Eliminating Inpatient Sliding-Scale Insulin: A Reeducation Project With Medical House Staff: Response to Peterson et al.

We thank Peterson, Charney, and Rennert (1) for their interest in our study (2). We share and applaud their interest in improving the level of house staff education for inpatient diabetes management. When we began our program 3 years ago, all inpatients received sliding-scale regular insulin and perpetual hyperglycemia was the rule. We felt that most of our 1st year residents did not know how to manage inpatient hyperglycemia, thus the universal default to sliding scale. We began with our medical house staff and taught 3 successive years using the approach described in the report and in the supplemental online appendix. As described at the end of the results section, we also collected survey data from our residents. A total of 100% of them felt competent to manage inpatient hyperglycemia using the basal/bolus approach after completing our educational program. Although we do not have formal data to assess the durability of the educational effort, we have been encouraged overall. We participated in the 2005 University HealthSystem Consortium benchmarking project on inpatient glycemic control. Thirty-seven out of 96 member academic health care centers each submitted extensive glycemic control/therapy data from 50 inpatients gathered from both medical and surgical services. Analysis of the dataset from 1,718 patients revealed that Rush University Medical Center was one of only two participating institutions that was awarded better performer designation in the project (3). Subsequently, in July 2005, we instituted a significantly updated approach to the use of subcutaneous basal/bolus insulin and have made the approach mandatory for all house staff and patients on all services hospital-wide. Sliding-scale regular insulin is now no longer permitted for any patient. We reduced the number of types of insulin available for inpatient use from seven to three (glargine or NPH for basal needs and aspart for prandial/correction needs). Since July 2005, we are now working each day with interns from all services in the hospital to educate them in the use of the new insulin protocol. We plan to reaudit 100 patients hospital-wide after 6 months to compare with our last audit done for the University HealthSystem Consortium study in early 2005.