Reducing Hyperglycemia Hospitalwide: The Basal-Bolus Concept
Reducing Hyperglycemia Hospitalwide: The Basal-Bolus Concept
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DOI：
10.1016/s1553-7250(09)35029-1
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发表时间：
2009-04-01
影响因子：
2.3
通讯作者：
Emanuele, Mary Ann
中科院分区：
文献类型：
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作者：
Murphy, Donna M.;Vercruysse, Rita A.;Emanuele, Mary Ann
背景：高血压已被确定为患者不良结局的一个有效和独立的风险因素。一项倡议进行，以减少高血糖hospitalwide在adults.Methods：在一个多步骤的过程中，胰岛素协议通过电子供应商订单输入系统在全院范围内实施。在实施前进行关于基础餐时胰岛素输注的教育。根据临床工作人员的反馈和血糖监测，持续修改方案。关键实践变化包括ICU患者初始管理的静脉注射胰岛素，基于基础餐时方法的胰岛素替代，取消滑动标度胰岛素，餐前血糖监测标准化，根据进食量调整餐时胰岛素剂量，餐后给予餐时剂量，根据胰岛素类型订购晚间零食，对于入院时血糖> 180 mg/dL的患者，测定糖化血红蛋白（A1 C）。使用统计过程控制方法评估糖尿病患者的中位住院血糖水平。结果：2004年1月至2007年9月，所有糖尿病住院患者的中位血糖水平从159 mg/dL下降15%至< 135 mg/dL。有一天血糖测量值高于180 mg/dl的糖尿病住院患者比例从66%下降到53%。低血糖（< 60 mg/dL）的频率并没有改变以下protocolsimplementation.Discussion：在医院范围内的血糖控制的主要改进是可行的和安全的，采用基于基础-餐时概念的标准协议。在持续的机构支持、多学科教育、临床服务之间的合作以及每季度监测临床结果的情况下，在四年的时间内持续改善。
Background: Hyperglycemia has been identified as a potent and independent risk factor for adverse outcomes for patients. An initiative was undertaken to reduce hyperglycemia hospitalwide in adults.Methods: In a multistep process, insulin protocols were implemented hospitalwide via an electronic provider order entry system. Education regarding basal bolus insulin delivery preceded implementation. Protocols were modified in an ongoing manner on the basis of clinical staff feedback and blood glucose monitoring. Key practice changes included intravenous insulin for initial management in ICU patients, insulin replacement based on the basal bolus approach, elimination of sliding-scale insulin, standardization of blood glucose monitoring before meals, adjustment of prandial dose insulin based on food consumed, administration of prandial dose after the meal, evening snacks ordered based on insulin type, and a glycosolated hemoglobin (A1C) determination for patients with admission glucose > 180 mg/dL. Median inpatient glucose levels in patients with diabetes were assessed using statistical process control methodology.Results: Between January 2004 and September 2007, median glucose for all inpatients with diabetes decreased 15% from 159 mg/dL to < 135 mg/dL. The percentage of inpatients with diabetes who experienced a day with a glucose measurement above 180mg/dl decreased from 66% to 53%. Frequency of hypoglycemia (< 60 mg/dL) did not change following protocol implementation.Discussion: Major improvements in hospitalwide blood glucose control are feasible and safe, employing standard protocols based on the basal-bolus concept. Improvement was sustained during a four-year period with ongoing institutional support, multidisciplinary education, collaboration between clinical services, and monitoring of clinical outcomes on a quarterly basis.