diabetes intensification therapy at discharge when needed.

CONCLUSION

Our educational strategy improved physician adoption of practice guidelines.

Perioperative care of the geriatric patient with diabetes or hyperglycemia

The incidence of diabetes in the geriatric population is increasing and the resulting co-morbidities have led to corresponding increases in hospital admissions and surgeries. The weight of the evidence and national guidelines should dissuade us from allowing uncontrolled hyperglycemia in the geriatric perioperative population, but the glycemic target should be modified upwards based on the individual patient characteristics, and in environments that do not have an established track record of reaching more aggressive targets safely. Insulin is the most effective and flexible regimen to achieve inpatient glycemic control, whether by infusion or by subcutaneous basal bolus regimens. Strategies for safe and effective dosing and adjustment of insulin regimens, and methods to avoid hypoglycemia in the perioperative period are outlined. Finally, discharge planning should take into consideration a patient's HbA1c, preoperative glycemic control, inpatient glycemic regimen and control, financial and physical limitations, social support, co-morbid medical conditions, episodes of hypoglycemia, and overall prognosis to create an individualized safe and effective medication regimen for optimal glycemic control at home.

Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes

BACKGROUND

Studies comparing the use of basal bolus with insulin analogs vs. split-mixed regimens with human insulins in hospitalized patients with type 2 diabetes are lacking.

RESEARCH DESIGN AND METHODS

In a controlled multicenter trial, we randomized 130 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dl to receive detemir once daily and aspart before meals (n = 67) or neutral protamine Hagedorn (NPH) and regular insulin twice daily (n = 63). Insulin dose was started at 0.4 U/kg.d for BG between 140 and 200 mg/dl or 0.5 U/kg.d for BG 201-400 mg/dl. Major study outcomes included differences in mean daily BG levels and frequency of hypoglycemic events between treatment groups.

RESULTS

Glycemic control improved similarly in both groups from a mean daily BG of 228 +/- 54 and 223 +/- 58 mg/dl (P = 0.61) to a mean daily BG level after the first day of 160 +/- 38 and 158 +/- 51 mg/dl in the detemir/aspart and NPH/regular insulin groups, respectively (P = 0.80). A BG target below 140 mg/dl before meals was achieved in 45% of patients in the detemir/aspart group and 48% in the NPH/regular group (P = 0.86). During treatment, 22 patients (32.8%) in the detemir/aspart group and 16 patients (25.4%) in the NPH/regular group had at least one episode of hypoglycemia (BG < 60 mg/dl) during the hospital stay (P = 0.34).

CONCLUSIONS

Treatment with basal/bolus regimen with detemir once daily and aspart before meals results in equivalent glycemic control and no differences in the frequency of hypoglycemia compared to a split-mixed regimen of NPH and regular insulin in patients with type 2 diabetes.

Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database

OBJECTIVE

To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care.

METHODS

We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care.

RESULTS

The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports).

CONCLUSION

An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.

Evaluation of hospital glycemic control at US academic medical centers

OBJECTIVE

To evaluate contemporary hospital glycemic management in US academic medical centers.

DESIGN

This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics.

RESULTS

In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%-63%) and timely admission laboratory glucose measurement (range, 39%-97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose <or=110 mg/dL. Hyperglycemia was common, 50% of all patients had >or=1 glucose measurement >or=180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days.

CONCLUSIONS

Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards.

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

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.

Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital

BACKGROUND

Information regarding practitioner beliefs about inpatient diabetes care is limited.

OBJECTIVE

To assess resident physician attitudes about inpatient hyperglycemia and determine perceived barriers to optimal glycemic control in an urban hospital setting.

DESIGN

A previously developed questionnaire was modified and administered. Residents were asked about the importance of inpatient glucose control, desirable glucose ranges, and problems encountered when managing hyperglycemia.

SETTING

Urban teaching hospital.

RESULTS

Of 85 resident physicians, 66 completed the survey (mean age, 31 years; 47% men; 33% in first residency year). Most respondents categorized glucose control as "very important" in critically-ill and perioperative patients but only "somewhat important" in non-critically-ill patients. Most residents said they would target a therapeutic glucose range within the recommended levels. Most residents (88%) also said they felt "very comfortable" or "somewhat comfortable" using subcutaneous insulin therapy, whereas some were "not at all comfortable" with either subcutaneous (11%) or intravenous (18%) administration. In general, respondents were not very familiar with existing institutional policies and preprinted order sets. The most commonly reported barrier to management of inpatient hyperglycemia was lack of knowledge about appropriate insulin regimens and their use. Anxiety about hypoglycemia was only the third most frequent concern.

CONCLUSION

Most residents acknowledged the importance of good glucose control in hospitalized patients and chose target glucose ranges consistent with existing guidelines. Lack of knowledge about insulin treatment options was the most commonly cited barrier to ideal management. Educational programs should emphasize inpatient treatment strategies for glycemic control.

Limited communication and management of emergency department hyperglycemia in hospitalized patients

BACKGROUND

Hyperglycemia is often overlooked and unaddressed in hospitalized patients, and early and intensive management may improve outcomes.

OBJECTIVE

To evaluate communication and early management of emergency department (ED) hyperglycemia.

METHODS

This was a retrospective cohort study of patients with an initial serum glucose >or=140 mg/dL at an urban, academic institution. We randomly selected cases from a consecutive sample of ED visits with at least 1 serum glucose result during a 1-year period. We recorded clinical data and compared the content of inpatient and ED-written discharge instructions.

RESULTS

Of the 27,688 initial ED glucose results during the study period, 3517 (13%) were 140-199 mg/dL, and 2304 (8%) values were >or=200 mg/dL. In our sample of 385 patients, 293 (76%) patients were hospitalized. Inpatient or ED discharge instructions informed 36 (10%) patients of their hyperglycemia and 23 (6%) of a plan for further evaluation and management. There was no difference between inpatient and ED instructions for either of these variables (P = 0.73 and 0.16, respectively). Overall, 107 (55%) patients with glucose values 140-199 mg/dL and 31 (16%) patients with glucose >or=200 mg/dL had no prior diabetes diagnosis. Only 61 (16%) received insulin in the ED for their hyperglycemia, and hyperglycemia was charted as a diagnosis in 36 (9%) cases.

CONCLUSIONS

Most ED patients with even mild hyperglycemia were hospitalized. Recognition, communication, and management of ED hyperglycemia were suboptimal and represent a missed opportunity to identify undiagnosed diabetes and to initiate early glycemic control for hospitalized patients.

Understanding and improving management of inpatient diabetes mellitus: the Mayo Clinic Arizona experience

We present an overview of strategies our institution has taken to understand the state of its inpatient diabetes management. We first describe how we utilized information systems to assess inpatient glycemic control and insulin management in noncritically ill patients and discuss our findings regarding mean bedside glucose levels, the prevalence and frequency hypoglycemic and hyperglycemic events, the patterns of insulin therapy, and evidence of inpatient clinical inertia. We also review the development of a survey to determine practitioner attitudes and beliefs about inpatient diabetes. Results of this survey study found that, in general, practitioners believed in the importance of controlling hyperglycemia but were not comfortable with many aspects of inpatient diabetes care, particularly with the use of insulin. Finally, we suggest steps to follow in developing a quality-improvement program for hospitals.

Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practitioners

PURPOSE

The purpose of this study is to explore attitudes among inpatient midlevel practitioners about hospital hyperglycemia and to identify perceived barriers to care.

METHODS

A questionnaire previously applied to resident physicians was administered to midlevel providers (physician assistants and nurse practitioners) to determine their beliefs about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in the hospital. Barriers to care reported in this study were also combined with responses from the prior resident survey.

RESULTS

Most respondents indicated that glucose control was very important in critically ill, noncritically ill, and perioperative patients. However, most felt only somewhat comfortable treating hyperglycemia and hypoglycemia and with using subcutaneous insulin; respondents expressed the least amount of confidence with using insulin infusions and insulin pumps. Respondents were not familiar with existing institutional polices and preprinted order sets relating to glucose management. The most commonly reported barrier to hyperglycemia management in the hospital was lack of familiarity with how to useinsulin, a finding that persisted after analyzing composite resident and midlevel responses.

CONCLUSIONS

Most midlevel providers acknowledged the importance of good glucose control in the hospital. Lack of familiarity with how to use insulin in the hospital was the most commonly cited barrier to care. Educational programs should heavily emphasize inpatient treatment strategies.

Improving glycemic control in medical inpatients: a pilot study

BACKGROUND

Inpatient hyperglycemia is associated with poor patient outcomes. Current guidelines recommend that in an inpatient non-ICU setting there be treatment to achieve a glucose level below 180 mg/dL.

METHODS

Objectives of this prospective quality-improvement pilot study were to implement a subcutaneous insulin protocol on a general medicine service, to identify barriers to implementation, and to determine the effect of this protocol on glycemic control. Eighty-nine patients with a preexisting diagnosis of type 2 diabetes or inpatient hyperglycemia were eligible. Study outcomes included resident acceptance of the protocol, insulin-ordering practices, and mean rate of hyperglycemia (glucose > 180 mg/dL) per person. Results were compared with those of a previously conducted observational study.

RESULTS

Residents agreed to use the protocol in 56% of cases. Reasons for declining the protocol included severity of a patient's other disease states, desire to titrate oral medications, and fear of hypoglycemia. Basal and nutritional insulin were prescribed more often in the pilot group compared with at baseline (64% vs. 49% for basal, P = .05; 13% vs. 0% for nutritional, P < .001). Basal insulin was started after the first full hospital day in 42% of patients, and only one-third of patients with any hypo- or hyperglycemia had any subsequent changes in their insulin orders. The mean rate of hyperglycemia was not significantly different between groups (31.6% of measurements per patient vs. 33.3%, P = .85).

CONCLUSIONS

Adherence to a new inpatient subcutaneous insulin protocol was fair. Barriers included fear of hypoglycemia, delays in starting basal insulin, and clinical inertia. Quality improvement efforts likely need to target these barriers to successfully improve inpatient glycemic control.

Inpatient point-of-care bedside glucose testing: preliminary data on use of connectivity informatics to measure hospital glycemic control

BACKGROUND

Point-of-care (POC) bedside glucose (BG) testing and timely evaluation of its effectiveness are important components of hospital inpatient glycemic control programs. We describe a new technology to evaluate inpatient POC-BG testing and report preliminary results of inpatient glycemic control from 10 U.S. hospitals.

METHODS

We used the Remote Automated Laboratory System RALS-Tight Glycemic Control Module (TGCM) (Medical Automation Systems, Charlottesville, VA) connected to the RALS-Plus to extract and analyze inpatient POC-BG tests from 10 U.S. hospitals for a 3-month period. POC-BG measurements were evaluated in aggregate from all 10 facilities for intensive care unit (ICU), non-ICU, and ICU + non-ICU combined.

RESULTS

A total of 742,154 POC-BGs were analyzed. The combined (ICU + non-ICU) mean POC-BG was 159 mg/dL, compared with 146 mg/dL for the ICU and 164 mg/dL for non-ICU. The proportion of hypoglycemic values (<70 mg/dL) was low at 4%, but the percentage of measurements that would be considered hyperglycemic (>180 mg/dL) was high, with more than 30% of values in the non-ICU and 20% in the ICU being elevated.

CONCLUSIONS

POC-BG data can be captured through automated data management software and can support hospital efforts to evaluate and monitor the status of inpatient glycemic control. These preliminary data suggest that there is a need to conduct broad-based efforts to improve inpatient glucose management. Increasing hospital participation in data collection has the potential to create a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial)

OBJECTIVE

We sought to study the optimal management of hyperglycemia in non-intensive care unit patients with type 2 diabetes, as few studies thus far have focused on the subject.

RESEARCH DESIGN AND METHODS

We conducted a prospective, multicenter, randomized trial to compare the efficacy and safety of a basal-bolus insulin regimen with that of sliding-scale regular insulin (SSI) in patients with type 2 diabetes. A total of 130 insulin-naive patients were randomized to receive glargine and glulisine (n = 65) or a standard SSI protocol (n = 65). Glargine was given once daily and glulisine before meals at a starting dose of 0.4 units x kg(-1) x day(-1) for blood glucose 140-200 mg/dl or 0.5 units x kg(-1) x day(-1) for blood glucose 201-400 mg/dl. SSI was given four times per day for blood glucose >140 mg/dl.

RESULTS

The mean admission blood glucose was 229 +/- 6 mg/dl and A1C 8.8 +/- 2%. A blood glucose target of <140 mg/dl was achieved in 66% of patients in the glargine and glulisine group and in 38% of those in the SSI group. The mean daily blood glucose between groups ranged from 23 to 58 mg/dl, with an overall blood glucose difference of 27 mg/dl (P < 0.01). Despite increasing insulin doses, 14% of patients treated with SSI remained with blood glucose >240 mg/dl. There were no differences in the rate of hypoglycemia or length of hospital stay.

CONCLUSIONS

Treatment with insulin glargine and glulisine resulted in significant improvement in glycemic control compared with that achieved with the use of SSI alone. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the management of non-critically ill, hospitalized patients with type 2 diabetes.

Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum

BACKGROUND

Little is known about management of hyperglycemia in inpatients.

OBJECTIVE

To gain insight into caring for hospitalized patients with hyperglycemia.

DESIGN

Retrospective analysis.

SETTING

Teaching hospital.

PATIENTS

Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycemia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed.

MEASUREMENTS

Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose.

RESULTS

The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycemia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL) during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycemia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycemia (negative therapeutic momentum).

CONCLUSIONS

Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycemia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy.

In-hospital treatment of hyperglycemia: effects of intensified subcutaneous insulin treatment

BACKGROUND

Hyperglycemia is common in hospitalized patients; however, glycemic control obtained during hospitalization is often suboptimal. No methods for achievement of proper glycemic control in this population have been validated in the in-hospital setting.

AIMS

To study the effect of a novel intensive subcutaneous insulin protocol on the quality of in-hospital glycemic control.

METHODS

Included in this prospective controlled study were all diabetic patients admitted to the internal medicine departments in a tertiary medical center during a 1-year period. The study was divided into pre-intervention (n = 94), intervention (n = 102) and post-intervention (n = 79) periods. During the intervention period all hospitalized diabetic patients with blood glucose > 200 mg/dL were treated with an intensive multi-injection protocol consisting of two or four times daily regular/NPH insulin injections.

RESULTS

Mean glucose level throughout hospitalization was 178.7 +/- 47 mg/dL in the intervention period versus 198.8 +/- 60 mg/dL in the pre-intervention period (p < 0.05). During the intervention period, the difference between mean admission and discharge day glucose levels was 43 mg/dL in patients treated with four times daily insulin injections, in contrast to no change noted in the other treatment groups. During the post-intervention period the rate of implementation of the intensive protocol by the internal medicine teams declined to 47.5%, in contrast to a 78.4% implementation rate during the intervention period. This decline was associated with deterioration of glycemic control.

CONCLUSIONS

The use of intensified insulin regimen improved the glycemic control of hospitalized diabetic patients. Successful incorporation of such intensive protocols into daily medical routines requires close involvement and continuous physician guidance by the hospital diabetes team.