Background: Glucose management of hospitalized patients with hyperglycemia has many challenges. One of these challenges is the timing of insulin administration in coordination with meal delivery. The Endocrine Society recommends assessing glucose levels within 60 minutes of prandial insulin administration and that rapid-acting insulin should be administered 15 minutes before or immediately after a meal.1 Inappropriate administration of insulin in relation to the timing of meals can lead to either hyperglycemia or hypoglycemia. One institution evaluated 50 occurrences of insulin administration and found that patients did not receive rapid acting insulin within 10 minutes of premeal or post meal 84% of the time.2 The purpose of this study was to evaluate the timing of insulin administration and point of care testing (POCT) glucose regarding meal tray delivery at our institution.
Methods: We conducted a single center, quality assessment project of patients greater than 18 years of age who were ordered for scheduled prandial insulin and admitted to a general medical or surgery floor at Brigham and Women’s Hospital. This study was approved by the hospital’s Institutional Review Board. Patients were identified via hospital reporting system for patients ordered for scheduled rapid-acting insulin with meals. A convenience sample of patients were selected based on the availability of an observer between May 2017 and October 2018. Workflow was observed on the floor with respect to when meal trays were delivered inside the patient room, timing of pre-meal glucose value, and scheduled rapid-acting insulin timing. Nursing staff on units being assessed were not made aware of the study to avoid any performance bias. The timing of insulin administration and point-of-care-test (POCT) glucose was based off the medication administration record documentation and test results respectively in the electronic medical record.
Results: We performed a 54 random mealtime observation of 31 hospitalized medical or surgical patients prescribed prandial insulin. Of the 31 patients, 30 of the patients had a diagnosis of diabetes (96.8%) prior to admission. Of the 30 patients with a diagnosis of diabetes, 25 patients were prescribed insulin prior to admission (83.3%). We evaluated 54 administrations of insulin, 37 (69%) patients had a POCT glucose done within one hour of the prandial insulin administration. Only 46% of patients received insulin within 15 minutes before or after meal tray delivery.
Conclusions: We observed room for improvement with the timing of POCT and insulin administration for patients with schedule meal-time rapid-acting insulin. The results of this quality assessment project will serve as a baseline for further quality improvement initiatives.