Long-term improvements in insulin prescribing habits and glycaemic control in medical inpatients associated with the introduction of a standardized educational approach
Introduction
Most hospitalizations for patients with diabetes are due to aggravation of underlying conditions, and hyperglycaemia management usually does not constitute a treatment focus during hospital admission [1]. However, inpatient hyperglycaemia has been associated with nosocomial infections, increased mortality, and increased length of stay [2].
At our institution, prior to March 2008, the standardized approach to control of hyperglycaemia in hospitalized patients was based on administration of subcutaneous regular insulin as sliding scale dosing. Upon admission diabetic patients received a predetermined amount of subcutaneous regular insulin, usually beginning with 2 units for blood glucose >150 or 200 mg/dL. The dose was increased by 2 units for every 50-mg/dL increase in blood glucose. Previous outpatient diabetes therapy was commonly maintained during admission. A limited number of physicians prescribed insulin as “basal-bolus-correction” approach, but none consistently followed available consensus guidelines. In April 2008 a standardized educational approach was implemented to disseminate the recommendations of the American Diabetes Association for inpatient hyperglycaemia management [3].
The purpose of this study was to evaluate how prescribing habits and glucose control were affected by the implementation of our educational strategy for inpatients in medical wards.
Section snippets
Methods
Our methods have been described in detail elsewhere [4] and are summarized here. The Hospital Marina Baixa Institutional Review Board approved the study.
Physicians attitude, barriers and facilitators
A total of 33 physicians completed the questionnaire for a response rate of 46%. Median and interquartilic range [IQR] of 5-point Likert scale for every item were: (1) willingness to use insulin as basal-bolus-correction dosage (median 5; IQR: 5–5); (2) perception of better glycaemic control with basal-bolus-correction insulin dosage (median 4; IQR: 4–5); (3) concerns about the greater risk of hypoglycaemia with basal-bolus-correction insulin dosage (median 4; IQR: 2.5–4); (4) simplicity of the
Effectiveness of the standardized educational approach
We found that our educational intervention was effective in improving glycaemic control of patients admitted to internal medicine wards. Particularly, after the education intervention we identified a high motivation of health professionals to adhere to the American Diabetes Association Clinical Practice Guideline and we assessed barriers and facilitators for the applicability of the recommendations. Along the study period we observed a dramatically reduction in the use of insulin administered
Learning points
- 1.
Despite current guidelines, administration of subcutaneous regular insulin as sliding scale dosing remains as the standard approach for glycaemia management in hospitalized patients in many institutions.
- 2.
Improving glucose control by standard protocols based on insulin administration as basal-bolus-correction dosage is feasible and safe.
- 3.
Protocol implementation caused significant improvements in blood glucose control without increasing the risk of hypoglycaemia.
- 4.
It is necessary to promote
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgements
We thank the physicians and healthcare workers of the Internal Medicine and Emergency Medicine Departments for their willingness to participate in this research Project.
Contributions. JE conceived and designed the study, undertook the statistical analysis and drafted the paper; RC assisted in study design and reviewed the paper; TL, AL and JTA assisted in study design, collected data and reviewed the paper; JFND helped draft the paper. All authors reviewed and approved the final manuscript.
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