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

J Hosp Med. 2009 Jan 12;4(1):3-15

Authors: Maynard G, Lee J, Phillips G, Fink E, Renvall M

BACKGROUND:: Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported. OBJECTIVE:: Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control. DESIGN:: Prospective observational. SETTING:: 400-bed academic center. PATIENTS:: Adult non-critical care inpatients with diabetes or hyperglycemia and point-of-care (POC) glucose testing. INTERVENTIONS:: Structured insulin orders, insulin management algorithm. MEASUREMENTS:: Percent of insulin orders with basal insulin. Percent uncontrolled patient-stays (day-weighted mean glucose >/=180 mg/dL) and uncontrolled patient-days (patient-day mean glucose >/=180 mg/dL). Percent of monitored patient-days and patient-stays with hypoglycemia (glucose </=60 mg/dL) and severe hypoglycemia (glucose </=40 mg/dL). RESULTS:: 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. CONCLUSIONS:: Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms. Journal of Hospital Medicine 2009;4:3-15. (c) 2009 Society of Hospital Medicine.

PMID: 19140173 [PubMed - as supplied by publisher]

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