Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.
BACKGROUND
Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients.


OBJECTIVE
To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control.


METHODS
Prospective cohort study.


METHODS
Hospitalist-run general medicine service of an academic teaching hospital.


METHODS
107 consecutive patients with diabetes mellitus or inpatient hyperglycemia.


METHODS
We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day.


RESULTS
The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day.


CONCLUSIONS
Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.
Schnipper
Jeffrey L
JL
Brigham and Women's/Faulkner Hospitalist Program, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120-1613, USA. jschnipper@partners.org
Barsky
Emily E
EE
Shaykevich
Shimon
S
Fitzmaurice
Garrett
G
Pendergrass
Merri L
ML
D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000097:blood* / Q000628:therapy; D019468:Disease Management; D005194:Family Practice / Q000379:methods*; D005260:Female; D038321:Glycemic Index / Q000502:physiology; D006760:Hospitalization; D006784:Hospitals, Teaching / Q000379:methods*; D006801:Humans; D006943:Hyperglycemia / Q000097:blood* / Q000628:therapy; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies
D001786:Blood Glucose