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.
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.


METHODS
Before-after trial.


METHODS
Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists.


METHODS
Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia.


METHODS
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.


METHODS
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.
Schnipper
Jeffrey L
JL
Brigham and Women's/Academic Hospitalist Program, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120-1613, USA. jschnipper@partners.org
Ndumele
Chima D
CD
Liang
Catherine L
CL
Pendergrass
Merri L
ML
D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy; D019468:Disease Management; D004360:Drug Therapy, Computer-Assisted / Q000379:methods / Q000592:standards*; D005260:Female; D006760:Hospitalization; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000188:drug therapy*; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods / Q000592:standards*; D010865:Pilot Projects; D011446:Prospective Studies; D016896:Treatment Outcome
D007328:Insulin