Effects of a Subcutaneous Insulin Protocol, Clinical Education, and Computerized Order Set on the Quality of Inpatient Management of Hyperglycemia: Results of a Clinical Trial

BACKGROUND: Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non-intensive care unit (ICU) setting. OBJECTIVE: To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia. DESIGN: Before-after trial. SETTING: Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists. PATIENTS: Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia. INTERVENTION: A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case-based educational workshops and lectures to nurses, physicians, and PAs. MEASUREMENTS: Mean percent Of glucose readings per patient between 60 and 180 mg/dL; percent patient-days with hypoglycemia; insulin use patterns; and hospital length of stay. RESULTS: The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%-18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% Cl, 0.6-2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% Cl, 2.0-9.9) and adjusted length of stay decreased by 25% (95% Cl, 9%-44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3. CONCLUSIONS: 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. Journal of Hospital Medicine 2009;4:16-27. (c) 2009 Society of Hospital Medicine.