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.
Trujillo
Jennifer M
JM
Northeastern University School of Pharmacy, Boston, MA 02115, USA. j.trujillo@neu.edu
Barsky
Emily E
EE
Greenwood
Bonnie C
BC
Wahlstrom
Stephanie A
SA
Shaykevich
Shimon
S
Pendergrass
Merri L
ML
Schnipper
Jeffrey L
JL
D000368:Aged; D001291:Attitude of Health Personnel; D001786:Blood Glucose / Q000032:analysis; D001900:Boston; D002985:Clinical Protocols; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy*; D005194:Family Practice / Q000193:education* / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage* / Q000627:therapeutic use; D007396:Internship and Residency / Q000592:standards*; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D010353:Patient Education as Topic; D010865:Pilot Projects; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D016896:Treatment Outcome
D001786:Blood Glucose; D007328:Insulin