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.