Background:
Management of hyperglycemia in hospitalized patients has historically relied upon the “insulin sliding scale” (SSI). In connection with persistent hyperglycemia, it leads to less than optimal outcomes in the majority of hospitalized patients.
Purpose:
To limit hyperglycemia, reduce the incidence of hypoglycemic events, and minimize or eliminate medication errors with insulin administration, a multidisciplinary team developed an intranet accessible “best practice” order set for tight glucose control in general medical inpatients utilizing subcutaneous basal and short‐acting insulin. The goal glycemic average for this initiative was 150 ‐ 180 mg/dL (AACE Consensus Guideline).
Description:
The multidisciplinary task force included all stakeholders and institutional experts. An extensive educational initiative, including tight glycemic control and effective utilization of basal and mealtime insulin, was launched and completed prior to order set implementation on a hospitalist medical ward. The ward nurses requested full guidance in the order set and their usual workflow was uninterrupted. The order set encouraged use of scheduled basal and mealtime insulin. Multilevel, standardized mealtime and bedtime correction dose scales and hypoglycemia protocols were incorporated as were instructions for patient selection, blood glucose goals and monitoring, snacks and diets, timing of insulin administration and orders to hold, recommended laboratory testing, and indications for endocrine, patient education, and nutrition consults. Blood glucose monitoring was recorded in the usual electronic format. IRB approval was obtained for retrospective cohort review.
Summary of Results:
Over four months, 181 patients were treated for hyperglycemia. The glycemic average was 198 mg/dL. For the purposes of analysis, management methods were grouped into three categories: usual care, i.e., SSI alone or with oral agents +/‐ AM/PM insulin (70%); basal or mealtime insulin with SSI (10%); and new order set basal/mealtime regimens (20%). Patients in these sub‐groups were provider‐selected and not evenly matched. No statistically significant difference in the incidence of hypoglycemic events occurred. Physician utilization of the new order set was voluntary, but actively promoted through emails and department meetings. The most commonly cited barrier to its use by physicians was its physical length of 4 pages. Also, implementation on the pilot ward alone made the ubiquitously available SSI form a simpler choice. To encourage acceptance by physicians, the form was shortened to a 2‐page order set for subsequent dose adjustments. Nurses on the pilot ward were empowered to recommend the order set to physicians when their patients' blood glucose levels were consistently above 180 mg/dL. As a result of this initiative, introduction of the order sets to all non‐critical care areas is underway.
Author Disclosure Block:
R.Y. Meadows, None; N. Fabre'‐LaCoste, None; S.B. Deitelzweig, None.