Insulin Order Sets Research Articles

Optimizing Inpatient Glycemic Control with Basal-Bolus Insulin Therapy

Hyperglycemia is highly prevalent in the acute-care setting and is associated with an increased risk of morbidity and mortality. Evidence suggests that glycemic control in this population is suboptimal, due in part to continued use of nonphysiologic sliding-scale insulin strategies without scheduled basal insulin doses or prandial insulin with concomitant correction doses. Although the ineffectiveness and risks of sliding-scale insulin regimens have been criticized for decades, sliding-scale insulin is still the most commonly prescribed subcutaneous insulin regimen among inpatients. Improving inpatient management requires the use of scheduled basal-bolus insulin therapy that includes basal insulin, nutritional insulin, and supplemental, or correctional, insulin. Insulin analogs are the preferred insulins, as they provide a more physiologic action than human insulin regimens, are associated with a lower risk of hypoglycemia, and are more convenient to administer than human insulins. Standardized insulin protocols and subcutaneous insulin order sets are critical components of effective inpatient glycemic control. Although preliminary data have demonstrated that inpatient diabetes management programs involving basal-bolus insulin therapy are effective and well tolerated, more research is needed.

Pharmacists’ role in ensuring safe and effective hospital use of insulin

To highlight the potential errors that may occur with insulin use in the inpatient setting and to describe how pharmacists can be part of the solution by implementing practices that reduce the likelihood of insulin-related medication errors. Insulin is a drug with a low therapeutic index, and it bears a heightened risk of causing significant patient harm when used in error, making it a high-alert medication. Both underdosing and overdosing of insulin may be associated with adverse outcomes. The use of standard insulin order sets for scheduled subcutaneous insulin administration and standard concentrations for i.v. insulin are recommended to ensure the safe use of this medication. Any ambiguous insulin therapy orders should be clarified in writing prior to administration. Preparation of all insulin infusions should occur within the pharmacy. Pharmacists should be aware of possible medication errors related to inappropriate use of abbreviations such as U for units. Safe insulin storage practices are recommended to reduce the risk for insulin error. Insulin pen delivery devices may be used in hospitals, but safe use depends on ongoing oversight by a multidisciplinary committee, introduction of one device at a time, and initial and regular follow-up education of nurses, including agency nurses and those who work part-time. In addition, ongoing monitoring is needed to assure ongoing safety. The use of sliding-scale insulin can lead to hyperglycemia and hypoglycemia and is confusing and prone to error; it is not recommended. Pharmacists can contribute to the safe use of insulin in the inpatient setting by minimizing the likelihood of medication errors related to prescribing, transcription, dispensing, administration, storage, and communication.

Impact of improvement efforts on glycemic control and hypoglycemia at a University Medical Center

Great emphasis is placed on optimizing treatment of hospitalized patients with diabetes and hyperglycemia. This study was conducted to determine if the application of hospital-wide insulin order sets improved inpatient safety by reducing the number of actual hypoglycemic and hyperglycemic events and increasing at-target blood glucose. A retrospective chart review was conducted of hypoglycemic and hyperglycemic events and at-target blood glucose occurring before and after institution of the insulin order sets and blood glucose protocols. The Medical University of South Carolina (MUSC) Medical Center is a 709-bed hospital and tertiary referral center for partnering hospitals in the southeastern United States. All patients were evaluated who had a documented history of diabetes or who had at least 1 finger-stick blood glucose above 180 mg/dL who were admitted for care to the MUSC adult main hospital (minimum of 18 years-of-age; maximum 100 years-of-age) during June 2004, June 2005, June 2006, and June 2007. The intervention involved institution of hospital-wide hypoglycemia, hyperglycemia, subcutaneous insulin, and intravenous insulin treatment protocols. Retrospective data on hypoglycemia, hyperglycemia, and at-target blood glucose incidence and frequency were collected via a computerized repository for all inpatients. The percent time in range improved by 10% with no increase in the amount of severe hypoglycemic episodes for the blood glucose results. Implementing standardized insulin order sets including hypoglycemia and hyperglycemia treatment protocols at MUSC produced expected benefits for patient safety for this patient population.

Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm

Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported. Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control. Prospective observational. 400-bed academic center. Adult non-critical care inpatients with diabetes or hyperglycemia and point-of-care (POC) glucose testing. Structured insulin orders, insulin management algorithm. Percent of insulin orders with basal insulin. Percent uncontrolled patient-stays (day-weighted mean glucose >or=180 mg/dL) and uncontrolled patient-days (patient-day mean glucose >or=180 mg/dL). Percent of monitored patient-days and patient-stays with hypoglycemia (glucose <or=60 mg/dL) and severe hypoglycemia (glucose <or=40 mg/dL). The percent sliding scale only insulin regimens decreased (72% versus 26% with structured insulin orders, P < 0.0001 chi square). The percent of uncontrolled patient-days was 37.8% versus 33.9% versus 30.1% (P < 0.005) (TP1-Baseline; TP2-Structured insulin orders; TP3-Orders plus Algorithm). Expressed as relative risk with 95% confidence interval (RR with CI), the RR of an uncontrolled patient-stay was reduced from baseline to 0.91 (CI 0.85-0.96) in TP2, and to 0.84 (CI 0.77-0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 POC values. The percent of patient-days with hypoglycemia was 3.8%, 2.9%, and 2.6% in 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59-0.78). Similar reductions were seen in risk for hypoglycemic patient-stays. Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms.

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.

Designing and implementing insulin infusion protocols and order sets

Influential trials and guidelines supporting the value of glucose control in hospital settings, particularly in the intensive care and postoperative settings, has led to the widespread adoption of intravenous infusions of human regular insulin. As groups have attempted to study the outcomes or to explore improved methods for improved glucose control, a number of insulin infusion protocols (IIPs) have been reported and validated. Now, many institutions are attempting to translate this experience into clinical practice in a systematic manner. The intent of this discussion is to highlight the authors' practical view of best practices in development and use of IIPs. As the implementation of IIPs has progressed, it has become apparent that this is not a simple process. It requires a carefully planned, inclusive, and continuous effort striving to attain effective glucose control while avoiding severe hypoglycemia. Whereas there are limitations in the literature comparing the IIPs, we identify design elements and implementation methods that increase the chances for staff acceptance and safe attainment of glycemic goals. Most importantly, this must be a team effort with attention to the numerous potential pitfalls that can disrupt the process and place patients at risk. In many cases, it is best to start more conservatively and methodically intensify the protocol. Continuous assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to overall success.

Inpatient Glycemic Control on the Vascular Surgery Service

To describe a structured inpatient insulin management protocol and order set for glycemic control on a vascular surgery service. Patients 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 as part 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. Both 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%. The 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.

Hospital protocols for targeted glycemic control: Development, implementation, and models for cost justification

Evolving elements of best practices for providing targeted glycemic control in the hospital setting, clinical performance measurement, basal-bolus plus correction-dose insulin regimens, components of standardized subcutaneous (s.c.) insulin order sets, and strategies for implementation and cost justification of glycemic control initiatives are discussed. Best practices for targeted glycemic control should address accurate documentation of hyperglycemia, initial patient assessment, management plan, target blood glucose range, blood glucose monitoring frequency, maintenance of glycemic control, criteria for glucose management consultations, and standardized insulin order sets and protocols. Establishing clinical performance measures, including desirable processes and outcomes, can help ensure the success of targeted hospital glycemic control initiatives. The basal-bolus plus correction-dose regimen for insulin administration will be used to mimic the normal physiologic pattern of endogenous insulin secretion. Standardized insulin order sets and protocols are being used to minimize the risk of error in insulin therapy. Components of standardized s.c. insulin order sets include specification of the hyperglycemia diagnosis, finger stick blood glucose monitoring frequency and timing, target blood glucose concentration range, cutoff values for excessively high or low blood glucose concentrations that warrant alerting the physician, basal and prandial or nutritional (i.e., bolus) insulin, correction doses, hypoglycemia treatment, and perioperative or procedural dosage adjustments. The endorsement of hospital administrators and key physician and nursing leaders is needed for glycemic control initiatives. Initiatives may be cost justified on the basis of the billings for clinical diabetes management services and/or the return- on-investment accrued to reductions in hospital length of stay, readmissions, and accurate documentation and coding of unrecognized or uncontrolled diabetes, and diabetes complications. Standardized insulin order sets and protocols may minimize risk of insulin errors. The endorsement of these protocols by administrators, physicians, nurses, and pharmacists is also needed for success.

Evolution of a Diabetes Inpatient Safety Committee

To develop a multidisciplinary team, the Diabetes Inpatient Safety Committee (DPSC), to effectively address the many barriers to achieving glycemic control in the inpatient setting. The development, implementation, and successes of the DPSC are described. By focusing on prevention of severe hypoglycemia, the DPSC identified and addressed areas related to inpatient management that contributed to uncontrolled glucose levels. The introduction of a hypoglycemia treatment protocol was followed by the development of a standardized order set for use of sliding scale insulin, with the eventual introduction of an Insulin Order Set guiding the use of scheduled and correctional insulin. Protocols and guidelines addressing more specific areas of inpatient glycemic management (insulin pump therapy, perioperative management, diabetic ketoacidosis, intravenous insulin) also have been developed. The successes of the DPSC to date have been directly related to strong institutional support, the dedication of a multidisciplinary team to address specific areas of glycemic management, the programmed introduction of order sets in conjunction with structured educational programs that accompany each protocol, and the use of quality improvement measures to evaluate the safety and efficacy of these protocols. Effective committees such as this will be instrumental in preventing errors and maximizing euglycemia.