Inpatient hyperglycemia is common and associated with adverse patient outcomes. Current guidelines recommend treatment to achieve glucose levels below 180 mg/dL in the inpatient non‐ICU setting. The best ways to achieve this glucose target are unknown.
We developed a multifaceted intervention to improve inpatient glycemic control consisting of: (1) a detailed subcutaneous insulin protocol based on American Diabetes Association guidelines; (2) an admission order set built into the hospital's computerized order entry system; and (3) case‐based educational workshops and lectures to nurses, physicians, and physician assistants (PAs). Workshops required a total of approximately 6 hours of instructor time in addition to the time typically devoted to educational activities. We then conducted a before‐after study of the Physician Assistant/Clinician Educator (PACE) service, a geographically localized general medical service with a dedicated cadre of nurses, hospitalists, and PAs. Study subjects were prospectively identified, consecutively enrolled patients with known diabetes or at least 1 random laboratory glucose value > 180 mg/dL. Patients with type 1 diabetes or with an indication for intravenous insulin infusion were excluded. We compared the results with the usual care, from July 15 to December 12, 2005, with those from the intervention, from January 18 to June 20, 2006. The primary outcome was mean percentage of glucose readings between 60 and 180 mg/dL of each patient. Multivariable binomial logistic regression using general estimating equations was conducted to adjust for potential confounders and clustering by patient.
We identified 133 study subjects: 52 usual care patients and 81 intervention patients. There were no significant differences between study groups in age, sex, race, admission glucose, HbA1C, insulin use prior to admission, or prior diagnosis of diabetes. The mean percentage of readings between 60 and 180 mg/dL per patient was 59% prior to the intervention and 66% afterward (adjusted odds ratio, 1.41, 95% CI: 0.99‐2.00, P = .056). Patient‐day weighted mean glucose decreased from 171 to 159 mg/dL (P = .01). The percentage of patient‐days with any hypoglycemia (glucose < 60 mg/dL) was 5.3% preintervention and 7.6% afterward (P = .36). Use of basal insulin increased from 79% to 99% of patients, and use of scheduled nutritional insulin increased from 37% to 78% (P < .001 for both comparisons).
This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin‐ordering practices and glycemic control among non‐ICU medical patients without a significant increase in hypoglycemia. Such an intervention is worthy of further refinement and study.
J. L. Schnipper, Novo Nordisk, research grants; M. L. Pendergrass, Novo Nordisk, research grants.