Insulin Use in Hospitalized Patients With Diabetes: Navigate With Care

Abstract

“ A man walks into a bar …” These classic words introduce countless humorous situations. “ A man enters a hospital …” Unfortunately, these words introduce distinctly serious situations that occur at the rate of > 35 million per year across the United States.1 These words introduce a story in people's lives that all too often includes mistakes, misadventures, and even preventable deaths. The hospital is a dangerous place. Approximately one-third of all deaths in this country occur in hospitals.2,3 On any given day, up to 30% of all hospitalized patients have diabetes, placing almost one-third of inpatients at greater risk for complications that may adversely affect their hospital stay. The majority of these hospitalized patients with diabetes are treated with insulin, a medication that occupies a prominent place on the list of high-alert medications of the Institute for Safe Medication Practices.4 It is the leading medication implicated in adverse events requiring treatment in a hospital emergency department.5 Moreover, insulin is responsible for more drug errors during acute hospital care than other commonly used hospital medications.6 What is the best approach to using insulin in the hospital setting? What skills and knowledge must providers have to make the most effective use of insulin and yet minimize the danger of hypoglycemia? There are no simple answers for these questions. As depicted in Figure 1, a single hospitalization often involves multiple transitions, each requiring a careful approach to insulin therapy. The transitions begin when patients enter the hospital. Patients may be admitted to a ward or to the intensive care unit (ICU), proceed directly to the operating room, or undergo various invasive procedures. Patients then move within the hospital among different levels of care with overlapping or sequential interventions such as nothing-by-mouth (nil per …