Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital

Efficacy of a training programme for the management of diabetes mellitus in the hospital: A randomized study (stage 2 of GOVEPAZ healthcare)

AIMS

To assess the efficacy of a structured educational intervention for health professionals on the appropriateness of inpatient diabetes care and on some clinical outcomes in hospitalised subjects.

METHODS

A multicentre (6 regional hospitals) cluster-randomized (2:1) two parallel-group pragmatic intervention trials, as a part of the GOVEPAZ study, was conducted in three clinical settings, that is, Internal Medicine, Surgery and Intensive Care. Intervention consisted of a 2-month structured education of clinical staff to inpatient diabetes care. Twelve wards - 2 for each hospital - and 6 wards - 1 for each hospital - were randomized to usual care and to the intervention arm, respectively. Consecutively hospitalised diabetic subjects (n = 524, age 74 ± 14 years, 57% males, median HbA1C 57 mmol/mol) were included. The clinical appropriateness of inpatient diabetes management was assessed by a previously validated multi-domain performance score (PS). Clinical outcomes included hypoglycemia, glucose control biomarkers, clinical conditions at discharge and inpatient mortality rate.

RESULTS

A numerically, but not statistically significant, higher PS (+0.94; 95% C.I.: -0.53 - +2.4) was achieved in the intervention than in the usual care wards. Hypoglycemias (p = 0.32), glucose control (p = 0.89) and survival rates (p = 0.71) were similar in the two experimental arms. Plasma glucose on admission (OR = 1.52 per 1 SD; C.I. 1.07-2.17; p = 0.021) and the number of hypoglycemic events per patient (OR = 1.55 per 1 SD; C.I.:1.11-2.16; p = 0.011) were independently associated with the inpatient mortality rate.

CONCLUSIONS

Structured education of the clinical staff failed to improve the inpatient appropriateness of diabetes care or clinical outcomes. In-hospital hypoglycemia was confirmed to be an independent indicator of death risk.

Development and validation of a machine learning model for classification of next glucose measurement in hospitalized patients

BACKGROUND

Inpatient glucose management can be challenging due to evolving factors that influence a patient's blood glucose (BG) throughout hospital admission. The purpose of our study was to predict the category of a patient's next BG measurement based on electronic medical record (EMR) data.

METHODS

EMR data from 184,361 admissions containing 4,538,418 BG measurements from five hospitals in the Johns Hopkins Health System were collected from patients who were discharged between January 1, 2015 and May 31, 2019. Index BGs used for prediction included the 5th to penultimate BG measurements (N = 2,740,539). The outcome was category of next BG measurement: hypoglycemic (BG  ≤  70 mg/dl), controlled (BG 71-180 mg/dl), or hyperglycemic (BG > 180 mg/dl). A random forest algorithm that included a broad range of clinical covariates predicted the outcome and was validated internally and externally.

FINDINGS

In our internal validation test set, 72·8%, 25·7%, and 1·5% of BG measurements occurring after the index BG were controlled, hyperglycemic, and hypoglycemic respectively. The sensitivity/specificity for prediction of controlled, hyperglycemic, and hypoglycemic were 0·77/0·81, 0·77/0·89, and 0·73/0·91, respectively. On external validation in four hospitals, the ranges of sensitivity/specificity for prediction of controlled, hyperglycemic, and hypoglycemic were 0·64-0·70/0·80-0·87, 0·75-0·80/0·82-0·84, and 0·76-0·78/0·87-0·90, respectively.

INTERPRETATION

A machine learning algorithm using EMR data can accurately predict the category of a hospitalized patient's next BG measurement. Further studies should determine the effectiveness of integration of this model into the EMR in reducing rates of hypoglycemia and hyperglycemia.

The Endocrine Hospitalist: Enhancing the Quality of Diabetes Care

The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.

Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes

OBJECTIVES

Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes.

METHODS

We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician.

RESULTS

One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant.

CONCLUSIONS

The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

The Financial Impact of an Inpatient Diabetes Management Service

CONTEXT

Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management.

OBJECTIVE

To review recent literature on the financial and clinical impact of IDMS in hospital settings.

METHODS

We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine.

FINDINGS

In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management.

CONCLUSION

IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

Collaboration of Hospital Pharmacists and Hospitalists to Address Glycemic Control of General Medicine Patients: Implementation of a Pilot Inpatient Diabetes Management Program

This study examined the clinical benefits of a collaborative pharmacist-physician inpatient diabetes management program that included daily blood glucose assessment and the recommendation and implementation of American Diabetes Association-recommended insulin regimens.

Noninsulin medication therapy for hospitalized patients with diabetes mellitus

PURPOSE

Published evidence regarding the role of noninsulin antidiabetic therapies in glycemic management of hospitalized patients with diabetes mellitus is reviewed.

SUMMARY

The American Diabetes Association recommends against the routine use of noninsulin antidiabetic therapies during hospitalization and supports insulin use instead. There are significant risks associated with insulin therapy, including hypoglycemia, and use of alternative therapies may be considered in hospitalized patients. A MEDLINE literature search was conducted to find articles on studies evaluating the use of noninsulin antidiabetic therapies in the inpatient setting; all full-text English-language publications presenting observational and randomized clinical trial data on the topic of interest were considered for inclusion in the review, with 9 publications selected for review. The majority of the reviewed research focused on incretin-based therapies, and favorable safety and efficacy outcomes were reported with the use of dipeptidyl peptidase-4 (DPP-4) inhibitors. The available evidence indicates that the use of other noninsulin medications, including glucagon-like peptide-1 receptor agonists and sulfonylureas, to achieve and maintain glycemic control in the inpatient setting may be limited by adverse effects.

CONCLUSION

Optimal glycemic control in hospitalized patients with diabetes is necessary to avoid adverse effects. Insulin therapy is currently the primary medication recommended for this patient population. DPP-4 inhibitors have been demonstrated to be safe and effective for use in the inpatient setting in patients with well-controlled diabetes. Further research is needed to help define the role of noninsulin medications in the inpatient setting.

CHANGING TO BASAL-BOLUS INSULIN THERAPY FOR THE INPATIENT MANAGEMENT OF HYPERGLYCEMIA-A NATURAL EXPERIMENT

Objective: Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known versus newly diagnosed type 2 diabetes. Methods: This natural experiment compared outcomes in 10,120 non-critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators. Results: Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n = 234), who experienced a statistically significant decline in the incidence of complications (P<.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (P<.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (P<.01). Conclusion: Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non-critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined. Abbreviation: ICD-9 = International Classification of Diseases-Ninth Revision.

Evaluation of Basal Insulin Dose Reductions in Hospitalized Patients With Diabetes While Unable to Eat

Background: The American Diabetes Association guidelines recommend a basal plus correction or basal insulin regimen for patients with type 2 diabetes mellitus (T2DM) receiving nothing by mouth (NPO; nil per os) in the non-intensive care unit setting. In the perioperative setting, 60% to 80% of long-acting insulin or half-dose morning insulin NPH is recommended. Objective: The goal of this study was to determine the impact of basal insulin dose reduction for hospitalized patients with insulin-dependent T2DM while NPO. Methods: This retrospective, single-center study evaluated patients admitted to the non-intensive care unit setting. Administration of >50% of home basal insulin was compared with administration of ≤50% of home basal insulin. The primary outcome was the difference in hypoglycemic events (blood glucose [BG] < 70 mg/dL). Secondary outcomes included comparing severe hypoglycemic events (BG < 40 mg/dL), hyperglycemic events (BG > 180 mg/dL), and hospital length of stay (LOS). Results: Two hundred fifty-eight patient encounters were included, of which 85 and 173 patients received ≤50% and >50% of their home basal insulin dose, respectively. There were no significant differences in hypoglycemia (21.2% vs 21.4%; P = .97), severe hypoglycemia (1.2% vs 2.9%; P = .67), and hospital LOS (3 [IQR 2.13-6.74] days vs 4.66 [IQR 2.94-8.17] days; P = .74). Hyperglycemia occurred at a higher rate in patients receiving ≤50% of their home basal insulin dose (97.6% vs 89%; P = .02). Conclusions: No differences were observed in hypoglycemic events between those patients receiving ≤50% and >50% of their home basal insulin.

Importance of inpatient hypoglycaemia: impact, prediction and prevention

Hypoglycaemia is a key barrier to achieving euglycaemic control in people who are hospitalized. Inpatient hypoglycaemia has been linked to adverse clinical outcomes, including mortality and longer stay in hospital. A number of studies have applied mathematical tools and statistical models to predict inpatient hypoglycaemia and identify factors that may result in hypoglycaemic events. Several different approaches have been tested to prevent inpatient hypoglycaemia. These can be categorized as human intervention, computerized methods or application of medical devices. In this review we provide an overview of the epidemiology of inpatient hypoglycaemia and its impact on patients and hospitals. We also discuss the existing methodology used to predict inpatient hypoglycaemia and the limited number of trials performed to prevent inpatient hypoglycaemia. The review highlights the urgent need for evidence-based methods to reduce inpatient hypoglycaemia.

Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon

BACKGROUND

Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions.

OBJECTIVE

The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients.

METHODS

The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence.

RESULTS

A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%).

CONCLUSION

Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.

Effect of Implementation of ADA/AACE Guidelines on the Management of Hospitalized Hyperglycemic Patients Through Training of Residents: A Tertiary Care Center Study

BACKGROUND

Hyperglycemia is a common comorbidity in hospitalized patients and may add to adverse outcomes. Various associations have issued guidelines for optimal management of hyperglycemia in ill patients. This study aims to assess the adherence to current guidelines in inpatient setting and the impact of educational interventions on the improvement in adherence to guidelines as well as its effect on the level of blood sugar control and patient outcomes.

MATERIALS AND METHODS

It was a quasi-experimental pretest and posttest study and was done in three phases, viz., observation of current practices, intervention in the form of educational interventions, and its effect on change in practices and patient outcomes.

RESULTS

There was statistically significant 22% increase in the use of recommended insulin regimens (P = 0.028). The proportion of blood sugars within recommended range in the first 48 h, mean daily blood sugars, and the incidence of severe hyperglycemia improved in phase 3 vs phase 1 and was statistically significant. On comparing the subgroups, viz., those who followed and those who did not follow the guidelines, the results of the proportion of blood sugar in recommended range and proportions of blood sugar of more than 250 were found to be statistically significant.

CONCLUSION

Dedicated educational interventions help in improving healthcare practices. According to current guidelines, rapid improvement in hyperglycemia and better glycemic control occur with adherence to protocol-based management of hyperglycemia.

Closed-loop insulin delivery: current status of diabetes technologies and future prospects

INTRODUCTION

Type 1 diabetes is characterised by destruction of pancreatic beta cells, leading to insulin deficiency and hyperglycaemia. The mainstay of treatment remains lifelong insulin therapy as a sustainable cure has as yet proven elusive. The burden of daily management of type 1 diabetes has contributed to suboptimal outcomes for people living with the condition. Innovative technological approaches have been shown to improve glycaemic and patient-related outcomes.

AREAS COVERED

We discuss recent advances in technologies in type 1 diabetes including closed-loop systems, also known as the 'artificial pancreas. Its various components, technical aspects and limitations are reviewed. We also discuss its advent into clinical practice, and other systems in development. Evidence from clinical studies are summarised.

EXPERT COMMENTARY

The recent approval of a hybrid closed-loop system for clinical use highlights the significant progress made in this field. Results from clinical studies have shown safety and glycaemic benefit, however challenges remain around improving performance and acceptability. More data is required to establish long-term clinical efficacy and cost-effectiveness, to fulfil the expectations of people with type 1 diabetes.

Glucose alert system improves health professional responses to adverse glycaemia and reduces the number of hyperglycaemic episodes in non-critical care inpatients

AIM

To investigate the effect of a novel glucose alert system, comprising the Melbourne Glucose Alert Pathway and glucose-alert-capable networked blood glucose meters, on nursing and hospital medical officer responses to adverse glycaemia.

METHODS

A prospective, pre- and post-observational study was undertaken in non-critical care wards of a tertiary hospital over 4 months (n=148 or 660 patient-days). The intervention consisted of two components designed to promote a consistent staff response to blood glucose measurements: (1) a clinical escalation pathway, the Melbourne Glucose Alert Pathway, and (2) networked blood glucose meters, which provide a visual alert for out-of-range blood glucose measurement. All consecutive inpatients with diabetes were assessed for diabetes management and capillary blood glucose. The primary outcome was documented nursing and medical staff action in response to episodes of adverse glycaemia (blood glucose >15 mmol/l or <4 mmol/l). Secondary outcomes consisted of glycaemic measures.

RESULTS

In response to episodes of adverse glycaemia, nursing action increased (proportion with nursing action: 45% to 73%; P<0.001), and medical action increased (proportion with medical action: 49% to 67%; P=0.011) with the glucose alert system in place. Patient-days with hyperglycaemia (any blood glucose value >15 mmol/l: 24% vs 16%; P=0.012) and patient-days with mean blood glucose >15 mmol/l (7.4% vs 2.6%; P=0.005) decreased. There was no difference in hypoglycaemia incidence.

CONCLUSIONS

Use of a novel glucose alert system improved health professional responses to adverse glycaemia and decreased hyperglycaemia in the hospital setting.

Glucometrics and Insulinometrics

PURPOSE OF REVIEW

Glucometrics is the systematic analysis of inpatient glucose data and is of key interest as hospitals strive to improve inpatient glycemic control. Insulinometrics is the systematic analysis and reporting of inpatient insulin therapy. This paper reviews some of the questions to be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines.

RECENT FINDINGS

There remains a lack of standardization on how glucometircs should be measured and reported. Before hospitals can commit resources to compiling and extracting data, consensus must be reached on such questions as which measures to report, definitions of glycemic targets, and how data should be obtained. Examples are provided on how insulin administration can be measured and reported. Hospitals should begin assessment of glucometrics and insulinometrics. However, consensus and standardization must first occur to allow for a national benchmarking process.

Inpatient glycemic management in internal medicine: an observational multicenter study in Nanjing, China

AIMS

To evaluate the prevalence of hyperglycemia among inpatients in internal medicine, and specifically, to assess the glycemic management of inpatients in non-endocrinology departments in three large urban hospitals in China.

METHODS

A multicenter observational study was conducted using electronic health records, and a survey of 1939 patients who were admitted to internal medicine units and followed until discharge. Those with previously diagnosed diabetes, newly diagnosed diabetes, or impaired fasting glucose were included. Aspects of glycemic management examined were (a) hyperglycemia, (b) endocrinology consultation for hyperglycemia and (c) hypoglycemia.

RESULTS

The prevalence of hyperglycemia in internal medicine was 45.7% (886 out of 1939). A total of 741 (83.6%) patients were treated by non-endocrinology departments; of those, 230 (31.1%) were in poor glycemic control and needed an endocrinology consultation. Yet only 57 (24.8%) received one. In 4 cases, the physician did not follow the consultants' advice. Among the remaining 53 consulted patients, 35 (66.1%) were still in poor glycemic control, yet only about half received a second consultation. Finally, among patients treated in non-endocrinology departments, 58 (7.8%) had hypoglycemia; less than half retested their blood glucose after treatment.

CONCLUSIONS

The majority of patients with hyperglycemia were in non-endocrinology departments. Their glycemic management was poor; the endocrinology consultation rate was low and the result was suboptimal. Also, the management of hypoglycemia was not ideal. Therefore, improving glycemic management is urgently needed in Chinese hospitals.

Premixed Insulin Analogue Compared with Basal-Plus Regimen for Inpatient Glycemic Control

BACKGROUND

No previous studies have investigated the use of a premixed insulin analogue in a hospital setting.

OBJECTIVE

To compare the efficacy and safety of treatment with premixed insulin analogue (insulin lispro mix 75/25, LM75/25) with the basal-plus regimen with insulin glargine in hospitalized patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

A randomized clinical trial in hospitalized patients with T2D and glucose >140 mg/dL on admission was performed. A total of 54 patients were randomized to receive insulin LM75/25 or glargine. In both groups, a correction dose of lispro was administered before meals. Insulin dose was adjusted to obtain a mean blood glucose (BG) between 100 and 140 mg/dL.

RESULTS

Improvement in the mean BG after the first day of treatment was similar in both groups (P = 0.470). Glycemic control at the end of follow-up was similar between the group with insulin LM75/25 (131.3 ± 28.4 mg/dL) and insulin glargine (143.8 ± 32.5 mg/dL, P = 0.153). The aim of a BG concentration of <140 mg/dL was obtained in 72% of the patients in the premixed insulin analogue group and 56% of patients in the basal-plus group (P = 0.239). There was no difference in the frequency of hypoglycemia between groups (7 vs. 10, P = 0.529).

CONCLUSION

Results of this trial indicate that the use of a premixed insulin analogue is as effective and safe as the basal-plus regimen to achieve glycemic control.

A Primer on Diabetes Mellitus: Foundations for the Incoming First-Year Resident

INTRODUCTION

Given the increasing prevalence of diabetes mellitus, trainees should have a strong foundation in the management of diabetes. Published literature on the knowledge base and comfort level of medical trainees in diabetes care describes varying levels of exposure to diabetes management in both inpatient and outpatient settings.

METHODS

This eight-module curriculum provides a foundation in the diagnosis, evaluation, and management of diabetes mellitus in the adult patient, as well as pharmacological treatment, patient education, and complications. Specifically, the modules consist of an introduction to diabetes, diagnosis and glycemic goals, patient education, basic nutrition, noninsulin therapies, insulin therapies, complications of diabetes, and financial considerations and cost. Each is a stand-alone presentation that may be viewed nonsequentially. We estimate each module taking 15 to 30 minutes to read. Students received a postsurvey.

RESULTS

We received responses from 23 (18%) of the total eligible residents over the course of 3 years. Approximately 50% of respondents completed an endocrinology elective as either a medical student or first-year resident. Overall, the majority of respondents felt that the modules had the correct amount of content, the online format was adequate, their understanding of diabetes was enhanced, and the curriculum led to altering their care.

DISCUSSION

This resource is unique to MedEdPORTAL as it includes basic information on diabetes education and medical-nutritional therapy. We have required completion of these modules by our internal medicine residents since the class that enrolled in 2013. The curriculum is directed towards incoming first-year internal medicine residents but may also be used by trainees in other primary care fields.

Overcoming clinical inertia in the management of postoperative patients with diabetes

OBJECTIVE

To assess the impact of an intervention designed to increase basal-bolus insulin therapy administration in postoperative patients with diabetes mellitus.

METHODS

Educational sessions and direct support for surgical services were provided by a nurse practitioner (NP). Outcome data from the intervention were compared to data from a historical (control) period. Changes in basal-bolus insulin use were assessed according to hyperglycemia severity as defined by the percentage of glucose measurements >180 mg/dL.

RESULTS

Patient characteristics were comparable for the control and intervention periods (all P≥.15). Overall, administration of basal-bolus insulin occurred in 9% (8/93) of control and in 32% (94/293) of intervention cases (P<.01). During the control period, administration of basal-bolus insulin did not increase with more frequent hyperglycemia (P = .22). During the intervention period, administration increased from 8% (8/96) in patients with the fewest number of hyperglycemic measurements to 60% (57/95) in those with the highest frequency of hyperglycemia (P<.01). The mean glucose level was lower during the intervention period compared to the control period (149 mg/dL vs. 163 mg/dL, P<.01). The proportion of glucose values >180 mg/dL was lower during the intervention period than in the control period (21% vs. 31% of measurements, respectively, P<.01), whereas the hypoglycemia (glucose >70 mg/dL) frequencies were comparable (P = .21).

CONCLUSION

An intervention to overcome clinical inertia in the management of postoperative patients with diabetes led to greater utilization of basal-bolus insulin therapy and improved glucose control without increasing hypoglycemia. These efforts are ongoing to ensure the delivery of effective inpatient diabetes care by all surgical services.

Inpatient Management of Diabetes Mellitus among Noncritically Ill Patients at University Hospital of Puerto Rico

OBJECTIVE

To describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes.

METHODS

This was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed.

RESULTS

A total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ≥180 mg/dL) and hypoglycemia (blood glucose <70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose.

CONCLUSION

The management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients.

Comparison of Subcutaneous Regular Insulin and Lispro Insulin in Diabetics Receiving Continuous Nutrition: A Numerical Study

BACKGROUND

Optimal management of non-critically ill patients with diabetes maintained on continuous enteral feeding (CEN) is poorly defined. Subcutaneous (SQ) lispro and SQ regular insulin were compared in a simulated type 1 and type 2 diabetic patient receiving CEN.

METHOD

A glucose-insulin feedback mathematical model was employed to simulate type 1 and type 2 diabetic patients on CEN. Each patient received 25 SQ injections of regular insulin or insulin lispro, ranging from 0-6 U. Primary endpoints were the change in mean glucose concentration (MGC) and change in glucose variability (GV); hypoglycemic episodes were also reported. The model was first validated against patient data.

RESULTS

Both SQ insulin preparations linearly decreased MGC, however, SQ regular insulin decreased GV whereas SQ lispro tended to increase GV. Hourly glucose concentration measurements were needed to capture the increase in GV. In the type 2 diabetic patient, "rebound hyperglycemia" occurred after SQ lispro was rapidly metabolized. Although neither SQ insulin preparation caused hypoglycemia, SQ lispro significantly lowered MGC compared to SQ regular insulin. Thus, it may be more likely to cause hypoglycemia. Analyses of the detailed glucose concentration versus time data suggest that the inferior performance of lispro resulted from its shorter duration of action. Finally, the effects of both insulin preparations persisted beyond their duration of actions in the type 2 diabetic patient.

CONCLUSIONS

Subcutaneous regular insulin may be the short-acting insulin preparation of choice for this subset of diabetic patients. Clinical trial is required before a definitive recommendation can be made.

Adherence to insulin treatment in insulin-naïve type 2 diabetic patients initiated on different insulin regimens

OBJECTIVE

We aimed to evaluate adherence to insulin treatment in terms of treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetic patients initiating insulin therapy with basal (long acting), basal-bolus, and premixed insulin regimens in a tertiary endocrinology outpatient clinic.

METHODS

A total of 433 (mean age of 55.5±13.0 years; 52.4% females) insulin-naïve type 2 diabetic patients initiated on insulin therapy were included in this questionnaire-based phone interview survey at the sixth month of therapy. Via the telephone interview questions, patients were required to provide information about persistence to insulin treatment, self-reported blood glucose values, and side effects; data on demographics and diabetes characteristics were obtained from medical records.

RESULTS

Self-reported treatment withdrawal occurred in 20.1% patients, while 20.3% patients were nonadherent to daily insulin. Negative beliefs about insulin therapy (24.1%) and forgetting injections (40.9%) were the most common reasons for treatment withdrawal and dose skipping, respectively. Younger age (49.5±15.0 vs 56.4±12.0 years) (P=0.001) and shorter duration of diabetes (4.8±4.3 vs 8.8±6.3 years) (P=0.0008) and treatment duration (5.2±2.4 vs 10.7±2.4 months) (P=0.0001) were noted, respectively, in discontinuers vs continuers. Basal bolus was the most commonly prescribed insulin regimen (51.0%), while associated with higher likelihood of skipping a dose than regular use (61.3% vs. 46.0%, P=0.04).

CONCLUSIONS

Persistence to insulin therapy was poorer than anticipated but appeared to be higher in patients with the basal bolus regimen. Negative perceptions about insulin therapy seemed to be the main cause for poor adherence in our cohort.

Impact of a pharmacy-based glucose management program on glycemic control in an inpatient general medicine population

OBJECTIVE

A pharmacy-based glucose management program was evaluated to determine whether improved glycemic control could be achieved in an inpatient general medicine patient population.

METHODS

A retrospective chart review of 151 patients with blood glucose (BG) values outside the range of 70 to 180 mg/dL within a 24-hour period was conducted. Observations for the baseline group with no pharmacy program in place were collected from admissions during July 2010 and for the intervention group in October 2010. The primary goal of the study was to determine if the pharmacy program improved patient days within the BG range of 70 to 250 mg/dL. The odds of poor glycemic control for patients in the intervention versus baseline groups were assessed by multivariate generalized estimating equations. These methods were also used to assess patient characteristics associated with poor glycemic control.

RESULTS

No evidence was observed that the pharmacy program decreased the number of days spent out of the targeted blood glucose range (70-250 mg/dL; odds ratio, 1.08; 95% CI, 0.88-1.24). However, the subgroup of patients whose admission BG was < 200 mg/dL (49% of the intervention group) experienced a significant reduction in days spent out of the BG range (70-250 mg/dL; odds ratio, 0.42; 95% CI, 0.22-0.82). No improvement in glycemic control was observed in patients with an admission BG ≥ 200 mg/dL; these patients had more disease- and social-related factors associated with poor glycemic control.

CONCLUSION

The primary finding of this analysis was that there was no global benefit of the pharmacy-based glucose management program for improving BG values compared with usual care. Patients whose admission glucose was < 200 mg/dL experienced improvement in glycemic control in the pharmacy-based program. Maintaining the BG level of the remaining patients was generally more complicated from a disease-state and social perspective and patients experienced no improvement. These patients may require a more intense, multidisciplinary approach that is better matched to the constellation of factors responsible for their condition.

Glycemic control and diabetes management in hospitalized patients in Brazil

BACKGROUND

The importance of tight blood glucose control among outpatients with diabetes mellitus is well established, however, the management of diabetes in the hospital setting is generally considered secondary in importance. This study sought to assess glycemic control and diabetes management in adult patients admitted to hospitals in Brazil.

METHODS

A cross-sectional and nationwide survey was conducted from July 2010 to January 2012. Eligible cases were 18 years of age or older, had a diagnosis of diabetes and a hospitalization length of stay ≥72 hours. Socio-demographic information, hospitalization details, and data on diabetes diagnosis, management and treatment were collected for all patients by chart review. Information on all blood glucose (BG) readings for a maximum of 20 consecutive days of hospitalization was recorded for each patient.

RESULTS

Overall, 2,399 patients were surveyed in 24 hospitals located in 13 cities from all five Brazilian regions. The prevalence of patients presenting hyperglycemic (BG >180 mg/dL) or hypoglycemic (BG <70 mg/dL) events was 89.4% and 30.9% in patients in general wards, and 88.2% and 27.7% in those in Intensive Care Units (ICUs), respectively. In addition, a BG measure >180 mg/dL was recorded in two-thirds of the patient-days. A high proportion of patients were treated with sliding-scale insulin regimen alone in the general wards (52.0%) and in the ICUs (69.2%), and only 35.7% and 3.9% received appropriate insulin therapy in general wards (basal + bolus insulin) and in ICUs (continuous IV insulin), respectively.

CONCLUSIONS

Inpatient glycemic control and diabetes management needs improvement. Opportunities to improve care in Brazilian hospitals include expanded use of intravenous insulin and subcutaneous basal-bolus insulin protocols, avoiding use of sliding-scale insulin alone, increased frequency of blood glucose monitoring, and institution wide quality improvement efforts targeting both physician and nursing behavior.

Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action

Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.

Clinical inertia during postoperative management of diabetes mellitus: relationship between hyperglycemia and insulin therapy intensification

OBJECTIVE

Our objective was to assess the application of insulin regimens in surgical postoperative patients with diabetes.

METHODS

A chart review was conducted of patients with diabetes who were hospitalized postoperatively between January 1 and April 30, 2011. Analysis was restricted to patients hospitalized for ≥3 days and excluded cases with an endocrinology consult. Insulin regimens were categorized as "basal plus short acting," "short acting only," or "none," and the pattern of use was evaluated by hyperglycemia severity according to tertiles of both mean glucose and the number of glucose measurements >180 mg/dl.

RESULTS

Among cases selected for analysis (n = 119), examination of changes in insulin use based on tertiles of mean glucose showed that use of basal plus short-acting insulin increased from 10% in the lowest tertile (mean glucose, 120 mg/dl) to 18% in the highest tertile (mean glucose, 198 mg/dl; p < .01); however, 70% of patients in the highest tertile continued to receive short-acting insulin only, with 12% receiving no insulin. Intensification of insulin to a basal plus short-acting regimen was also seen when changes were evaluated by the number of measurements >180 mg/dl (p < .01), but 70% and 12% of patients in the highest tertile still remained only on short-acting insulin or received no insulin, respectively.

CONCLUSIONS

Use of basal plus short-acting insulin therapy increased with worsening hyperglycemia, but many cases did not have therapy intensified to the recommended insulin regimen--evidence of clinical inertia. Strategies should be devised to overcome inpatient clinical inertia in the treatment of postoperative patients with diabetes.

Practical approach to management of inpatient hyperglycemia in select patient populations

Hospitalized patients frequently transition between various levels of care and changing clinical situations. Optimal management of hospitalized patients with hyperglycemia includes awareness of situations that may significantly affect glucose and/or insulin metabolism. A review of published clinical trials reveals practical approaches to the management of hyperglycemia in select patient populations that may prove useful for the hospital clinician. We outline approaches to the management of hyperglycemia in hospitalized patients receiving glucocorticoids, patients with severe or end-stage renal disease undergoing hemo- or peritoneal dialysis, and patients receiving total parenteral or enteral feeding, in addition to patients transitioning from intravenous insulin infusion to subcutaneously administered insulin. Key considerations underlying these management methods include a proactive approach, frequent blood glucose monitoring, daily review of blood glucose patterns, and daily reassessment of the insulin regimen and associated orders.

Trends in glycemic control over a 2-year period in 126 US hospitals

BACKGROUND

Cross-sectional data on inpatient glucose control in a large sample of US hospitals are now available, but little is known about changes in glycemic control over time in these institutions.

OBJECTIVE

To evaluate trends in glycemic control in US hospitals over 2 years.

DESIGN

Retrospective analysis.

METHODS

Point-of-care blood glucose (POC-BG) test results at 126 hospitals during January to December 2007 and January to December 2009 were extracted using the Remote Automated Laboratory System-Plus (Medical Automation Systems, Charlottesville, VA), and patient-day-weighted mean glucose levels were compared.

SETTING/PATIENTS

Hospitalized patients.

RESULTS

A total of 12,541,929 POC-BG measurements from 1,010,705 patients were analyzed for 2007, and 10,659,418 POC-BG measurements from 656,206 patients were analyzed for 2009. Patient-day-weighted mean POC-BG in 2009 decreased by 5 mg/dL in the non-intensive care unit (non-ICU) data compared with that in 2007 (154 mg/dL vs 159 mg/dL, respectively; P < 0.001). However, POC-BG values were clinically unchanged in intensive care unit (ICU) data from 2009 vs 2007 (167 mg/dL vs 166 mg/dL; P < 0.001). From 2007 to 2009, the proportion of patient-day-weighted mean POC-BGs that were >180 mg/dL declined from 28% to 25% in non-ICU patients (P < 0.001), but not in ICU. Decreases in patient-day-weighted mean POC-BG values in non-ICU patients were significant regardless of hospital size, type, and geographic region (all P < 0.001), but similar decreases were not found in ICU data.

CONCLUSIONS

In this first analysis of glucose changes in US hospitals, improvements over 2 years occurred in non-ICU patients. Ongoing analysis will determine whether this trend continues.

Failure to control hyperglycemia in noncritically ill diabetes patients despite standard glycemic management in a hospital setting

BACKGROUND

Successful control of hyperglycemia has been shown to improve outcomes for diabetes patients in a clinical setting. We assessed the quality of physician-based glycemic management in two general wards, considering the most recent recommendations for glycemic control for noncritically ill patients (<140 mg/dl for premeal glucose).

METHODS

Quality of glycemic management of 50 patients in two wards (endocrinology, cardiology) was assessed retrospectively by analyzing blood glucose (BG) levels, the glycemic management effort, and the online questionnaire.

RESULTS

Glycemic control was clearly above the recommended target (mean BG levels: endocrinology: 175 ± 62 mg/dl; cardiology: 186 ± 68 mg/dl). When comparing the first half with the second half of the hospital stay, we found no difference in glycemic control (endocrinology: 168 ± 32 vs 164 ± 42 mg/dl, P = .67; cardiology: 174 ± 36 mg/dl vs 170 ± 42 mg/dl, P =.51) and in insulin dose (endocrinology: 15 ± 14 IU vs 15 ± 13 IU per day, P = .87; cardiology: 27 ± 17 IU vs 27 ± 18 IU per day, P = .92), despite frequent BG measurements (endocrinology: 2.7 per day; cardiology: 3.2 per day). A lack of clearly defined BG targets was indicated in the questionnaire.

CONCLUSION

The recommended BG target range was not achieved in both wards. Analysis of routine glycemic management demonstrated considerable glycemic management effort, but also a lack of translation into adequate insulin therapy. Implementation of corrective measures, such as structured treatment protocols, is essential.

Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia

CONTEXT

Transition of diabetic patients from iv insulin infusion to s.c. insulin frequently results in rebound hyperglycemia.

OBJECTIVES

We hypothesized that initiation of a long-acting insulin therapy concurrently with i.v. insulin infusion would decrease the rate of rebound hyperglycemia after discontinuation of the insulin infusion.

DESIGN AND INTERVENTION

Sixty-one diabetic patients receiving i.v. insulin therapy participated in this prospective randomized study. Subjects in the intervention group received daily injections of glargine s.c. (0.25 U/kg body weight) starting within 12 h of initiation of i.v. insulin infusion. Capillary blood glucose measurements were obtained up to 12 h after discontinuation of insulin infusion. Rebound hyperglycemia was defined as a blood glucose level greater than 180 mg/dl.

SETTING

The study was conducted at the University of Colorado Hospital.

PATIENTS

Sixty-one hospitalized patients with known type 1 or type 2 diabetes receiving i.v. insulin infusion participated in the study.

MAIN OUTCOME

The primary outcome of this study was to compare the rates of rebound hyperglycemia between the control and the intervention groups after i.v. insulin infusion is discontinued.

RESULTS

Overall, 29 subjects in the control group (93.5%) had at least one glucose value above 180 mg/dl during the 12-h follow-up period. This was significantly greater than the rate of rebound hyperglycemia in the intervention group (10 subjects or 33.3%, P < 0.001). The effect of the intervention was apparent in subjects who presented with diabetic ketoacidosis, after solid organ transplantation, and in patients with other surgical and medical diagnoses. There were three hypoglycemic measurements in two control subjects (68, 62, and 58 mg/dl) and none in the intervention group.

CONCLUSIONS

Once-daily s.c. insulin glargine administered during i.v. insulin infusion is a safe method for preventing future rebound hyperglycemia, without increased risk of hypoglycemia.

[Interns' viewpoints and knowledge about management of hyperglycemia in the hospital setting]

BACKGROUND AND OBJECTIVE

In many hospitals, adequate glycemic control is not achieved despite implementation of new insulin therapy protocols. Our aim was to assess resident physician' attitudes toward inpatient hyperglycemia, barriers to achieve optimum control, and impact on them of an insulin training program

MATERIAL AND METHODS

A questionnaire was used to assess understanding and standard management of hyperglycemia before and six months after implementation of an inpatient insulin treatment program.

RESULTS

Twenty-five interns completed the questionnaire. Glycemic control was considered "very important" in all admission situations, but was only considered "very important" in conventional hospitalization by 36% of interns. Most of these felt "comfortable" using sliding scales, but not with the basal/bolus regimen, which was the least commonly used. Perception of number of well-controlled patients and comfort and use of basal/bolus therapy increased at six months, but use of "sliding scales" remained high. The greatest difficulty reported for adequate management of hyperglycemia was the lack of knowledge.

CONCLUSIONS

Most residents are aware of the importance of adequate glycemic control, but cannot achieve it because of inadequate knowledge. The insulin training program led to an improved perception and applicability of basal-bolus insulin regimens. However, despite all efforts, use of sliding scales remains high. Training programs should emphasize management of hyperglycemia.

Improving the management of diabetes in hospitalized patients: the results of a computer-based house staff training program

BACKGROUND

Poorly controlled diabetes in hospitalized patients is associated with poor clinical outcomes. We hypothesized that computer-based diabetes training could improve house staff knowledge and comfort for the management of diabetes in a large tertiary-care hospital.

METHODS

We implemented a computer-based training program on inpatient diabetes for internal medicine house staff at the Brigham and Women's Hospital (Boston, MA) in September 2009. House staff were required to complete the program and answer a set of questions, before and after the program, to evaluate their level of comfort and knowledge of inpatient diabetes. Chart reviews of all non-critically ill patients with diabetes managed by house staff in August 2009 (before the program) and December 2009 (after the program) were performed. Chart reviews were also performed for August 2008 and December 2008 to compare house staff management practices when the computer-based educational program was not available.

RESULTS

A significant increase in comfort levels and knowledge in the management of inpatient diabetes was seen among house staff at all levels of training (P<0.02), but the increase was smaller for senior house staff compared with junior house staff. Nonsignificant trends suggesting increased use of basal-bolus insulin (P=0.06) and decreased use of sliding-scale insulin (P=0.10) were seen following the educational intervention in 2009, whereas no such change was seen in 2008 (P>0.90). Overall, house staff evaluated the training program as "very relevant" and the technology interface as "good."

CONCLUSIONS

A computer-based diabetes training program can improve the comfort and knowledge of house staff and potentially improve their insulin administration practices at large academic centers.

Basal-bolus insulin protocols enter the computer age

Diabetes affects approximately one quarter of all hospitalized patients. Poor inpatient glycemic control has been associated with increased risk for multiple adverse events including surgical site infections, prolonged hospital length of stay, and mortality. Inpatient glycemic control protocols based on physiologic basal-bolus insulin regimens have been shown to improve glycemia and clinical outcomes and are recommended by the American Diabetes Association, the American Association of Clinical Endocrinologists, and the Society of Hospital Medicine for inpatient glycemic management of noncritically ill patients. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act will catalyze widespread computerized medication order entry implementation over the next few years. Here, we focus on the noncritical care setting and review the background on inpatient glycemic management as it pertains to computerized order entry, the translation and efficacy of computerizing glycemic control protocols, and the barriers to computerizing glycemic protocols.

[Glycemic control in non-critical hospitalized patients]

OBJECTIVES

To assess in hospitalized patients the prevalence of hyperglycemia, degree of glycemic control, rate of hypoglycemia, and treatment used.

PATIENTS AND METHODS

A prospective, observational study.

RESULTS

Hyperglycemia was found in 185 (26.7%) of 691 patients, of whom 85% had been diagnosed with diabetes and 15% had no diabetes. Preprandial mean blood glucose was 169 mg/dL (95% CI 160-177). Control goals were achieved by 34.5% of patients (blood glucose ≤140 mg/dL). In 121 patients only sliding-scale regular insulin was used, while 64 patients received both basal and regular insulin. The mean daily insulin dose used was 19.5 units. Oral antidiabetics were given to 11.4% of patients. Thirteen patients (7%) experienced hypoglycemia (< 70 mg/dL), none of them severe.

CONCLUSIONS

Glycemic control is not adequate in hospitalized patients, probably because of overuse of sliding scales and the low insulin doses used.

Management of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols

OBJECTIVE

To provide insulin protocols and adjustment guidance for management of hyperglycemia in common inpatient clinical scenarios.

METHODS

We performed a PubMed search of pertinent existing literature from 1980 to 2010.

RESULTS

Hyperglycemia is frequently encountered in general medical and surgical wards and has been linked to adverse clinical outcomes, prolonged hospital length of stay, and increased institutional care needs after discharge. No randomized controlled trial has been conducted to define optimal glycemic goals or to investigate the effects of intensive glycemic control in the non-intensive care unit (ICU) setting. Nonetheless, it is advocated by the American Association of Clinical Endocrinologists and the American Diabetes Association, in their 2009 Consensus Statement on Inpatient Glycemic Control, that optimization of glycemia in hospitalized patients with diabetes and hyperglycemia be judiciously offered. This approach is clinically sound, in light of the known deleterious consequences of hyperglycemia in critically and noncritically ill patients and the benefits observed with improved glycemic control in intensive care settings. The approach to hyperglycemia in non-ICU inpatients should follow the principles of provision of basal-nutritional-supplemental insulin. Herein we provide insulin protocols and adjustment guidance for management of hyperglycemia in common clinical scenarios. Recommendations reflect the opinion of national experts in the field and our departmental consensus at Penn State Institute for Diabetes and Obesity.

CONCLUSION

Glycemic control in the non-ICU setting is a relevant clinical situation that should be addressed and managed effectively and prudently. We present a practical guide for management of hyperglycemia individualized to various clinical scenarios encountered in the general hospital wards.

[Management of hyperglycemia in the non-critical hospitalized patients with oral feeding]

A 67-year-old woman with a history of hypertension, hyperlipidemia and 6 years of evolution of type 2 diabetes mellitus presented with fever, purulent sputum and right chest pain. She was on treatment with metformin 850 mg/bid, glimepiride 4 mg/day, candesartan 16 mg/day, atorvastatin 10mg/day and acetylsalicylic acid 100mg/day. Standing out in the physical examination was blood pressure 90/50 mmHg, temperature 38.6 °C, pulse 112/min, respirations 24/min, weight 8 5 kg, height 1.68 m. She had crackling rales in the right lung-base and edema in lower limbs. The blood analysis showed leukocytosis, glucose 348 mg/dl, urea 70 mg/dl, creatinine 1.5mg/dl and HbA1c 8.4%. A chest x-ray revealed condensation in the lower lobe of the right lung. Antibiotic treatment was begun, maintaining an oral diet from admission. What is the best strategy regarding the treatment of this patient's hyperglycemia, its management and what evidence is there on this subject?

Implementation of a dedicated hospital subcutaneous insulin prescription chart: effect on glycaemic control

A dedicated subcutaneous insulin prescription chart incorporating glucose monitoring results, forced functions, and management guidelines was introduced to facilitate better hospital diabetes control. Point of care capillary blood glucose monitoring charts for 99 people with diabetes from the period before the introduction of the new chart, and 106 after its introduction were reviewed. A total of 12,649 blood glucose levels (BGLs) were collected for glucometric analysis. Following the introduction of the chart, there was an increase in the number of BGLs performed daily from 4.5 ± 1.2 to 4.9 ± 1.3 (p = 0.05). There was an increase in the proportion of BGLs within the ideal range of 4-9.9 mmol/L (51.8% vs. 54.1%, p = 0.01). There was a reduction in hypoglycaemic events (proportion of BGLs <4 mmol/L in the whole population decreased from 5.2% to 3.4% (p < 0.001), proportion of BGLs <4 mmol/L for each patient decreased from 5.6 ± 9.2% to 2.9 ± 5.4% (p = 0.01), proportion of days where patient had a BGL <4 mmol/L decreased from 17.6 ± 22.6% to 11.4 ± 18.8% (p = 0.03)), despite an increase in the use of supplemental insulin (14.2 ± 35.7 vs. 29.4 ± 51.4 u nits/patient, p = 0.02). We conclude that the use of a dedicated hospital subcutaneous insulin prescription chart can reduce hypoglycaemia and improve some measures of glycaemic control.

Does type of bolus insulin matter in the hospital? Retrospective cohort analysis of outcomes between patients receiving analogue versus human insulin

BACKGROUND

Poor glycemic control in hospitalized patients has been associated with increased morbidity and mortality. Research suggests that analogue bolus insulin may be more effective in achieving blood glucose (BG) control compared with human bolus insulin.

OBJECTIVE

This study compares mortality, length of stay (LOS), costs, and BG control in hospitalized patients receiving either analogue or human bolus insulin.

METHODS

This retrospective cohort analysis used data from January 1, 2004, to December 31, 2007, within the Health Facts database (Cerner Corporation, Kansas City, Missouri). Nonsurgical adult patients who received exclusively analogue or human bolus insulin during hospitalization were included in the study. Propensity score matching and multivariate regression analyses were used to compare patients treated with analogue versus human bolus insulin. The study outcomes were in-hospital mortality, hospital LOS among survivors (to avoid potentially short hospitalizations among nonsurvivors distorting results), and hospitalized BG control (present vs absent), defined as having a mean BG of 70 to <200 mg/dL during hospitalization.

RESULTS

In total, 35,049 participants met the inclusion criteria and 5568 of 7754 patients in the analogue group were matched by their propensity scores to patients in the human bolus group (mean age, 67.1 years; 53% women; 77% white). On propensity score analysis, analogue bolus insulin was associated with lower mortality (relative risk [RR] = 0.52; 95% CI, 0.45-0.61) and shorter LOS (0.668-day reduction; 95% CI, 0.44-0.89) compared with human bolus insulin. However, analogue insulin was associated with only a modest benefit for BG control (RR = 0.88; 95% CI, 0.81-0.95). The multivariate regression analysis produced similar findings.

CONCLUSIONS

In this cohort of hospitalized patients, analogue bolus insulin was associated with lower mortality, shorter LOS, and modestly better BG control compared with patients treated with human bolus insulin. These results highlight the need for a randomized controlled clinical trial comparing outcomes by bolus insulin type in the hospital setting to determine a true mortality benefit.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery)

OBJECTIVE

The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known.

RESEARCH DESIGN AND METHODS

This randomized multicenter trial compared the safety and efficacy of a basal-bolus insulin regimen with glargine once daily and glulisine before meals (n = 104) to sliding scale regular insulin (SSI) four times daily (n = 107) in patients with type 2 diabetes mellitus undergoing general surgery. Outcomes included differences in daily blood glucose (BG) and a composite of postoperative complications including wound infection, pneumonia, bacteremia, and respiratory and acute renal failure.

RESULTS

The mean daily glucose concentration after the 1st day of basal-bolus insulin and SSI was 145 ± 32 mg/dL and 172 ± 47 mg/dL, respectively (P < 0.01). Glucose readings <140 mg/dL were recorded in 55% of patients in basal-bolus and 31% in the SSI group (P < 0.001). There were reductions with basal-bolus as compared with SSI in the composite outcome [24.3 and 8.6%; odds ratio 3.39 (95% CI 1.50-7.65); P = 0.003]. Glucose <70 mg/dL was reported in 23.1% of patients in the basal-bolus group and 4.7% in the SSI group (P < 0.001), but there were no significant differences in the frequency of BG <40 mg/dL between groups (P = 0.057).

CONCLUSIONS

Basal-bolus treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with type 2 diabetes.

Optimizing inpatient glycemic control with basal-bolus insulin therapy

Hyperglycemia is highly prevalent in the acute-care setting and is associated with an increased risk of morbidity and mortality. Evidence suggests that glycemic control in this population is suboptimal, due in part to continued use of nonphysiologic sliding-scale insulin strategies without scheduled basal insulin doses or prandial insulin with concomitant correction doses. Although the ineffectiveness and risks of sliding-scale insulin regimens have been criticized for decades, sliding-scale insulin is still the most commonly prescribed subcutaneous insulin regimen among inpatients. Improving inpatient management requires the use of scheduled basal-bolus insulin therapy that includes basal insulin, nutritional insulin, and supplemental, or correctional, insulin. Insulin analogs are the preferred insulins, as they provide a more physiologic action than human insulin regimens, are associated with a lower risk of hypoglycemia, and are more convenient to administer than human insulins. Standardized insulin protocols and subcutaneous insulin order sets are critical components of effective inpatient glycemic control. Although preliminary data have demonstrated that inpatient diabetes management programs involving basal-bolus insulin therapy are effective and well tolerated, more research is needed.

Effects of an educational program and a standardized insulin order form on glycemic outcomes in non-critically ill hospitalized patients

BACKGROUND

The optimal approach to managing hyperglycemia in noncritically ill hospital patients is unclear.

OBJECTIVE

To investigate the effects of targeted quality improvement interventions on insulin prescribing and glycemic control.

DESIGN

A cohort study comparing an intervention group (IG) to a concurrent control group (CCG) and an historic control group (HCG).

SETTING

University of Michigan Hospital.

PATIENTS

Hyperglycemic, noncritically ill hospital patients treated with insulin.

INTERVENTION

Physician and nurse education and a standardized insulin order form based on the principles of physiologic insulin use.

MEASUREMENTS

Glycemic control and insulin prescribing patterns.

RESULTS

Patients in the IG were more likely to be treated with a combination of scheduled basal and nutritional insulin than in the other groups. In the final adjusted regression model, patients in the IG were more likely to be in the target glucose range (odds ratio [OR], 1.72; P = 0.01) and less likely to be severely hyperglycemic (OR, 0.65; P < 0.01) when compared to those in the CCG. Patients in the IG were also less likely to experience hypoglycemia than those in the CCG (P = 0.06) or the HCG (P = 0.01). Over 80% of all patient-days for all groups contained glucose readings outside of the target range.

CONCLUSIONS

Standardized interventions encouraging the physiologic use of subcutaneous insulin can lead to significant improvements in glycemic control and patient safety in hospitalized patients. However, the observed improvements are modest, and poor metabolic control remains common, despite these interventions. Additional research is needed to determine the best strategy for safely achieving metabolic control in these patients.