Implementation of a Standardized Admission Hyperglycemia Insulin Order Set in a Veterans Hospital
Erin K. Yeung*, Mark Wong and Dana Wong
Department of Pharmacy Services, South Texas Veterans Health Care System & The University of Texas Health Science Center San Antonio, USA
Submission: May 04, 2018;Published: May 16, 2018
*Corresponding author: Erin K. Yeung, Department of Pharmacy Services, South Texas Veterans Health Care System, San Antonio, TX, Pharmacotherapy Education & Research Center, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA, Email: firstname.lastname@example.org
How to cite this article: Yeung K, Wong M, Wong D. Implementation of a Standardized Admission Hyperglycemia Insulin Order Set in a Veterans
Hospital. 2018; 7(1): 555701. DOI: 10.19080/JOJCS.2018.07.555701.
Purpose: The efficacy of an implemented hyperglycemia admission insulin order set containing basal-bolus-correction regimens to facilitate protocol-adherent prescribing in non-critically ill patients was evaluated.
Method: In this retrospective, single-center, observational study, patients age 18 years or older with a history of type 2 diabetes or admission blood glucose >180mg/dL were identified through electronic medical record review of patients admitted to medicine wards. Patients were excluded if admitted to intensive care or surgical units during hospitalization, identified to have a history of type I diabetes, treated for diabetic ketoacidosis, pregnant, or allergic to insulin. Patients were evaluated pre- and post-protocol implementation. The primary endpoint was mean hospitalization glucose levels. Secondary endpoints included: percentage of patients with average hospitalization glucose < 180mg/dL, percentage of basal insulin utilization, and hypoglycemia incidence.
Results: A total of 200 patients were included in this study, with 100 patients in each group. Average hospitalization glucose was not significantly lower in the post-implementation group compared to the pre-implementation group (169 vs. 177mg/dL, p=0.33). More patients in the post-implementation group had mean hospitalization glucose < 180mg/dL, though this was not significant (66 vs. 55%, p=0.15). However, percentage of patients with basal insulin use did not change (43% vs 44%, p=1.00). There was no difference in hypoglycemic episodes (27 vs 24 events, p=0.75).
Conclusion: The new basal-bolus-correction insulin order set at STVHCS is not associated with any difference in inpatient hyperglycemia control. Education at multiple interdisciplinary levels is required for effective hyperglycemia protocol implementation
Inpatient hyperglycemia is a common problem during hospitalization affecting numerous patients across institutions worldwide. Diabetes mellitus was associated with over 7.7 million hospitalizations in the United States in 2008, contributing to the incidence of inpatient hyperglycemia and increased hospital costs [1,2]. The management of inpatient hyperglycemia is affected by a multitude of factors, including acute illness, concurrent medications, inconsistent caloric intake, and insulin administration . Stress hyperglycemia and various medications such as corticosteroids, calcineurin inhibitors, and atypical antipsychotics can increase glucose levels in patients, with or without diabetes mellitus . Additionally, outpatient oral antihyperglycemic agents are typically discontinued during hospitalization to prevent complications with inpatient management, furthering the risk of hyperglycemia. Conversely, inconsistent dietary intake due to illness-associated loss of appetite, “nothing by mouth” (NPO) dietary precautions, and improper insulin use may increase the risk of hypoglycemia . Hyperglycemia in hospitalized patients with or without diabetes mellitus has significant impact on patient care as it has been associated with worsened outcomes, including increased rates of infection, longer lengths of stay, and increased mortality [5-7]. Therefore, effective inpatient hyperglycemia management is essential to optimize patient outcomes.
Due to complications associated with oral antihyperglycemic agents in the inpatient setting, insulin is often used as the sole agent in inpatient hyperglycemia management . Sliding scale insulin has been a common hyperglycemia strategy used in the United States as early as the 1930s. Despite evidence demonstrating no clinical benefit with this strategy, sliding scale insulin has remained pervasive in clinical practice . Sliding scale insulin practices a reactive hyperglycemia management style that has been associated with higher rates of hypoglycemic
events, suboptimal glycemic control, and longer hospital stays
compared to basal-bolus insulin strategies. In basal-bolus
insulin strategies, long-acting basal insulin provides stable
plasma insulin concentrations and stable fasting hyperglycemia
control. The bolus component of basal-bolus insulin strategies
is comprised of rapid-acting insulin intended to control postprandial
hyperglycemia induced by nutritional intake .
The basal-bolus insulin strategy has demonstrated superior
hyperglycemia control compared to sliding scale in controlled
trials evaluating multiple type 2 diabetic populations, including
general surgery and non-critically ill patients [11,12]. Basal-bolus
insulin regimens have even been compared to pre-mixed insulin’s
(i.e. 30% regular insulin with 70% NPH insulin) in a randomized
controlled trial, demonstrating a significantly reduced risk for
hypoglycemia (24% vs 64%, p< 0.001) without any difference in
glycemic control . In non-critically ill patients with type 2
diabetes mellitus, the RABBIT-2 trial demonstrated significant
improvement in glycemic control with basal-bolus-correction
insulin regimens without an increase in hypoglycemia or length
of stay compared to sliding-scale regular insulin . Therefore,
current guidelines recommend basal-bolus-correction insulin
strategies over sliding scale insulin for inpatient hyperglycemia
management. The 2016 American Diabetes Association (ADA)
guidelines recommend initiating insulin therapy for persistent
hyperglycemia at a threshold of blood glucose levels >180mg/
dL, with a goal of 140-180mg/dL. For non-critically ill patients,
basal-bolus-correction insulin regimens are recommended with
good nutritional intake; the use of sliding scale insulin only is
strongly discouraged .
Current ADA guidelines recommend the use of routine
structured order sets that include computerized advice for
glucose control . At our institution, sliding scale insulin was
previously the only insulin option available on medicine floor
admission order sets. Separate orders were required for basal
insulin when needed for hyperglycemia management. This often
led to a postponed addition of basal insulin to hyperglycemia
regimens and delayed insulin administration due to missing
orders. To address difficulties with hyperglycemia management,
the medicine department at our institution developed a new
hyperglycemia protocol (Appendix 1). Thereafter, in April
2016, a new admission insulin order set containing basalbolus-
correction ordering options was implemented to
facilitate prescribing per protocol for inpatient hyperglycemia
management in non-critically ill patients (Figure 1).
This is a retrospective, single-center, observational study
of veterans. The study protocol was formally reviewed and
exempted by the university-affiliated institutional review board.
Patients admitted between August 1, 2015 to September 30,
2015 (pre-implementation) and August 1, 2016 to September
30, 2016 (post-implementation) were identified through an
electronic medical record review of patients admitted to non-
ICU or non-surgical wards. Patients were evaluated pre- and
post-protocol implementation. Glycemic management in the
pre-implementation group was determined by individual
physician discretion. A 4-month lead-in time from protocol
implementation was allowed for staff acclimation to the protocol
and training of incoming house staff in July 2016.
Patients age >18 years were included if admitted to a
general medicine ward for at least 3 days with a history of type 2
diabetes or admission blood glucose >180mg/dL. Patients were
excluded if admitted to intensive care or surgical units during
hospitalization, identified to have a history of type I diabetes,
treated for diabetic ketoacidosis, pregnant, or allergic to insulin.
The primary endpoint was mean hospitalization glucose
level compared between the pre- and post-implementation
groups. Secondary endpoints included percentage of patients
with average hospitalization glucose <180mg/dL, percentage of
basal insulin utilization, percentage of sliding scale insulin only
utilization, 30-day mortality, length of stay, and hypoglycemia
incidence. A hypoglycemic event was defined as >1 consecutive
blood glucose reading of <70mg/dL. A planned subgroup
analysis on average hospitalization blood glucose in patients
receiving corticosteroids was also performed.
Categorical data were compared using Fisher’s exact test.
Continuous data were compared using student t test if normally
distributed and the Mann-Whitney U test if not normally
distributed. Normally distributed data were described using
mean ± SD. Non-normally distributed data were described using
median values and interquartile ranges (IQR). The primary
outcome was compared using the Mann-Whitney U tests for
independent samples. A p-value of <0.05 was considered to be
statistically significant. Means, standard deviations, medians,
and counts were used for descriptive statistics.
A total of 2407 patients in the pre-implementation group,
and 2417 patients in the post-implementation group were
initially identified in the EMR. Patients were randomly evaluated
to determine study inclusion. A total of 699 evaluated patients
met exclusion criteria or did not match inclusion criteria. A total
of 100 patients in the pre- and post-implementation groups were
identified. Background characteristics, including pre-admission
A1C and home antihyperglycemic regimens, were found to be
similar in both groups (Table 1 & 2).
Patients in the post-protocol were found to have lower
average hospitalization glucose, but this was not found to be
statistically significant (177+ 55.3 vs. 169 + 48.4mg/dL, p=0.33).
Additionally, more patients in the post-protocol group had
mean hospitalization glucose <180mg/dL, indicating greater
hyperglycemic control, though this was also not statistically
significant (55% vs 66%, p=0.15). Despite indications of
hyperglycemic improvement in the post-implementation group,
basal insulin utilization did not change from the pre- to postimplementation
periods (43% vs 44%, p=1.00). Furthermore,
there was no difference in sliding scale insulin monotherapy
utilization, although a non-significant decrease from pre- to postimplementation
was observed (52% vs 47%, p-value=0.48).
There was no difference in the number of patients receiving
corticosteroids between the two groups (7 vs. 8 patients,
p=1.00). Glycemic control in patients receiving corticosteroids
appeared to be improved in the post-implementation group
compared to pre-implementation (185 vs. 228mg/dL, p=0.32),
but this difference was not significant and is limited by a small
Despite non-significant indications of improved
hyperglycemia control, there was no significant difference in
hypoglycemic episodes from the pre- to post-implementation
periods (27 vs 24 events, p=0.75). There was also no significant
difference in the median length of stay between groups (5 vs. 4
days, p-value=0.50) or overall 30-day mortality (3 vs 1 deaths,
Although basal-bolus-correction insulin strategies for inpatient hyperglycemia management have demonstrated
benefit in previous literature and are recommended by current guidelines, its implementation appears to have some barriers
In this study, a trend towards improved hyperglycemia
management using the newly implemented admission order
set was observed, but no significant differences were found. It
also appears that the new admission order set had no impact
on basal insulin ordering. This was unusual considering there
were more patients in the post-implementation group who were
initially on home basal insulin regimens, though this difference
was not significant. Although no significant improvement
in hyperglycemia control was observed, there were also no
differences in adverse events such as hypoglycemia, which is
consistent with previous literature . A subgroup analysis on
patients receiving corticosteroids was pre-planned in this study.
The number of patients treated with corticosteroids was similar
between groups and no significant difference in glucose control
was found, but the sample size was very small, limiting any
generalizations of the impact of basal-bolus-correction insulin
strategies on glucocorticoid-induced hyperglycemia.
A similar insulin protocol evaluation study at another
Veteran Affairs Medical Center found that their implementation
of a basal-bolus-correction insulin protocol significantly
reduced hypoglycemic events. However, mean blood glucose
values increased . While their study showed that
protocol implementation could improve patient safety by
decreasing hypoglycemic events, the optimal protocol design
for hyperglycemia management is still unclear. Design and
implementation may be dependent on many institution-specific
factors such as compliance, staff education, and workflow
processes. Through the development of a hyperglycemia
protocol and the implementation of a new admission insulin
order set in this study, basal-bolus-correction insulin ordering
recommendations are more consistently and readily available
for providers to utilize in hyperglycemia management.
This study reflects real-life implementation of a
hyperglycemia protocol and was well matched between the
pre- and post-protocol groups. Interestingly, baseline A1C levels
in the pre- and post-implementation groups were not elevated
to a degree that would warrant consistent use of basal insulin
for glycemic control. Both groups had a baseline A1C <8%,
which is approximately equal to an average glucose of 183mg/
dL, and approximately 50% of patients in both groups did not
require home basal insulin . This implicates that perhaps the
majority of patients in this study could have achieved adequate
inpatient glycemic control with sliding scale insulin alone,
explaining the unchanged rate of basal insulin utilization despite
its addition to the admission order set.
Overall, the results of this study are generalizable to a large
population of hyperglycemia inpatients, but more specifically to
those in the non-critically ill setting receiving care at an academic
medical center where house staff rotation is common. This
study is limited primarily by its failure to measure adherence.
Inappropriate dosing, frequency of dose adjustments, and
nursing administration of dosages were not analyzed but may
have impacted overall glycemic control. The study also included
a small sample size and retrospective design.
Another potential limitation of this study is in adequate time
allotment for house staff education prior to post-implementation
analysis. Post-protocol analysis was performed only 5 months
after implementation, and only one month after the introduction
of new house staff. In retrospect, this analysis time may not have
been sufficient to ensure appropriate implementation of the
evaluated order set and protocol.
Most importantly, staff feedback regarding the order set
and protocols from this study have revealed several barriers
to hyperglycemia protocol implementation. These barriers
occurred at multiple interdisciplinary levels of care, including
a) Inappropriate insulin adjustments by house staff due
to fear of hypoglycemia and
b) Improper nursing insulin administration in patients
with NPO diets.
For example, persistent hyperglycemia due to extremely
conservative up titration of insulin dosages by house staff was
reported. These observations further revealed a general fear of
hypoglycemia. The risk of hypoglycemia associated with basalbolus-
correction insulin strategies, however, is not different than
that of sliding scale insulin in non-critically ill patients . The
management of hypoglycemic episodes with frequent glucose
monitoring by nursing staff is also potentially more safe and
effective in the inpatient setting compared to patient self-care.
Misconceptions regarding insulin administration in NPO
patients were also discovered. Nursing requests to hold basal
insulin doses in NPO patients were reported, despite the
intended long-acting baseline glycemic control associated
with basal insulin. Furthermore, these nursing requests
were approved by house staff, leading to inappropriate and
suboptimal hyperglycemia control. It was also found that
correctional sliding scale doses of rapid-acting insulin were
occasionally held in NPO patients, despite its intended purpose
of glucose level “correction” independent of nutritional intake.
This problem may be associated with the fact that “bolus” rapidacting
insulin’s typically withheld in NPO patients are identical
to the correctional rapid-acting insulin. Correctional insulin at
our institution is scheduled as “three times a day before meals”
to standardize administration times with pre-prandial rapidacting
insulin administration times in patients with a regular
diet. Despite explicit statements to give correctional insulin in
NPO patients on electronic orders, “before meals” administration
times may mislead nursing staff to hold correctional insulin
doses, as NPO patients will not receive meals and therefore do
not match administration instructions.
Since the completion of this study, several initiatives to
guide future directions have been implemented. Regular
education for house staff regarding proper hyperglycemia
management and insulin dose initiation/titration (per protocol/
ADA guidelines) has been implemented in collaboration with
endocrine staff. House staff has also requested reminders about
the availability of the basal-bolus-correction insulin order
set and hyperglycemia protocol prior to all general medicine
rotations. Inpatient hyperglycemia management education for
nursing staff is also in development as a result of this study in
order to improve outcomes from a multidisciplinary approach.
Due to the discovered misinterpretations of correctional insulin
instructions, administration timing will also be reviewed to
determine optimal administration instructions for nursing staff.
Re-evaluation of inpatient glycemic control after establishment
of multidisciplinary education is warranted. Evaluation of
admission insulin order set efficacy in a population with higher
baseline glucose levels may also provide clearer insight into
basal-bolus-correction insulin efficacy and utilization.
The newly implemented basal-bolus-correction insulin
order set was not associated with any difference in inpatient
hyperglycemia control. Education at multiple interdisciplinary
levels appears to be a crucial requirement for effective
hyperglycemia protocol implementation and improved glycemic