By Dr. Jordan Messler
In 1921, Sir Frederick G. Banting, Charles H. Best and JJR Macleod discovered insulin at the University of Toronto. This innovation changed the course of history for individuals with type 1 diabetes, caregivers and others who require insulin.
The 100 years that followed have been revolutionary. Additional outpatient inventions, such as insulin pens, smartphone applications and continuous glucose monitors, drastically improved the lives of individuals living with diabetes.
On the inpatient side, however, we still have a long way to go. It’s easy to find instances when someone living with diabetes had to intervene and “override doctor’s orders to ensure [their] own safety” during a hospital stay. There are message boards where dozens of people living with diabetes discussed their checklist for a hospital stay because they were not confident that clinicians would be equipped to manage their condition properly.
After 100 years of insulin and diabetes management innovation, how are we still here?
Unfortunately, many health systems today battle therapeutic inertia. They rely on outdated methodology and face challenges in adopting new software and systems. The good news is that the implementation of new glycemic processes doesn’t have to be difficult. Moreover, advancements in inpatient insulin management software not only improve patient safety but also alleviate challenges for clinicians and save health systems money.
Barriers to Adopting Inpatient Diabetes Technology
Clinicians are encumbered by protocols or technology that are inadequate to manage the complexity of best-in-class glycemic management. Protocols are often limited in scope, hospitals lack insights into glycemic outcomes, institutional misconceptions abound regarding glycemic care and there is often limited endocrinologist support. The continued reliance on dated tools and protocol result in the inability to sustain glycemic best practices and s.
Paper-based insulin dosing protocols are used by many hospitals to manage IV insulin and require manual calculations or multiple steps that are imprecise, not personalized to patient needs and error-prone. For subcutaneous insulin dosing, many hospitals use “sliding scale” protocols as monotherapy. Sliding scale has been shown to be ineffective and can be dangerous, yet continues to be used by hospitals who have not committed to practice change. The American Diabetes Association (ADA) even warns against using sliding scale, stating “use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged.”
Many hospitals also lack standardized order sets and protocols to consistently address glucose control for patients. The focus is generally put on reactive measures once hyperglycemia is out of control or to only treat hyperglycemia when it’s the primary concern, such as with patients with diabetic ketoacidosis (DKA). However, proper glycemic management has been shown in study after study to improve outcomes for comorbid conditions that may generally be the primary focus of treatment, such as
Recommendations to Improve Inpatient Glycemic Management
While these steps only scratch the surface of advanced improvement processes, most experts will provide the following ADA recommendations for inpatient settings:
- Insulin should be used for most hospitalized patients with hyperglycemia
- Continuous intravenous insulin infusion should be utilized to treat persistent hyperglycemia for critically ill patients
- Intravenous insulin infusions should be administered based on validated written or computerized protocols that allow for predefined adjustments in the infusion rate, account for glycemic fluctuations and achieve low rates of hypoglycemia
- Use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged
- A basal insulin or a basal plus bolus correction insulin regimen with mealtime adjustments as warranted is preferred to treat noncritically ill hospitalized patients
- Health systems should transition patients to subcutaneous insulin schedules using institutional protocols before discontinuing intravenous insulin infusions
Benefits of Advanced Insulin Management Software
Insulin management software can support these recommendations, standardize practices and take inpatient glycemic management programs to the next level. Not all insulin management software is the same though: advanced solutions not only provide clinically-proven technology, they also act as a partner in glycemic management excellence by providing expertise and change management support to help their partners achieve glycemic management success.
Advanced solutions provide the ability to deliver insulin dosing decision support at the point of care. These solutions leverage real-time and historical data to personalize insulin dosing, helping patients get into target range faster. Additional features like glycemic analytics, continuous patient surveillance, automated blood glucose check reminders and dashboards help standardize practices and optimize insulin management across every department.
Forward-thinking hospitals that adopted advanced insulin management software are seeing the benefits this type of technology can deliver. For example, through the use of insulin management software, Grady Health System reduced inpatient severe hypoglycemia by 99.8%. In addition, Kaweah Delta Medical Center reduced the average length of stay by more than three days and saved nearly $3,000 per hypoglycemic event. Duke University showed that health systems could save up to 72 minutes per nurse per patient when managing IV insulin with advanced software.
The Next Wave of Insulin Innovation
Before 1921, it was unexpected for individuals living with type 1 diabetes and other glycemic challenges to live more than one or two years. Insulin reversed that trajectory, and further advancements have made it easier for individuals to manage their blood glucose levels to live healthy, safe and informed lives.
Despite these advancements, many health systems are stuck in the past when it comes to insulin and glycemic management. Glucose control is a fundamental tenet of high-reliability care. We shouldn’t have patients overriding orders or developing checklists for their stay. We need to do better. That’s why the next wave of insulin innovation needs to focus on best-in-class inpatient insulin management.
About Jordan Messler
Jordan Messler, MD, SFHM, FACP is the Chief Medical Officer with Glytec. He trained in internal medicine at Emory University in Atlanta, and subsequently served as an academic hospitalist at Emory University for several years after residency. He is the former medical director for the Morton Plant Hospitalist group in Clearwater, Florida (serving BayCare Health), where he continues to work as a hospitalist. He is the current physician editor for the Society of Hospital Medicine’s (SHM) blog, The Hospital Leader. In addition, he previously chaired SHM’s Quality and Patient Safety Committee and has been active in several of their national mentoring programs, including Project BOOST and Glycemic Control. He has talked at national conferences on a variety of topics such as teamwork in the hospital, quality and patient safety, the history of hospitals and mentoring quality improvement projects.