Improving Glycemic Control in Non–Critically III Hospitalized Patients

Background:

Blood glucose (BG) control is difficult to achieve in the hospital setting, and the best approach to BG control in non‐critically ill patients is unclear. A few quality improvement studies have demonstrated improvements in glycemic control with the use of education and standardized physician orders, but most of these studies showed only modest improvements and did not delineate the key clinical factors associated with improvement.

Methods:

We performed a quasi‐experimental cohort study comparing glycemic control in 3 groups of hyperglycemic patients treated with insulin. Patients in the intervention group (IG) were treated using a mandatory standardized insulin order form and trained physicians and nurses. The IG was compared to both a concurrent control group (CCG — no standardized insulin order form or nurse training) and a historic control group (HCG — 2 years prior, no interventions). Examined outcomes were rates of hyperglycemia, hypogly‐cemia, and the insulin regimens that were prescribed. An analysis of clinical variables associated with glycemic control was performed.

Results:

A total of 245 patients provided 1315 analyzable patient‐days. Patients in the 3 groups were demographically similar, but the use of high‐dose steroids was higher in the CCG group than in the IG group (19.8% vs. 14.6%, P = 0.4). Patients in the IG group were more likely to be treated with a combination of scheduled basal plus nutritional insulin (the recommended regimen) than those in the other groups. Compared to the CCG group, patients in the intervention group experienced more days within the target glucose range (17% vs. 10.6%, P < 0.01), fewer days with severe hyperglycemia (48.3% vs. 59.2%, P < 0.01), and a lower day‐weighted average blood glucose (195.9 vs. 212.6, P < 0.01). Compared with the HCG, patients in the iG experienced similar rates of hyperglycemia but fewer hypoglycemic days (5.1% vs. 9.2%, P < 0.02). Univariate analysis revealed no association between any specific insulin regimen and improved glycemic control. The use of high‐dose steroids was associated with severe hyperglycemia (OR 1.8, 95% Cl 1.33– 2.44). More than 80% of all patient‐days for all groups contained glucose readings outside the target range.

Conclusions:

Quality improvement efforts utilizing education and standardized insulin ordering can lead to significant changes in insulin prescribing practices and improvements in glycemic control. However, in this study, a superior insulin regimen could not be identified, and glycemic control was frequently outside the recommended target range. Additional studies are needed to delineate specific BG control strategies and quality improvement interventions that will lead to more robust improvements in BG control in this population.

Author Disclosure:

D. Wesorick, none; J. Grunawalt, none; R. Gianchandani, speakers bureau, sanofi‐aventis.