Surgery News - October 2007 - (Page 20)

20 PRACTICE TRENDS SURGERY NEWS • O C T O B E R 2 0 0 7 Standardized Insulin Protocols Can Aid Glycemic Control ommendations laid out in an earlier American Diabetes Association report (Diabetes Care 2004;27:553-91). Poor glycemic control is a pervasive problem among D A L L A S — Implementation of standardized subcuta- diabetic inpatients. Indeed, studies indicate 35%-40% of neous insulin order sets and an insulin management al- all inpatients with known diabetes or new hyperglycemia gorithm across nearly all services in a 400-bed hospital re- have a mean blood glucose level higher than 200 mg/dL sulted in significantly improved glycemic control, Dr. throughout their hospital stay. This poor glycemic conGregory A. Maynard reported at the annual meeting of trol is strongly associated with increased mortality, higher infection rates, and greater length of stay. Physician the Society of Hospital Medicine. “I guess that shouldn’t be too surprising. But maybe knowledge and practice patterns regarding inpatient diwhat is surprising is that it also reduces hypoglycemia, if abetes management are highly variable. For all of these reasons, the ADA and the American Asdone well,” said Dr. Maynard, chief of the division of hospital medicine at the University of California, San Diego, sociation of Clinical Endocrinologists have recommended that hospitals implement standardized subcutaneous Medical Center. His study was the first hospitalwide validation of rec- order sets and insulin management algorithms. And that message is being heard: In a recent national survey of 700 clinical endocrinologists, threequarters indicated that their hospital is in the Monitored Patient-Days With Hypoglycemia process of trying to improve glucose manageHypoglycemia Any severe hypoglycemia ment, according to Dr. Maynard. He presented a study of the effect of these 3.7% interventions on inpatient glycemic control 0.7% and hypoglycemia at his institution. The inter2.8% 0.5% 2.6% 0.5% ventions, developed by a multispecialty task force, were implemented on all services except 12 months 18 months after 8 months following critical care and obstetrics. The study populapreintervention standardized insulin management subcutaneous algorithm tion consisted of more than 11,000 adult inpainsulin set tients who underwent 53,466 patient-days of point-of-care blood glucose monitoring. Note: Based on a study of 11,057 patients who underwent 53,466 The first major intervention, introduced in patient-days of point-of-care glucose monitoring. November 2003, was the standardized subcuSource: Dr. Maynard taneous insulin order set. It encouraged the use BY BRUCE JANCIN Else vier Global Medical Ne ws of basal, nutritional, and correction-dose insulin in lieu of the traditional sliding-scale insulin. “Sliding-scale insulin regimens generally lead to a roller coaster effect, with increased hyperglycemia and increased hypoglycemia,” Dr. Maynard said. Glargine was selected as the preferred basal insulin, lispro as the correctional insulin. “It’s less important which choice you make than that you make a choice and standardize the process in your medical center,” he explained. “You limit the choices in order to get people more used to using a standardized regimen. The second key intervention was a one-page insulin management algorithm introduced in May 2005. It provided guidance on calculating insulin dosage and monitoring glucose, and specified preferred regimens for inpatients in various nutritional situations. Before the interventions, on a month-by-month basis, 70%-75% of patients requiring insulin were on a slidingscale only regimen. Today, across all services, that’s down to about 20%, meaning 80% of patients have some basal insulin on board. The percentage of patients with a mean blood glucose of 180 mg/dL or less on hospital days 1-14 rose significantly from 63% at baseline to 68% after introduction of standardized insulin orders to 73% post algorithm. The percentage of hospital days when all patients’ blood glucose values were 60-180 mg/dL rose similarly. Moreover, the percentage of monitored hospital days when patients had hypoglycemia or severe hypoglycemia declined by about 30% (see box), to the surprise of the Continued on following page CLASSIFIEDS CONTINUING EDUCATION Have questions on classifieds? Call Danny Wang (212) 633-3158 for more information. 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Surgery News - October 2007

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