Background: Studies have demonstrated that oral medications such as metformin are safe to continue in the hospital, and that when insulin is used in a hospital setting, a basal or basal-bolus regimen is more effective than sliding scale monotherapy (1-2). Despite mounting evidence and society guidelines, clinicians have been slow to adopt these practices in the medical inpatient setting (3).

Purpose: The purpose was to increase appropriate use of oral diabetes medications and basal insulin with the overall goal of improving glycemic control in the inpatient setting across an 11-hospital system.

Description: The quality improvement initiative was implemented across an urban, 11-hospital safety net health system. We implemented a multifaceted intervention consisting of: (1) an education and awareness campaign, (2) local clinical consensus guidelines, and (3) electronic medical record order set enhancement.To facilitate system-wide education and increase awareness, materials were sent to clinical leaders at each of our 11 hospitals, including a slide deck with guidelines for oral diabetes medications and insulin dosing as well as a one-pager tip sheet with our primary recommendations. At select sites, lunchtime educational sessions for residents and students were also conducted.Inpatient diabetes management recommendations were approved by members of the High Value Care Council, including system leadership from quality, patient safety, pharmacy, laboratory, and nursing. Further consensus was achieved by members of the Internal Medicine and Endocrine leadership.The system-wide inpatient diabetes order set was modified to encourage continuation of appropriate home oral medications (metformin and/or sitagliptin) and ordering of either basal-only or basal-bolus regimens for patients who require insulin instead of sliding scale monotherapy (Figure 1). Within individual insulin orders, user-friendly dose calculators were embedded to help determine appropriate initial dosing.Pre-intervention data (11/3/2020 to 2/9/2021, 99 days) were compared to post-intervention data (2/10/2021 to 8/14/2021, 186 days). All patients > 18 years old admitted to medical, surgical, or psychiatric services were included. Patients admitted to intensive care units were excluded. Patients admitted with COVID-19 were excluded from analyses of metformin, sitagliptin, and basal insulin administration. The combined rate of metformin and sitagliptin administrations increased 21.7% (52 to 63 administrations per 1000 patient days, p < 0.001). The combined rate of basal insulin orders (insulin detemir and NPH) remained unchanged (-1.0%, 1199 to 1186 administrations per 1000 patient days, p = 0.459). Rate of hypoglycemia (glucose < 70) decreased by 0.19% (2.14% to 1.96%, p < 0.001). Similarly, the rate of hyperglycemia (glucose > 200) decreased by 0.86% (25.19% to 24.33%, p < 0.001).

Conclusions: The introduction of an inpatient diabetes order set resulted in increased use of metformin and sitagliptin. Rates of hyperglycemia and hypoglycemia also decreased. Basal insulin usage did not significantly change.Shifting practice toward oral diabetes medications is achievable in large settings. It can deter use of unnecessary sliding scale insulin monotherapy regimens and may lead to improved glycemic control. This has the potential to encourage the use of inpatient diabetes medications that more readily translate into outpatient regimens for these patients.

IMAGE 1: Modified Inpatient Diabetes Order Set