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†‡
2009
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. © 2009 Society of Hospital Medicine.
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