Institutional Inpatient Diabetes Management—We're Still Not Doing It Right

Introduction: Morbidity and mortality increase with substantial glucose excursions during hospitalizations. The American Diabetes Association recommends an optimal glucose target of 140-180mg/dL for most inpatients with diabetes; glucose ranges of 80-180mg/dL are acceptable. They recommend against using correctional insulin alone; however, previous surveys have shown widespread use. The aim of this project was to identify current glycemic management patterns in our institution and find areas for improvement.

Methods: We investigated inpatient admissions to San Antonio Military Medical Center from March to September 2017. Patients included adults on medical or surgical services who received subcutaneous insulin, regardless of diabetes status. Data were collected for insulin orders, administration times, glucose values, and HbA1c levels.

Results: There were 1656 patients; 59% received only correctional insulin; 27% received basal and correctional insulin; 13% received basal/bolus insulin. Most patients (73%) did not reach glycemic targets; rates of hypoglycemia were 4-23%, which was higher than expected. Patients with HbA1c values of 8-9% were more likely to receive basal insulin; despite this, glycemic control remained poor. Troublingly, 13% of patients receiving correctional insulin alone had normoglycemia or normal baseline HbA1c values; 19% of these patients developed hypoglycemia during hospitalization.

Conclusion: Despite national guidelines, the majority of patients in our institution received only correctional insulin and did not achieve glucose targets. Additionally, most patients receiving basal/bolus insulin did not achieve glucose targets, suggesting inadequate titration. This requires systematic interventions to improve inpatient diabetes management.

Disclaimer: The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its Components.