Prescriber Compliance with a New Computerized Insulin Guideline for Noncritically Ill Adults.
BACKGROUND
In March 2008, the University of California, Davis Medical Center (UCDMC), implemented a guideline for the inpatient management of diabetes in noncritically ill adults. In accordance with national guidelines, all patients with type 2 diabetes are prescribed basal, nutritional, and correctional insulin. The guideline was added to the electronic medical record as a standardized physician order set in April 2008 and provider training on the insulin guideline occurred in May 2008.


OBJECTIVE
To evaluate provider compliance with a new electronic standardized insulin order set in a hospital setting.


METHODS
All patients with insulin orders admitted to the general internal medicine service between June 1, 2008, and November 1, 2008, were evaluated in this single-center retrospective chart review at UCDMC in Sacramento. Patients older than 18 years with a history of type 2 diabetes were included in the analysis. Insulin orders were categorized as preferred (followed the guideline) or nonpreferred regimens (did not follow all components of the guideline).


RESULTS
A total of 265 patients were identified during the study period. The preferred regimen was ordered in 82 (30.9%) of the evaluated patient admissions. Of the 183 (69.1%) nonpreferred regimens, more than half (54.6%) contained correctional insulin alone; 84.2% of patient admissions prescribed nonpreferred regimens lacked nutritional insulin. Average admission blood glucose readings were higher in the preferred versus nonpreferred regimen group (224.4 vs 164.8 mg/dL, p < 0.001).


CONCLUSIONS
The preferred regimen was not prescribed for the majority of patients admitted with a history of type 2 diabetes, despite computerized decision support. Nutritional insulin was the most common missing component in the nonpreferred regimens. Baseline clinical factors, educational modalities, and guideline content may have influenced prescribing patterns.
Evan Clemens PharmD, Transplant/ICU Clinical Pharmacist, University of California, San Francisco, Medical Center evan.clemens@gmail.com.
Evan
E
Clemens
Timothy Cutler PharmD CGP, Associate Professor of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco; Director, University of California, Davis-Sacramento, Experiential Program.
Timothy
T
Cutler
Janice Canaria PharmD, Staff Pharmacist, Palomar Pomerado Health, Escondido, CA.
Janice
J
Canaria
Komal Pandya PharmD, Critical Care Pharmacy Resident, University of Kentucky, Lexington.
Komal
K
Pandya
Patricia Parker PharmD BCPS, Clinical Coordinator, University of California, Davis, Inpatient Pharmacy Services; Pharmacy Practice Residency Director, University of California, Davis, Medical Center; Associate Clinical Professor, School of Medicine, University of California, Davis, and School of Pharmacy, University of California, San Francisco.
Patricia
P
Parker
D000328:Adult; D001786:Blood Glucose / Q000032:analysis; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D057286:Electronic Health Records; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007297:Inpatients; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies
D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin