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.