Cheryl W. O'Malley

Subcutaneous insulin order sets and protocols: Effective design and implementation strategies†‡

6 Yale Diabetes Center, Yale New Haven Hospital, New Haven, Connecticut. I npatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published, and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding-scale regimens. Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports detail clinical inertia and the continued widespread use of sliding-scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic ‘‘basal-nutrition-correction dose’’ insulin regimens endorsed by these reviews. Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure tomedications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use. A ‘‘Call to Action’’ consensus conference, hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set. The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful No honoraria were paid to any authors for time and expertise spent on the writing of this article.

Management of Diabetes and Hyperglycemia in the Hospital: A Practical Guide to Subcutaneous Insulin Use in the Non-Critically Ill, Adult Patient

5 MedStar Diabetes Institute, Washington, DC. R ecently, there has been a heightened interest in improving the quality and safety of the management of diabetes and hyperglycemia in the hospital. While observational data strongly suggests an association of hyperglycemia with morbidity and mortality in adults on general medicine and surgery units, clinical research has not yet defined the best practices for managing hyperglycemia in the hospital outside the intensive care unit (ICU). As a result, many physicians do not have a well-formulated approach to managing hyperglycemia in the noncritically ill hospital patient, and the use of insulin therapy to attain targeted blood glucose (BG) control is often subject to practice variability, leading to suboptimal glycemic outcomes. Practical ‘‘guidelines’’ for the management of this common clinical problem have been formulated by experts in the field, based on understanding of the physiology of glucose and insulin dynamics, the characteristics of currently available insulin preparations, and clinical experience. In 2004, in Clement et al., the American Diabetes Association published a technical review promoting the use of physiologic (‘‘basal-nutritional-correction dose’’) insulin regimens in the hospital to achieve targeted glycemic outcomes. This approach has been disseminated via review articles, and more recently, a randomized, controlled trial demonstrated that hospitalized type 2 diabetes patients experienced better glycemic control when treated with a physiologic insulin regimen than when treated with sliding-scale insulin alone. The Society of Hospital Medicine has assembled a Glycemic Control Task Force, which is charged with providing physicians and hospitals with practical tools to improve the safety and efficacy of diabetes management in the hospital. One product of this work is an educational module that serves as a tutorial on the best practice for the management of diabetes and hyperglycemia in the noncritically ill hospital patient. This article is based on that module, and provides a practical summary of the key concepts that will allow clinicians to confidently employ physiologic insulin regimens when caring for their hospital patients. Case: Ms. X is a 56-year-old obese woman with type 2 diabetes mellitus who is admitted for treatment of an infected diabetes-related foot ulcer. The patient will be allowed to eat dinner in a couple of hours, but the surgeons have requested that she be kept ‘‘nothing by mouth’’ (NPO) after midnight for surgical debridement in the morning. Her current weight is 100 kg, and her No honoraria were paid to any authors for time and expertise spent on the writing of this article.

Bridge over troubled waters: Safe and effective transitions of the inpatient with hyperglycemia

4 Department of Medicine, Division of General Internal Medicine, Hospitalist Program, University of California, Irvine, Irvine, California. P rofessional and patient safety organizations have recognized the importance of safe transitions as patients move through the health care system, and such attention is even more critical when attempting to achieve glycemic control. Since the publication of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), we have known that intensive glycemic control in the ambulatory setting prevents complications in both type 1 and type 2 diabetes mellitus (DM). Despite the increased risk of hypoglycemia, these trials changed practice patterns in the outpatient settings in favor of intensification of diabetes therapy. In the same way, randomized, prospective trials using intravenous (IV) insulin therapy have revolutionized our thinking about inpatient care by showing that tight glycemic control in the critically ill and patients with acute myocardial infarction reduces mortality and morbidity. These, as well as additional observational studies associating hyperglycemia with poor outcomes in a variety of medical and surgical patients, have led to increased attention on glycemic control in all venues of care. Concerns over excessive hypoglycemia and a nonsignificant increase in mortality in certain populations of medical intensive care unit (ICU) patients have raised questions over whether the initial studies can be reproduced or generalized to other groups of inpatients. Additional studies are underway to clarify these questions but consensus exists that blood glucose values should at least be less than 180 mg/dL and that the traditional practice of ignoring hyperglycemia is no longer acceptable. While a uniform focus on glycemic control will allow our patients to receive a consistent message about diabetes, the unique limitations inherent to each practice setting requires different therapeutic regimens and intentional focus on the risks as patients transition from one care area to another. This work addresses several areas of care transition that are particularly important in safely achieving glycemic control including: transition into the hospital for patients on a variety of home regimens, transitions within the hospital (related to changes in dietary intake, change from IV to subcutaneous [SC] therapy, and the perioperative setting), and the transition from the hospital to home or another healthcare facility.

Perioperative Care of the Geriatric Patient with Diabetes or Hyperglycemia

The incidence of diabetes in the geriatric population is increasing and the resulting co-morbidities have led to corresponding increases in hospital admissions and surgeries. The weight of the evidence and national guidelines should dissuade us from allowing uncontrolled hyperglycemia in the geriatric perioperative population, but the glycemic target should be modified upwards based on the individual patient characteristics, and in environments that do not have an established track record of reaching more aggressive targets safely. Insulin is the most effective and flexible regimen to achieve inpatient glycemic control, whether by infusion or by subcutaneous basal bolus regimens. Strategies for safe and effective dosing and adjustment of insulin regimens, and methods to avoid hypoglycemia in the perioperative period are outlined. Finally, discharge planning should take into consideration a patients HbA1c, preoperative glycemic control, inpatient glycemic regimen and control, financial and physical limitations, social support, co-morbid medical conditions, episodes of hypoglycemia, and overall prognosis to create an individualized safe and effective medication regimen for optimal glycemic control at home.

Visiting professorship in hospital medicine: An innovative twist for a growing specialty

INTRODUCTION As an emerging and rapidly growing specialty, academic hospitalists face unique challenges in career advancement. Key mentoring needs, especially developing reputation and relationships outside of their institution are often challenging. METHODS We describe the structure of a novel Visiting Professorship in Hospital Medicine Program. It utilizes reciprocal exchanges of hospitalist faculty at the rank of late assistant to early associate professor. The program is designed explicitly to facilitate spread of innovation between institutions through a presentation by the visiting professor and exposure to an innovation at the host hospital medicine group. It provides a platform to advance the career success of both early- and midcareer hospitalist faculty through 1-on-1 coaching sessions between the visiting professor and early-career faculty at the host institution and commitment by visiting professors to engage in mentoring after the visit. RESULTS Five academic hospitalist groups participated. Seven visiting professors met with 29 early-career faculty. Experience following faculty exchange visits demonstrates program effectiveness, as perceived by both early-career faculty and the visiting professors, in advancing the goals of mentorship and career advancement. One-year follow-up suggests that 62% of early-career faculty will engage in subsequent interactions with the visiting professor, and half report spread of innovation between academic hospital medicine groups. CONCLUSIONS The Visiting Professorship in Hospital Medicine offers a low-cost framework to promote collaboration between academic hospital medicine groups and facilitate interinstitutional hospitalist mentoring. It is reported to be effective for the goal of professional development for midcareer hospitalists. Journal of Hospital Medicine 2016;11:714-718.