Effects of a Subcutaneous Insulin Protocol, Clinical Education, and Computerized Order Set on the Quality of Inpatient Management of Hyperglycemia: Results of a Clinical Trial
Effects of a Subcutaneous Insulin Protocol, Clinical Education, and Computerized Order Set on the Quality of Inpatient Management of Hyperglycemia: Results of a Clinical Trial
复制标题
DOI：
10.1002/jhm.385
复制
发表时间：
2009-01-01
影响因子：
2.6
通讯作者：
Pendergrass, Merri L.
中科院分区：
文献类型：
--
作者：
Schnipper, Jeffrey L.;Ndumele, Chima D.;Pendergrass, Merri L.
背景：住院患者高血糖与患者预后不良相关。目前尚不清楚如何最好地实施血糖管理策略在非重症监护室（ICU）setting.Objective：以确定多方面的质量改善干预的影响，对管理内科住院患者的糖尿病或高血糖症。设计：前后试验。设置：地理定位的一般医疗服务，由医生助理（PA）和住院医师。患者：连续招募2型糖尿病或住院高血糖患者。干预：详细的皮下胰岛素协议，医院计算机化订单输入系统中内置的入院订单集，以及基于病例的教育研讨会和护士，医生和PA的讲座。每例患者血糖读数在60和180 mg/dL之间的平均百分比;低血糖患者天数百分比;胰岛素使用模式;和住院时间。干预前每例患者读数在60和180 mg/dL之间的平均百分比为59%，干预后为65（校正效应量9.7%; 95%置信区间[CI]，0.6%-18.8%）。发生任何低血糖的患者天数百分比在干预前为5.5%，干预后为6.1%（校正比值比1.1; 95% CI，0.6-2.1）。计划营养胰岛素的使用从40%增加到75%（比值比4.5; 95% CI，2.0-9.9），调整后的住院时间缩短了25%（95% CI，9%-44%）。每日胰岛素调整没有改善，住院3天后血糖控制也没有改善。结论：这种多方面的干预，易于实施，需要的资源最少，与非ICU医疗患者的胰岛素订购实践和血糖控制的改善有关。医院医学杂志2009;4：16-27. (c)2009年医院医学会。
BACKGROUND: Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non-intensive care unit (ICU) setting.OBJECTIVE: To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia.DESIGN: Before-after trial.SETTING: Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists.PATIENTS: Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia.INTERVENTION: A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case-based educational workshops and lectures to nurses, physicians, and PAs.MEASUREMENTS: Mean percent Of glucose readings per patient between 60 and 180 mg/dL; percent patient-days with hypoglycemia; insulin use patterns; and hospital length of stay.RESULTS: The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%-18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% Cl, 0.6-2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% Cl, 2.0-9.9) and adjusted length of stay decreased by 25% (95% Cl, 9%-44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3.CONCLUSIONS: This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin ordering practices and glycemic control among non-ICU medical patients. Journal of Hospital Medicine 2009;4:16-27. (c) 2009 Society of Hospital Medicine.