Insulin therapy for inpatients with diabetes: Perceptions of resident physicians from disparate geographic training programs

Background: Improving diabetes management in hospitalized patients will require educational efforts for all practitioners, particularly resident physicians. Thus, a better understanding of residents' beliefs about diabetes in the hospital must be obtained.Objective: The purpose of this article was to compare and contrast perceptions of resident physicians from 2 geographically distinct training programs regarding management of inpatients with diabetes.Methods: Residents from training programs in the southwestern and southeastern United States were surveyed in 2006 and 2007 about their views on the importance of inpatient glucose control, their perceptions about desirable target glucose ranges, and the problems they encountered when trying to manage hyperglycemia in hospitalized patients.Results: Responses were obtained from 52 of 66 residents at site 1 and from 65 of 85 residents at site 2 (N = 117 total respondents; total response, 77%; mean age, 31 years; 48% men; 61% primary care). Combined analyses revealed that respondents believed that glucose control was “very important” in critically ill patients (96%), perioperative patients (82%), and noncritically ill patients (66%). Most residents indicated that they would target a therapeutic glucose range within published recommendations. Less than half felt “very comfortable” managing inpatient hyperglycemia, hypoglycemia, subcutaneous insulin, or insulin drips. Respondents were not very familiar with existing institutional policies or preprinted order sets for insulin therapy. The most commonly reported barrier to management of inpatient hyper-glycemia was lack of knowledge about appropriate insulin regimens and their use.Conclusions: Trainees from 2 very different educational programs shared common beliefs, knowledge deficits, and perceived barriers about inpatient glucose management. Our findings indicate that trainees were uncertain about how to use insulin therapy in the hospital. Future inpatient diabetes quality-improvement efforts should focus on development of uniform educational programs targeting the management of inpatient diabetes, particularly as it relates to insulin use.     

Tratamiento de la hiperglucemia en el hospital. Impresiones y conocimientos del médico residente

Background and objectiveIn many hospitals, adequate glycemic control is not achieved despite implementation of new insulin therapy protocols. Our aim was to assess resident physician’ attitudes toward inpatient hyperglycemia, barriers to achieve optimum control, and impact on them of an insulin training programMaterial and methodsA questionnaire was used to assess understanding and standard management of hyperglycemia before and six months after implementation of an inpatient insulin treatment program.ResultsTwenty-five interns completed the questionnaire. Glycemic control was considered “very important” in all admission situations, but was only considered “very important” in conventional hospitalization by 36% of interns. Most of these felt “comfortable” using sliding scales, but not with the basal/bolus regimen, which was the least commonly used. Perception of number of well-controlled patients and comfort and use of basal/bolus therapy increased at six months, but use of “sliding scales” remained high. The greatest difficulty reported for adequate management of hyperglycemia was the lack of knowledge.ConclusionsMost residents are aware of the importance of adequate glycemic control, but cannot achieve it because of inadequate knowledge. The insulin training program led to an improved perception and applicability of basal-bolus insulin regimens. However, despite all efforts, use of sliding scales remains high. Training programs should emphasize management of hyperglycemia.     

Use Of Incretin-Based Therapy in Hospitalized Patients with Hyperglycemia

ObjectiveHyperglycemia is common in hospitalized patients with and without prior history of diabetes and is an independent marker of morbidity and mortality in critically and noncritically ill patients. Tight glycemic control using insulin has been shown to reduce cardiac morbidity and mortality in hospitalized patients, but it also results in hypoglycemic episodes, which have been linked to poor outcomes. Thus, alternative treatment options that can normalize blood glucose levels without undue hypoglycemia are being sought. Incretin-based therapies, such as glucagon-like peptide (GLP)-1 receptor agonists (RAs) and dipeptidyl peptidase (DPP)-4 inhibitors, may have this potential.MethodsA PubMed database was searched to find literature describing the use of incretins in hospital settings. Title searches included the terms “diabetes” (care, management, treatment), “hospital,” “inpatient,” “hypoglycemia,” “hyperglycemia,” “glycemic,” “incretin,” “dipeptidyl peptidase-4 inhibitor,” “glucagon-like peptide-1,” and “glucagon-like peptide-1 receptor agonist.”ResultsThe preliminary research experience with native GLP-1 therapy has shown promise, achieving improved glycemic control with a low risk of hypoglycemia, counteracting the hyperglycemic effects of stress hormones, and improving cardiac function in patients with heart failure and acute ischemia. Large, randomized controlled clinical trials are necessary to determine whether these favorable results will extend to the use of GLP-1 RAs and DPP-4 inhibitors.ConclusionsThis review offers hospitalist physicians and healthcare providers involved in inpatient diabetes care a pathophysiologic-based approach for the use of incretin agents in patients with hyperglycemia and diabetes, as well as a summary of benefits and concerns of insulin and incretin-based therapy in the hospital setting. (Endocr Pract. 2014;20:933-944)     

Inpatient insulin therapy

Background: Many diabetic, as well as nondiabetic, hospitalized patients develop hyperglycemia. Numerous studies have demonstrated that critically ill, as well as noncritically ill, hospitalized patients who develop hyperglycemia are at increased risk for morbidity and mortality.Objective: The objective of this article was to review the risks associated with hyperglycemia in hospitalized patients, the biologic rationale for using insulin to prevent increases in glucose levels, and strategies for managing hyperglycemia in the hospital setting.Methods: We conducted a computerized search of biomedical journal literature from MEDLINE, PubMed, and Ovid published from 1994 to March 2008. We reviewed English-language original and review articles found under the subject headings “hospitalization and insulin therapy,” “inpatient diabetes and complications,” and “insulin and inflammation.”Results: More than 200 references were found during the literature search. According to the literature, the adverse outcomes that are associated with hyperglycemia may be attributed to the inflammatory and pro-oxidant effects of elevated glucose levels. The use of insulin, which has anti-inflammatory, vasodilatory, and antioxidant properties as well as the ability to inhibit lipolysis and platelet aggregation, can prevent many of these adverse outcomes.Conclusions: Hospitals should have protocols in place for using insulin to treat and prevent hyperglycemia. Subcutaneous insulin may be used for both purposes in most noncritically ill patients, whereas intravenous infusion of insulin is preferred in critically ill patients.     

Effects of a Computerized Order Set on the Inpatient Management of Hyperglycemia: A Cluster-Randomized Controlled Trial

ObjectiveTo determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia.MethodsWe conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital’s computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL.ResultsBetween April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose < 40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58).ConclusionThe use of an order set built into a hospital’s CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program. (Endocr Pract. 2010;16:209-218)     

Inpatient Management of Diabets Mellitus Among Noncritically Ill Patients at the University Hospital of Puerto Rico

ObjectiveTo describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes.MethodsThis was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed.ResultsA total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ≥ 180 mg/dL) and hypoglycemia (blood glucose < 70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose.ConclusionThe management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients. (Endocr Pract. 2014;20:452-460)     

Is There A “July Effect” for Inpatient Glycemic Control?

ObjectiveThe period of resident turnover in teaching hospitals is considered by some to worsen health outcomes and is called the “July effect.” We sought to study glycemic control in patients admitted to medical floors and identify any adverse outcomes related to a “July effect.”MethodsThis was a single-center retrospective cohort study that compared inpatient glycemic control at the start and end of a single academic year (July 2009 to June 2010). A total of 108 patients with a diagnosis of diabetes mellitus were included in the first group (Group 1: July to September 2009), and 134 were in the second group (Group 2: April to June 2010). Four capillary blood glucose measurements were taken from Days 2 to 6 of hospitalization, and clinical data pertinent to glycemic management were collected.ResultsData analysis showed no significant difference in the overall inpatient glycemic control between the 2 groups. The mean glucose levels were 168.67 mg/dL and 168.59 mg/dL for Groups 1 and 2, respectively. Overall, 67% of patients in Group 1 and 72.9% in Group 2 were within a blood glucose range of 70 to 179 mg/dL, and 32% of patients in Group 1 and 44.1% of patients in Group 2 were within the range of 140 to 179 mg/dL. Hypoglycemia occurred in 17% and 18.6% of Groups 1 and 2, respectively. No difference in diabetes treatment ordering practices of residents was detected.ConclusionThis study did not show any evidence to support the “July effect” on overall inpatient glycemic control. (Endocr Pract. 2014;20:919-924)     

Diabetes and Hyperglycemia Quality Improvement Efforts in Hospitals in the United States: Current Status,Practice Variation,and Barriers to Implementation

ObjectiveTo determine the status of diabetes and hyperglycemia quality improvement efforts in hospitals in the United States.MethodsWe designed and administered a survey to a convenience sample of hospitals, and the responses were analyzed statistically.ResultsWe received 269 responses from 1,151 requested surveys. The sample was similar to hospitals in the United States on the basis of hospital type and geographic region (P = no significant difference) but not on the basis of number of beds (P < .001). Among responding hospitals, 39%, 21%, and 15% had fully implemented inpatient diabetes and hyperglycemia quality improvement programs for critically ill, non-critically ill, and perioperative patients, respectively. Moreover, 77%, 44%, and 49% had fully implemented protocols for hypoglycemia, hyperglycemic crises, and diabetic ketoacidosis, respectively. Variations in glucose target ranges were noted. The responding hospitals had no standard biochemical definition of hypoglycemia; 47% defined hypoglycemia as a glucose level ≤ 70 mg/dL, but 29%, 8%, 6%, and 4% used < 60, ≤ce:hsp sp="0.10"/>50, < 40, and < 80 mg/dL, respectively. Almost a third of reporting hospitals had no metric to track the quality of inpatient diabetes and hyperglycemia care. More than half (59%) indicated that they did not have an automated capability to extract and analyze glucose data. The most frequent barrier to implementing a glycemic control program was concern regarding hypoglycemia (61%).ConclusionHospitals are addressing the issue of inpatient diabetes and glycemic control but face obstacles to implementation of quality improvement programs and vary in their approach to management. Improving the consistency of glucose control practices within hospitals in the United States should help enhance patient care and safety. Future efforts to help hospitals overcome barriers to introducing glucose control programs could include developing standardized glycemic control metrics, improving data collection and reporting methods, and providing improved tools that enable clinicians to control glucose safely. (Endocr Pract. 2010;16:219-230)     

The Dawn Phenomenon Revisited: Implications for Diabetes Therapy

ObjectiveTo summarize current data on the magnitude, prevalence, variability, pathogenesis, and management of the dawn phenomenon in patients with diabetes mellitus.MethodsOn the basis of the pertinent available literature and clinical experience, we propose a quantitative definition of the dawn phenomenon, discuss potential pathogenic mechanisms, and suggest management options.ResultsThe “dawn phenomenon” is a term used to describe hyperglycemia or an increase in the amount of insulin needed to maintain normoglycemia, occurring in the absence of antecedent hypoglycemia or waning insulin levels, during the early morning hours. To be clinically relevant, the magnitude of the dawn increase in blood glucose level should be more than 10 mg/dL or the increase in insulin requirement should be at least 20% from the overnight nadir. Controversy exists regarding the frequency, reproducibility, and pathogenesis of the dawn phenomenon. Approximately 54% of patients with type 1 diabetes and 55% of patients with type 2 diabetes experience the dawn phenomenon when the foregoing quantitative definition is used. The most likely pathogenic mechanism underlying the dawn phenomenon is growth hormone-mediated impairment of insulin sensitivity at the liver and muscles. The exact biochemical pathways involved are unknown. Therapeutic decisions aimed at correcting fasting hyperglycemia should take into account the variability and magnitude of the dawn phenomenon within individual patients. Successful insulinization appears to minimize the effects of the dawn phenomenon. Currently, no subcutaneous depot preparation of insulin exists that is capable of mimicking the basal insulinsecretion of the healthy pancreas.ConclusionIncreases in the bedtime doses of hypoglycemic agents with nighttime peaks in action may correct early morning hyperglycemia but be associated with undesirable nocturnal hypoglycemia. Targeted continuous subcutaneous insulin infusion programming can facilitate the prevention of early morning hyperglycemia in selected patients. (Endocr Pract. 2005;11:55-64)     

Glycemic Outcomes of Hospitalized Patients on Ambulatory Humulin-R U-500 Insulin

ObjectiveManaging hospitalized patients on ambulatory U-500 insulin is challenging because of limited guidance on how to safely adjust insulin doses during admission. We sought to evaluate glycemic outcomes in relation to inpatient insulin doses in patients receiving U-500 prior to hospitalization.MethodsRetrospective study of hospitalized patients on ambulatory U-500 seen consecutively from January 2015 to December 2019. Primary outcomes were inpatient hypoglycemia, hyperglycemia, and normoglycemia at different insulin dosages expressed as weight-based (unit/kg/d) inpatient total daily dose (TDD) and ratio of inpatient to outpatient TDD.ResultsWe identified 66 admissions of 46 unique patients. The median (interquartile range) body mass index was 41.0 kg/m² (35.1, 46.8), home TDD 212 units (120, 300), and home insulin dose 1.6 units/kg/d (1.1, 2.2). The median (interquartile range) inpatient insulin dose was 0.7 unit/kg/d (0.3, 1.0) and the ratio of inpatient to outpatient TDD was 0.4 (0.2, 0.8). Hyperglycemia persisted throughout the hospitalization. For the outcomes of hyperglycemia and normoglycemia, we found no association between increased levels of insulin dosages. For the outcome of hypoglycemia, significantly higher odds were observed when non-fasting patients received an inpatient TDD that was either > 40% of their home TDD or > 0.6 unit/kg/d of insulin.ConclusionPatients on ambulatory U-500 have significant hyperglycemia during admission. Inpatient insulin doses of 40% of home TDD or ≤ 0.6 unit/kg were not associated with increased hypoglycemia risk. Further prospective studies are needed to determine effective doses in these high-risk patients.     

Improving IV insulin administration in a community hospital

Diabetes mellitus is a major independent risk factor for increased morbidity and mortality in the hospitalized patient, and elevated blood glucose concentrations, even in non-diabetic patients, predicts poor outcomes. The 2008 consensus statement by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) states that "hyperglycemia in hospitalized patients, irrespective of its cause, is unequivocally associated with adverse outcomes." It is important to recognize that hyperglycemia occurs in patients with known or undiagnosed diabetes as well as during acute illness in those with previously normal glucose tolerance. The Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study involved over six thousand adult intensive care unit (ICU) patients who were randomized to intensive glucose control or conventional glucose control. Surprisingly, this trial found that intensive glucose control increased the risk of mortality by 14% (odds ratio, 1.14; p = 0.02). In addition, there was an increased prevalence of severe hypoglycemia in the intensive control group compared with the conventional control group (6.8% vs. 0.5%, respectively; p < 0.001). From this pivotal trial and two others, Wyoming Medical Center (WMC) realized the importance of controlling hyperglycemia in the hospitalized patient while avoiding the negative impact of resultant hypoglycemia. Despite multiple revisions of an IV insulin paper protocol, analysis of data from usage of the paper protocol at WMC shows that in terms of achieving normoglycemia while minimizing hypoglycemia, results were suboptimal. Therefore, through a systematical implementation plan, monitoring of patient blood glucose levels was switched from using a paper IV insulin protocol to a computerized glucose management system. By comparing blood glucose levels using the paper protocol to that of the computerized system, it was determined, that overall, the computerized glucose management system resulted in more rapid and tighter glucose control than the traditional paper protocol. Specifically, a substantial increase in the time spent within the target blood glucose concentration range, as well as a decrease in the prevalence of severe hypoglycemia (BG < 40 mg/dL), clinical hypoglycemia (BG < 70 mg/dL), and hyperglycemia (BG > 180 mg/dL), was witnessed in the first five months after implementation of the computerized glucose management system. The computerized system achieved target concentrations in greater than 75% of all readings while minimizing the risk of hypoglycemia. The prevalence of hypoglycemia (BG < 70 mg/dL) with the use of the computer glucose management system was well under 1%.     

The Management of Hyperglycemia in Noncritically ill Hospitalized Patients Treated with Continuous Enteral or Parenteral Nutrition

Objective: Hyperglycemia is a common problem in hospitalized patients receiving artificial nutrition, and this development of hyperglycemia during parenteral nutrition therapy (PNT) and enteral nutrition therapy (ENT) increases the risks of hospital-related complications and mortality. This review aims to discuss the pathogenesis of hyperglycemia from artificial nutrition in the hospital, summarize current evidence on the treatment of hyperglycemia with insulin in these patients, and review current guidelines.Methods: A systematic literature review using PubMed and the Medical Subject Headings (MeSH) terms “hyperglycemia,” “enteral nutrition,” and “parenteral nutrition” were used to evaluate the current evidence available for treating noncritically ill patients with hyperglycemia who were receiving artificial nutrition.Results: The literature review showed that few randomized control trials exist regarding treatment of hyperglycemia in this cohort of patients, and the multiple retrospective evaluations that have addressed this topic provided varied results. In general, intravenous (IV) continuous insulin infusion offers the best glycemic control; however, this route of insulin administration is often burdensome for floor patients and their care teams. Administration of scheduled subcutaneous (SQ) insulin in patients on ENT or PNT is a safe and effective way to manage hyperglycemia, however limited data exist on an appropriate insulin regimen.Conclusion: Further prospective, randomized control trials are necessary to determine the optimal treatment of hyperglycemia for patients receiving ENT or PNT.Abbreviations: BG = blood glucose; CG = conventional glycemic control; ENT = enteral nutrition therapy; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; IG = intensive glycemic control; IV = intravenous; NPH = neutral protamine Hagedorn; PNT = parenteral nutrition therapy; SQ = subcutaneous; T2DM = type 2 diabetes mellitus; TDD = total daily dose; TPN = total parenteral nutrition     

Insulin Infusion Protocols for Critically ILL Patients: A Highlight of Differences and Similarities

ObjectiveTo discuss the major differences and similarities among the currently published insulin infusion protocols (IIPs) for critically ill patients.MethodsIIPs were identified by searching MED-LINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The reference lists for all retrieved protocols were also reviewed to identify any IIPs that were not surfaced with use of our initial search strategies. The major differences and similarities among the IIPs were identified and examined. In addition, strategies for successful implementation of IIPs were outlined.ResultsOur search strategies retrieved 17 IIPs. Currently, no published studies have compared one insulin protocol with another. The major differences or similarities among the published IIPs were in the following areas: patient characteristics, target glucose level, time to achieve target glucose level, incidence of hypoglycemia, rationale for adjusting the rates of insulin infusion, and methods of blood glucose measurements. Because of variations in the definition of hypoglycemia, methods of blood glucose measurement, and types of blood samples used, some comparisons across the protocols were difficult. Use of a multidisciplinary team and gaining administrative support are crucial for addressing issues and provision of necessary resources for implementing a protocol for “tight” glycemic control in critically ill patients.ConclusionClinicians should evaluate the type of patients in their critical care units, the mean baseline glucose levels, and the available resources to determine the most appropriate and practical IIP for their institution. (Endocr Pract. 2007;13:137-146)     

Prevalence of Diabetes,Prediabetes, and Stress Hyperglycemia: Insulin Therapy and Metabolic Control in Patients on Total Parenteral Nutrition (Prospective Multicenter Study)

ObjectiveThe prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved.MethodsWe undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment.ResultsThe study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of > 180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P < .001).ConclusionThe prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved. (Endocr Pract. 2015;21:59-67)     

Inpatient Glycemic Control on the Vascular Surgery Service

ObjectiveTo describe a structured inpatient insulin management protocol and order set for glycemic control on a vascular surgery service.MethodsPatients admitted to the vascular surgery service with underlying diabetes were enrolled in a study of use of a preprinted basal-bolus insulin order set based on a total daily dose of 0.5 U/kg (0.25 U/kg of insulin glargine and 0.25 U/kg of insulin aspart divided into 3 equal mealtime doses). Outcomes included the mean glycemic control at each of 5 established time intervals, the percentage of blood glucose measurements within the target range of 70 to 180 mg/dL, the incidence of hypoglycemia, and the insulin dosages. Historical control patients with diabetes from the same hospital service were used for comparison.ResultsBoth the study group and the control group consisted of 26 patients. The number of finger-stick blood glucose measurements performed was 871 in the control group and 896 in the intervention group. The mean blood glucose level (± SD) for the intervention group was 149.4 ± 50.7 mg/dL, in comparison with 165.2 ± 64.4 mg/dL for the control group. The incidence of hypoglycemia decreased 50% in the intervention group—from 32 (4% of the finger-stick assessments in the control group) to 19 (2% of the finger-stick blood glucose measurements in the study group). The blood glucose target range of 70 to 180 mg/dL was achieved in 75% of the measurements in the study group versus 61% in the control group. The basal insulin dose was unchanged in 65% of the patients, and of the 9 patients requiring a change in the dose, 5 had the dose decreased by 10% and 4 had the dose increased by 10%.ConclusionThe use of a standardized basal-bolus weight-based insulin regimen was successful at achieving improved glycemic control as well as reducing the incidence of hypoglycemia in an inpatient population with diabetes. (Endocr Pract. 2008;14:185-192)     

Insulin Requirements in Patients With Type 2 Diabetes Undergoing Bariatric Surgery in the Inpatient Setting and Upon Discharge: A Single-Center Retrospective Analysis of Insulin Management Strategies

ObjectiveRapid improvement in blood glucose (BG) after weight-loss surgery (WLS) can make postoperative glucose management challenging in patients with type 2 diabetes mellitus (T2DM). Our study examined the safety and efficacy of insulin management strategies during hospitalization and after discharge following WLS.MethodsThis single-center retrospective cohort study included 160 adult patients with type 2 diabetes mellitus undergoing WLS. Patients with glycated hemoglobin A1C (HbA1C) level <7% (53 mmol/mol) and not on antihyperglycemic medications or metformin monotherapy were excluded. BG and insulin dosing during hospitalization and at 2-week follow-up, and impact of preoperative HbA1C level were analyzed.ResultsMean age was 46.3 years. Median preoperative HbA1C level was 8% (64 mmol/mol). Postoperatively, most patients received basal insulin plus sliding-scale insulin (SSI; 79/160, 49%) or SSI alone (77/160, 48%). The initial postoperative basal dose was 0.23 units/kg/day. The median basal insulin dose at discharge was 61% lower than preoperative dose. At 2-week follow-up, 34 of 44 patients (77%) had BG levels between 70-200 mg/dL and 1 of 44 (2.2%) had BG levels >200 mg/dL, with no hypoglycemia. Patients with HbA1C level >9% (75 mmol/mol) had higher BG on admission and during hospitalization, required higher insulin doses while hospitalized, and were more frequently discharged on insulin.ConclusionSSI is effective in managing BG in some patients immediately after WLS. However, about half of the patients may require basal insulin at doses similar to those required by other inpatients. Preoperative hyperglycemia may affect inpatient insulin needs and BG. Low-dose basal insulin appears safe and effective upon discharge for select patients.     

Individualization Through Standardization: Electronic Orders for Subcutaneous Insulin in the Hospital

ObjectiveThe objective was to design electronic order sets that would promote safe, effective, and individualized order entry for subcutaneous insulin in the hospital, based on a review of best practices.MethodsSaint Francis Hospital in Evanston, Illinois, a community teaching hospital, was selected as the pilot site for 6 hospitals in the Health Care System to introduce an electronic medical record. Articles dealing with man agement of hospital hyperglycemia, medical order entry systems, and patient safety were reviewed selectively.ResultsIn the published literature on institutional glycemic management programs and insulin order sets, features were identified that improve safety and effectiveness of subcutaneous insulin therapy. Subcutaneous electronic insulin order sets were created, designated in short: “patients eating”, “patients not eating”, and “patients receiving overnight enteral feedings.” Together with an option for free text entry, menus of administra tion instructions were designed within each order set that were applicable to specific insulin orders and expressed in standardized language, such as “hold if tube feeds stop” or “do not withhold.”ConclusionTwo design features are advocated for electronic order sets for subcutaneous insulin that will both standardize care and protect individualization. First, within the order sets, the glycemic management plan should be matched to the carbohydrate exposure of the patients, with juxtaposition of appropriate orders for both glucose monitoring and insulin. Second, in order to convey precautions of insulin use to pharmacy and nursing staff, the prescriber must be able to attach administration instructions to specific insulin orders. (Endocr Pract. 2012;18:976-987)     

Management Of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols

ObjectiveTo provide insulin protocols and adjustment guidance for management of hyperglycemia in common inpatient clinical scenarios.MethodsWe performed a PubMed search of pertinent existing literature published between 1980 and 2010.ResultsHyperglycemia is frequently encountered in general medical and surgical wards and has been linked to adverse clinical outcomes, prolonged hospital length of stay, and increased institutional care needs after discharge. No randomized controlled trial has been conducted to define optimal glycemic goals or to investigate the effects of intensive glycemic control in the non-intensive care unit (ICU) setting. Nonetheless, it is advocated by the American Association of Clinical Endocrinologists and the American Diabetes Association, in their 2009 Consensus Statement on Inpatient Glycemic Control, that optimization of glycemia in hospitalized patients with diabetes and hyperglycemia be judiciously offered. This approach is clinically sound, in light of the known deleterious consequences of hyperglycemia in critically and noncritically ill patients and the benefits observed with improved glycemic control in intensive care settings. The approach to hyperglycemiain non-ICU inpatients should follow the principles of provision of basal-nutritional-supplemental insulin. Herein we provide insulin protocols and adjustment guidance for management of hyperglycemia in common clinical scenarios. Recommendations reflect the opinion of national experts in the field and our departmental consensus at Penn State Institute for Diabetes and Obesity.ConclusionGlycemic control in the non-ICU setting is a relevant clinical situation that should be addressed and managed effectively and prudently. We present a practical guide for management of hyperglycemia individualized to various clinical scenarios encountered in the general hospital wards. (Endocr Pract. 2011;17:249-260)     

Changing to Basal-Bolus Insulin Therapy for the Inpatient Management of Hyperglycemia—A Natural Experiment

Objective: Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known versus newly diagnosed type 2 diabetes.Methods: This natural experiment compared outcomes in 10,120 non–critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators.Results: Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n = 234), who experienced a statistically significant decline in the incidence of complications (P<.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (P<.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (P<.01).Conclusion: Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non–critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined.Abbreviation: ICD-9 = International Classification of Diseases–Ninth Revision