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

BACKGROUND

Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients.

OBJECTIVE

To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control.

DESIGN

Prospective cohort study.

SETTING

Hospitalist-run general medicine service of an academic teaching hospital.

PATIENTS

107 consecutive patients with diabetes mellitus or inpatient hyperglycemia.

MEASUREMENTS

We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day.

RESULTS

The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day.

CONCLUSIONS

Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.