Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel

Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting

OBJECTIVES

More than one-third of hospitalized patients have hyperglycemia. Despite evidence that improving glycemic control leads to better outcomes, achieving recognized targets remains a challenge. The objective of this study was to evaluate the implementation of a computerized insulin order set and titration algorithm on rates of hypoglycemia and overall inpatient glycemic control.

METHODS

A prospective observational study evaluating the impact of a glycemic order set and titration algorithm in an academic medical center in non-critical care medical and surgical inpatients. The initial intervention was hospital-wide implementation of a comprehensive insulin order set. The secondary intervention was initiation of an insulin titration algorithm in two pilot medicine inpatient units. Point of care testing blood glucose reports were analyzed. These reports included rates of hypoglycemia (BG < 70 mg/dL) and hyperglycemia (BG >200 mg/dL in phase 1, BG > 180 mg/dL in phase 2).

RESULTS

In the first phase of the study, implementation of the insulin order set was associated with decreased rates of hypoglycemia (1.92% vs 1.61%; p < 0.001) and increased rates of hyperglycemia (24.02% vs 27.27%; p < 0.001) from 2010 to 2011. In the second phase, addition of a titration algorithm was associated with decreased rates of hypoglycemia (2.57% vs 1.82%; p = 0.039) and increased rates of hyperglycemia (31.76% vs 41.33%; p < 0.001) from 2012 to 2013.

CONCLUSIONS

A comprehensive computerized insulin order set and titration algorithm significantly decreased rates of hypoglycemia. This significant reduction in hypoglycemia was associated with increased rates of hyperglycemia. Hardwiring the algorithm into the electronic medical record may foster adoption.

Facilitating the safe use of insulin pens in hospitals through a mentored quality-improvement program

PURPOSE

Results of the MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM℠ (MQIIP) on Ensuring Insulin Pen Safety in Hospitals, which was part of an ASHP educational initiative aimed at ensuring the safe use of insulin pens in hospitals, are described.

METHODS

During this ASHP initiative, which also included continuing-education activities and Web-based resources, distance mentoring by pharmacists with expertise in the safe use of insulin pens was provided to interprofessional teams at 14 hospitals between September 2014 and May 2015. The results of baseline assessments of nursing staff knowledge of insulin pen use, insulin pen storage and labeling audits, and insulin pen injection observations conducted in September and October 2014 were the basis for insulin pen quality-improvement plans. Postintervention data were collected in April and May 2015.

RESULTS

Compared with the baseline period, significant improvements in nurses' knowledge of insulin pen use, insulin pen labeling and storage, and insulin pen administration were observed in the postintervention period despite the relatively short time frame for implementation of quality-improvement plans. Program participants are committed to sustaining and building on improvements achieved during the program. The outcome measures described in this report could be adapted by other health systems to identify opportunities to improve the safety of insulin pen use.

CONCLUSION

Focused attention on insulin pen safety through an interprofessional team approach during the MQIIP enabled participating sites to detect potential safety issues based on collected data, develop targeted process changes, document improvements, and identify areas requiring further intervention. A sustained organizational commitment is required to ensure the safe use of insulin pen devices in hospitals.

Participation in a mentored quality-improvement program for insulin pen safety: Opportunity to augment internal evaluation and share with peers

PURPOSE

UF Health's participation in a mentored quality-improvement impact program for health professionals as part of an ASHP initiative-"Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital"-is described.

SUMMARY

ASHP invited hospitals to participate in its initiative at a time when UF Health was evaluating the risks and benefits of insulin pen use due to external reports of safety concerns and making a commitment to continue insulin pen use and optimize safeguards. Improvement opportunities in insulin pen best practices and staff education on insulin pen preparation and injection technique were identified and implemented. The storage of insulin pens for patients with contact isolation precautions was identified as a problem in certain patient care areas, and a practical solution was devised. Other process improvements included implementation of barcode medication administration, with scanning of insulin pens designated for specific patients to avoid inadvertent and intentional sharing of pens among multiple patients. Mentored calls with teams at other hospitals conducted as part of the program provided the opportunity to share experiences and solutions to improve insulin pen use.

CONCLUSION

Participating with a knowledgeable mentor and other hospital teams struggling with the same issues and concerns related to safe insulin pen use facilitated problem solving. Discussing challenges and sharing ideas for solutions to safety concerns with other hospitals identified new process enhancements, which have the potential to improve the safety of insulin pen use at UF Health.

A Review of Insulin for the Treatment of Diabetes Mellitus

Insulin is commonly used in the treatment of diabetes in the home care setting. Understanding the wide variety of insulin preparations available will assist the clinician in guiding people with diabetes and their caregivers through the complexities of self-care and promote safe and optimal glucose control. The purpose of this article is to review the various available insulin preparations and discuss their use in the treatment of diabetes mellitus.

Challenges With Insulin in the Inpatient Setting

IN BRIEF This article reviews potential challenges to and necessary considerations for ensuring the safe and effective use of insulin in the hospital setting. It offers practical suggestions for managing insulin-related issues regarding medication reconciliation, general inpatient management, and the use of concentrated insulin products.

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children

OBJECTIVE

Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.

METHODS

Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.

RESULTS

After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.

CONCLUSIONS

Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.

Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system

PURPOSE

Substantial reductions in inpatient episodes of severe hypoglycemia achieved by a large healthcare system through enhanced use of technology and sustained quality-improvement initiatives are described.

SUMMARY

After internal data collection and analysis revealed that severe hypoglycemia accounted for 75% of all systematically monitored adverse drug events in its hospital network, St. Louis-based BJC HealthCare designed and executed a multifaceted approach to reducing hypoglycemia events. Initiated by a pharmacist-led task force, the project entailed (1) automated event detection and creation of dashboards for comparing hypoglycemia rates among at-risk patients at 11 BJC facilities, (2) implementation of evidence-based and internal best practices in use at BJC's top-performing hospitals, (3) development of an online "Hypoglycemic Event Analysis Tool" (HEAT) to support event investigation and collection of data on causative factors, and (4) the assembly of targeted interventions at a "Hypoglycemia Facility Strategy Tracking" (H-FaST) intranet site. As a result of the launch of the HEAT and H-FaST tools and associated provider education activities, the systemwide rate of hypoglycemia events in the specified at-risk patient population declined from 6.45 per 1000 patient-days during a preimplementation baseline period (July-December 2009) to 1.32 per 1000 patient-days during a designated postimplementation period (January-June 2014), an 80% overall reduction in hypoglycemia (p < 0.01); reductions in severe hypoglycemia events ranging from 70% to 100% were observed at all 11 hospitals.

CONCLUSION

A multifaceted, evidence-based, data-driven approach enabled a large healthcare system to markedly reduce the frequency of severe hypoglycemia events.

PREVENTION AND MANAGEMENT OF INSULIN-ASSOCIATED HYPOGLYCEMIA IN HOSPITALIZED PATIENTS

OBJECTIVE

To determine whether appropriate therapeutic changes in insulin doses are made to prevent and manage insulin-associated hypoglycemic events in non-critically ill hospitalized patients.

METHODS

This retrospective study was conducted in hospitalized adults on medical or surgical floors with insulin-associated hypoglycemia, excluding treatment with insulin infusions, insulin pumps, and parenteral nutrition. The first hypoglycemic event after 48 hours of admission was the index event. Over the 1-year study period, a total of 457 insulin-associated hypoglycemic events were included as index events.

RESULTS

An indication for an insulin dose adjustment was identified in 32 and 42% of patients on day -2 and day -1, respectively, before the index hypoglycemic event, of which 35 and 55%, respectively, had an insulin dose reduction ≥10%. Following the hypoglycemic event, 44% of patients had an insulin dose reduction of ≥20%. Therapeutic reduction of the total daily insulin dose by ≥20% was associated with increased odds of normoglycemia and lower odds of hyperglycemia but was not associated with lower odds of recurrent hypoglycemia on the day following the index hypoglycemic event. There was a high prevalence of hypoglycemic risk factors in this population, with kidney disease and nil per os status being the most prevalent contributing factors.

CONCLUSION

Adherence to the current practice recommendation to reduce insulin doses in patients with borderline hypoglycemia and following overt hypoglycemia was modest. Further studies are needed to understand the associated risks and to define appropriate therapeutic changes for insulin treated patients with borderline and overt hypoglycemia.

ABBREVIATIONS

AKI = acute kidney injury BG = blood glucose CKD = chronic kidney disease ESRD = end-stage renal disease ICU = intensive care unit NPH = Neutral Protamine Hagedorn NPO = nil per os OR = odds ratio TDD = total daily dose.

Predictors of recurrent hypoglycemia following a severe hypoglycemic event among hospitalized patients

OBJECTIVES

Severe hypoglycemia is associated with poor hospital outcomes, but variables contributing to the adequacy of treatment have not been described. The objective of this study was to determine predictors of recurrent hypoglycemia among hospitalized patients with a severe hypoglycemic event.

METHODS

Patients with severe hypoglycemia (glucose <40 mg/dl) with a concomitant insulin order were identified using the study institution's Information Warehouse. The primary outcome was the prevalence of recurrent hypoglycemia (defined as <70 mg/dl within 24 hours) and to identify independent predictors of recurrent hypoglycemia. Secondary outcomes included time to blood glucose recheck, time to blood glucose ≥ 70 mg/dl, and rebound hyperglycemia (defined as glucose >300 mg/dl within 24 hours). Multivariable linear and logistic regression models were performed.

RESULTS

A total of 129 patients with severe hypoglycemia were identified. The median time to repeat glucose measurement was 29 (IQR 15-61) minutes, while the time to resolution of hypoglycemia was 49 (IQR 26-103) minutes. Recurrent hypoglycemia occurred in 49% of patients, while 19% of patients experienced rebound hyperglycemia. Independent predictors of recurrent hypoglycemia included lower repeat glucose (p = 0.025), low glomerular filtration rate (p = 0.033), and lack of insulin adjustment (p = 0.012). Independent predictors of maximum glucose post-event were type 1 diabetes (p = 0.0003), history of any diabetes (p = 0.013), and total bolus dose of insulin (p < 0.0001). Overnight timing of events was the only predictor of shorter time to hypoglycemia resolution (p < 0.0001).

CONCLUSIONS

Recurrent hypoglycemia following severe hypoglycemia is common in the hospital, suggesting the need for enhanced monitoring in such patients. Further research is needed to identify methods to reduce the incidence of recurrent hypoglycemia.

Comparison of Inpatient Glycemic Control with Insulin Vials Versus Insulin Pens in General Medicine Patients

BACKGROUND

The Institute for Safe Medication Practices has recommended against routine use of insulin pen devices for inpatients, but the quality of inpatient glycemic control that is achieved with insulin pens versus insulin vials and syringes has not been compared.

OBJECTIVE

To evaluate the quality of glycemic control achieved with insulin vials versus insulin pens in type 2 diabetic general medicine patients.

METHODS

This retrospective cohort study compared glycemic control between 2 groups of patients on rapid-acting insulin protocols: those receiving insulin via patient-specific pen devices and those receiving insulin from patient-specific vials. Patients on a prespecified subacute care floor with a diagnosis of type 2 diabetes and at least 24 hours of glucose monitoring while on an insulin protocol with insulin lispro were included. Glycemic control was compared by area under the curve (AUC) estimations of average overall glucose and average glucose above, below, and within goal range (70-180 mg/dL). Percentages of time above, below, and within goal range were also compared.

RESULTS

The mean ± SD AUC-estimated average glucose for pens was 160 ± 39 mg/dL compared to 158 ± 45 mg/dL for vials (P = .752). The mean ± SD percentage time within goal range was 68.2% ± 28.1% in the pen group versus 69.4% ± 31.8% percent in the vial group (P = .825). No statistically significant differences were detected between those receiving pens or vials for any outcome before and after adjusting for baseline differences and significant covariates.

CONCLUSION

Glycemic control did not differ based on insulin delivery system.

[Predictors of mean blood glucose control and its variability in diabetic hospitalized patients]

INTRODUCTION

This study was intended to assess the effectiveness and predictors factors of inpatient blood glucose control in diabetic patients admitted to medical departments.

MATERIAL AND METHODS

A retrospective, analytical cohort study was conducted on patients discharged from internal medicine with a diagnosis related to diabetes. Variables collected included demographic characteristics, clinical data and laboratory parameters related to blood glucose control (HbA1c, basal plasma glucose, point-of-care capillary glucose). The cumulative probability of receiving scheduled insulin regimens was evaluated using Kaplan-Meier analysis. Multivariate regression models were used to select predictors of mean inpatient glucose (MHG) and glucose variability (standard deviation [GV]).

RESULTS

The study sample consisted of 228 patients (mean age 78.4 (SD 10.1) years, 51% women). Of these, 96 patients (42.1%) were treated with sliding-scale regular insulin only. Median time to start of scheduled insulin therapy was 4 (95% CI, 2-6) days. Blood glucose control measures were: MIG 181.4 (SD 41.7) mg/dL, GV 56.3 (SD 22.6). The best model to predict MIG (R(2): .376; P<.0001) included HbA1c (b=4.96; P=.011), baseline plasma glucose (b=.056; P=.084), mean capillary blood glucose in the first 24hours (b=.154; P<.0001), home treatment (versus oral agents) with basal insulin only (b=13.1; P=.016) or more complex (pre-mixed insulin or basal-bolus) regimens (b=19.1; P=.004), corticoid therapy (b=14.9; P=.002), and fasting on admission (b=10.4; P=.098).

CONCLUSION

Predictors of inpatient blood glucose control which should be considered in the design of DM management protocols include home treatment, HbA1c, basal plasma glucose, mean blood glucose in the first 24hours, fasting, and corticoid therapy.

Improvement in inpatient glycemic care: pathways to quality

The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.

Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management

OBJECTIVE

Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management.

METHODS

POPULATION

all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs).

INTERVENTIONS

hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs.

MEASURES AND ANALYSIS

Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL.

RESULTS

A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80).

CONCLUSION

Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.

Economic Impact of Converting from Pen and 10-mL Vial to 3-mL Vial for Insulin Delivery in a Hospital Setting

Purpose

To compare the impact on acquisition cost and purchased volume of rapid- and short-acting insulins following conversion from 3-mL disposable pens and 10-mL vials to 3-mL vials for individual patient supply (IPS) in a hospital setting.

Methods

On February 1, 2010, St. Joseph's Hospital and Medical Center of Dignity Health in Phoenix, Arizona, converted from pens to 3-mL vials for IPS subcutaneous (SC) injection and from 10-mL short-acting insulin vials to 3-mL vials for intravenous (IV) preparation. Pharmacy purchasing data were analyzed over 6-month periods before and after conversion (March 1 through August 31, 2009, and March 1 through August 31, 2010).

Results

Before conversion, acquisition costs were $27,866 for 5,335 mL of rapid-acting insulins and $53,336 for 26,310 mL of short-acting insulins. After conversion, insulin acquisition costs were $24,211 for 5,850 mL of rapid-acting insulins (13.1% decrease in costs, 9.7% rise in volume), with cost reduction attributable to the lower cost of 3-mL vials. Acquisition costs were $17,395 for 14,700 mL of short-acting insulins after conversion (67.4% decrease in costs, 44.1% reduction in volume), with cost reduction attributable to lower cost of 3-mL vials versus pens for IPS SC injections and 10-mL vials for IV preparation. The reduction in purchased volumes of short-acting insulins may be partly due to decreased insulin use in IV preparation.

Conclusion

Conversion from pens and 10-mL vials to 3-mL vials for rapid-and short-acting insulins resulted in reduced acquisition costs and decreased use of short-acting insulin in IV preparations.

Economic impact of converting from 10-mL insulin vials to 3-mL vials and pens in a hospital setting

PURPOSE

The economic impact associated with the conversion from 10-mL vials of insulin to 3-mL vials and pens at a community hospital was assessed.

METHODS

Pharmacy purchasing and administrative data from Providence St. Vincent Hospital in Portland, Oregon, were used in this analysis. The hospital converted floor-stock 10-mL vials of insulin in October 2010 to individual patient supply (IPS) 3-mL vials and pens. Insulin acquisition costs from the nine-month preconversion period were compared with those during the nine-month postconversion period.

RESULTS

Before the conversion, total acquisition costs were $168,783 for 5,086,500 units of insulin. After the conversion, total acquisition costs were reduced by 8.6% (to $154,303) and units purchased were reduced by 33.1% (to 3,404,900 units of insulin). The analyses also examined the results of converting to 3-mL vials of rapid-, short-, or intermediate-acting insulin to 3-mL pens of long-acting insulin analog. Conversion from 10- to 3-mL vials was associated with a 37.6% reduction in units of insulin and a 23.5% reduction in acquisition costs. In contrast, switching from 10-mL vials to 3-mL pens was associated with a 10.1% increase in costs, despite the fact that there was a 11.5% reduction in units purchased.

CONCLUSION

Conversion from floor-stock 10-mL insulin vials to IPS 3-mL insulin vials or pens reduced the number of units of insulin purchased and expenditures for insulin. The overall cost savings was driven by the conversion from 10- to 3-mL vials, whereas cost increased for the conversion of 10-mL vials to 3-mL pens for long-acting insulin analogs.

Effectively identifying the inpatient with hyperglycemia to increase patient care and lower costs

Recent years have seen an increased focus on merging quality care and financial results. This focus not only extends to the inpatient setting but also is of major importance in assuring effective transitions of care from hospital to home. Inducements to meld the 2 factors include tying payment to quality standards, investing in patient safety, and offering new incentives for providers who deliver high-quality and coordinated care. Once seen as the purview of primary care or specific surgical screening programs, identification of patients with hyperglycemia or undiagnosed diabetes mellitus now presents providers with opportunities to improve care. Part of the new focus will need to address the length of stay for patients with diabetes mellitus. These patients are proven to require longer hospital stays regardless of the admission diagnosis. With reducing length of stay as a major objective, efficiency combined with improved quality is the desired outcome. Even with the mounting evidence supporting the benefits of improving glycemic control in the hospital setting, institutions continue to struggle with inpatient glycemic control. Multiple national groups have provided recommendations for blood glucose assessment and glycated hemoglobin testing. This article identifies the key benefits in identifying patients with hyperglycemia and reviews possible ways to identify, monitor, and treat this potential problem area and thereby increase the level of patient care and cost-effectiveness.

Glycemic control and diabetes management in hospitalized patients in Brazil

BACKGROUND

The importance of tight blood glucose control among outpatients with diabetes mellitus is well established, however, the management of diabetes in the hospital setting is generally considered secondary in importance. This study sought to assess glycemic control and diabetes management in adult patients admitted to hospitals in Brazil.

METHODS

A cross-sectional and nationwide survey was conducted from July 2010 to January 2012. Eligible cases were 18 years of age or older, had a diagnosis of diabetes and a hospitalization length of stay ≥72 hours. Socio-demographic information, hospitalization details, and data on diabetes diagnosis, management and treatment were collected for all patients by chart review. Information on all blood glucose (BG) readings for a maximum of 20 consecutive days of hospitalization was recorded for each patient.

RESULTS

Overall, 2,399 patients were surveyed in 24 hospitals located in 13 cities from all five Brazilian regions. The prevalence of patients presenting hyperglycemic (BG >180 mg/dL) or hypoglycemic (BG <70 mg/dL) events was 89.4% and 30.9% in patients in general wards, and 88.2% and 27.7% in those in Intensive Care Units (ICUs), respectively. In addition, a BG measure >180 mg/dL was recorded in two-thirds of the patient-days. A high proportion of patients were treated with sliding-scale insulin regimen alone in the general wards (52.0%) and in the ICUs (69.2%), and only 35.7% and 3.9% received appropriate insulin therapy in general wards (basal + bolus insulin) and in ICUs (continuous IV insulin), respectively.

CONCLUSIONS

Inpatient glycemic control and diabetes management needs improvement. Opportunities to improve care in Brazilian hospitals include expanded use of intravenous insulin and subcutaneous basal-bolus insulin protocols, avoiding use of sliding-scale insulin alone, increased frequency of blood glucose monitoring, and institution wide quality improvement efforts targeting both physician and nursing behavior.