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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
Author(s) -
Schnipper Jeffrey L.,
Ndumele Chima D.,
Liang Catherine L.,
Pendergrass Merri L.
Publication year - 2009
Publication title -
journal of hospital medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.128
H-Index - 65
eISSN - 1553-5606
pISSN - 1553-5592
DOI - 10.1002/jhm.385
Subject(s) - medicine , glycemic , hypoglycemia , hospital medicine , odds ratio , confidence interval , diabetes mellitus , emergency medicine , insulin , diabetes management , pediatrics , type 2 diabetes , endocrinology
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.