Effectiveness of Inpatient Insulin Order Sets Using Human Insulins in Noncritically Ill Patients in A Rural Hospital |
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| Institution: | 1. From the Gallup Indian Medical Center, Gallup, New Mexico;2. Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women''s Hospital, Boston, Massachusetts and Department of Medicine, Harvard Medical School, Boston, Massachusetts,;3. Psychiatric Epidemiology Research Program, McLean Hospital, Belmont, Massachusetts and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.;1. Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand;7. School of Mathematics and Statistics, University of Canterbury, Christchurch, New Zealand;71. Intensive Care Unit, Christchurch Hospital, Christchurch, New Zealand;1. From the Departments of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio.;2. Clinical Pathology, Cleveland Clinic, Cleveland, Ohio.;3. Endocrinology, Cleveland Clinic, Cleveland, Ohio. |
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| Abstract: | Objective: Recent guidelines recommend a physiologic approach to non–intensive care unit (ICU) inpatient glucose management utilizing basal-bolus with correctional (BBC) insulin over traditional sliding-scale insulin monotherapy. Unfortunately, few studies exist using a BBC approach restricted to human insulins (regular and neutral protamine Hagedorn NPH]). This study evaluated changes in provider prescribing patterns, effects on blood glucose, and safety with implementation of hospital order sets for BBC using human insulins.Methods: Order sets were developed for non-ICU inpatients, consisting of basal, prandial, and correctional insulin using NPH and regular human insulins. Evaluation compared a 4-month period before (admissions, n = 274) with a 4-month period after order set availability (n = 302). Primary outcome was change in insulin prescribing patterns. Secondary outcomes included use of nonpreferred diabetes treatments, hemoglobin A1c testing, mean daily blood glucose, and incidence of hypoglycemia.Results: Use of BBC insulin regimen increased from 10.6 to 27.5% after order set implementation (P<.001). Use of oral antihyperglycemic agents decreased from 24.1 to 14.9% after implementation (P = .006). Hemoglobin A1c testing rose from 50.0 to 62.3% after (P = .003). Mean daily blood glucose improved, with an estimated mean difference of 14.4 mg/dL (95% confidence interval, 2.2 to 26.5 mg/dL) over hospital days 3 through 9 (P = .02). There was no significant change in the incidence of moderate or severe hypoglycemia.Conclusion: Implementation of hospital-wide human insulin order sets led to improvements in prescribing practices and blood glucose control, without increasing the incidence of hypoglycemia. These order sets may be useful for facilities limited by formulary and cost considerations to the use of older human insulins.Abbreviations: BBC = basal-bolus with correctional insulin ICU = intensive care unit NPH = neutral protamine Hagedorn NPO = nil per os |
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