Subcutaneous insulin order sets and protocols: Effective design and implementation strategies

6 Yale Diabetes Center, Yale New Haven Hospital, New Haven, Connecticut. I npatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published, and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding-scale regimens. Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports detail clinical inertia and the continued widespread use of sliding-scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic ‘‘basal-nutrition-correction dose’’ insulin regimens endorsed by these reviews. Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure tomedications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use. A ‘‘Call to Action’’ consensus conference, hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set. The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful No honoraria were paid to any authors for time and expertise spent on the writing of this article.