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.
J Hosp Med. 2009 Jan 12;4(1):16-27
Authors: Schnipper JL, Ndumele CD, Liang CL, Pendergrass ML
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. Journal of Hospital Medicine 2009;4:16-27. (c) 2009 Society of Hospital Medicine.
PMID: 19140191 [PubMed - as supplied by publisher]