Successful Models of Implementation

Key Points

  • Hyperglycemia in the hospital affects quality of care, patient safety, length of stay, and cost; hence, addressing hyperglycemia in hospitalized patients can unite professionals in a common quest.

  • Models for implementation of improved control of hyperglycemia include:

    • Consultant Model
    • Diabetes Team Model
    • System-Wide Model

  • It is important to adapt the model you choose to fit your particular institution’s needs.

  • Critical success factors often include:

    • A committed champion of the effort
    • Administrative support—a major early goal
    • An engaged multidisciplinary steering committee

  • The multidisciplinary steering committee should:

    • Include medical staff, administration, nursing, case management, pharmacy, nutrition, dietary, laboratory, quality improvement, and information systems
    • Assess current processes, quality of care, and barriers to practice change
    • Strive to achieve broad buy-in to facilitate successful implementation of initiatives

  • Successful implementation of a program to improve glycemic control in the inpatient setting should usually include the following components:

    • Policies
    • Protocols and algorithms
    • Standardized order sets
    • Metrics for evaluation
    • Educational programs (including for physicians and nurses)

Suggested Reading

Clinical Guidelines and Certification

Joint Commission. Advanced certification in inpatient diabetes.

Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.

Society of Hospital Medicine. The case for supporting inpatient glycemic control programs now: the evidence and beyond. 2008.

Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.

Additional Reading

Alfonso A, Koops MK, Mong DP, Vigersky RA. Glycemic control with regular versus lispro insulin sliding scales in hospitalized type 2 diabetics. J Diabetes Complications. 2006;20:153-157.

Anthony M. Treatment of hypoglycemia in hospitalized adults: a descriptive study. Diabetes Educ. 2007;33:709-715.

Chen HJ, Steinke DT, Karounos DG, Lane MT, Matson AW. Intensive insulin protocol implementation and outcomes in the medical and surgical wards at a Veterans Affairs Medical Center. Ann Pharmacother. 2010;44:249-256.

Cook CB, Wellik KE, Kongable GL, Shu J. Assessing inpatient glycemic control: what are the next steps? J Diabetes Sci Technol. 2012;6:421-427.

Cook CB, Stockton L, Baird M, et al. Working to improve care of hospital hyperglycemia through statewide collaboration: the Georgia Hospital Association Diabetes Special Interest Group. Endocr Pract. 2007;13:45-50.

DeSantis AJ, Schmeltz LR, Schmidt K, et al. Inpatient management of hyperglycemia: the Northwestern experience. Endocr Pract. 2006;12:491-505.

Donaldson S, Villanuueva G, Rondinelli L, et al. Rush University guidelines and protocols for the management of hyperglycemia in hospitalized patients: elimination of the sliding scale and improvement of glycemic control throughout the hospital. Diabetes Educ. 2006;32:954-962.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15:89-91.

Fiore LD, Brophy M, Ferguson RE, et al. A point-of-care clinical trial comparing insulin administered using a sliding scale versus a weight-based regimen. Clin Trials. 2011;8:183-195.

Fraser DD, Robley LR, Ballard NM, Peno-Green LA. Collaborative development of an insulin nomogram for intensive insulin therapy. Crit Care Nurs Q. 2006;29:96-105.

Goldberg PA, Siegel MD, Russell RR, et al. Experience with the continuous glucose monitoring system in a medical intensive care unit. Diabetes Technol Ther. 2004;6:339-347.

Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10(suppl 2):100-108.

Inzucchi SE. Diabetes facts and guidelines. New Haven, CT: Yale Diabetes Center; 2011.

Krinsley JS. Translating evidence into practice in managing inpatient hyperglycemia. J Hosp Med. 2007;2:13-19.

Ku SY, Sayre CA, Hirsch IB, et al. New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf. 2005;31:141-147.

Lipton JA, Barendse RJ, Akkerhuis KM, Schinkel AF, Simoons ML. Evaluation of a clinical decision support system for glucose control: impact of protocol modifications on compliance and achievement of glycemic targets. Crit Pathw Cardiol. 2010;9:140-147.

Lipton JA, Barendse RJ, Schinkel AF, Akkerhuis KM, Simoons ML, Sijbrands EJ. Impact of an alerting clinical decision support system for glucose control on protocol compliance and glycemic control in the intensive cardiac care unit. Diabetes Technol Ther. 2011;13:343-349.

Magee MF, Clement S. Subcutaneous insulin therapy in the hospital setting: issues, concerns, and implementation. Endocr Pract. 2004;10(suppl 2):81-88.

Markovitz LJ, Wiechmann RJ, Harris N, et al. Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery. Endocr Pract. 2002;8:10-18.

Matheny ME, Shubina M, Kimmel ZM, et al. Treatment intensification and blood glucose control among hospitalized diabetic patients. J Gen Intern Med. 2008;23:184-189.

Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med. 2009;4:3-15.

Mills RD, Schwartz F, Shubrook JH. Evaluation of diabetes management in a rural community hospital. Endocr Pract. 2008;14:50-55.

Moghissi ES, Hirsch IB. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2005;34:99-116.

Morris AH, Orme J, Jr., Truwit JD, et al. A replicable method for blood glucose control in critically ill patients. Crit Care Med. 2008;36:1787-1795.

Mozdzan M, Ruxer J, Loba J, Siejka A, Markuszewski L. Safety of various methods of intensive insulin therapy in hospital condition assessed by hypoglycaemic episodes detected with the use of continuous glucose monitoring system. Adv Med Sci. 2006;51:133-136.

Munoz M, Pronovost P, Dintzis J, et al. Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Jt Comm J Qual Patient Saf. 2012;38:195-206.

Newton CA, Young S. Financial implications of glycemic control: results of an inpatient diabetes management program. Endocr Pract. 2006;12(suppl 3):43-48.

Oeyen SG, Hoste EA, Roosens CD, Decruyenaere JM, Blot SI. Adherence to and efficacy and safety of an insulin protocol in the critically ill: a prospective observational study. Am J Crit Care. 2007;16:599-608.

Olson L, Muchmore J, Lawrence CB. The benefits of inpatient diabetes care: improving quality of care and the bottom line. Endocr Pract. 2006;12(suppl 3):35-42.

Osburne RC, Cook CB, Stockton L, et al. Improving hyperglycemia management in the intensive care unit: preliminary report of a nurse-driven quality improvement project using a redesigned insulin infusion algorithm. Diabetes Educ. 2006;32:394-403.

Pollom RD. Optimizing inpatient glycemic control with basal-bolus insulin therapy. Hosp Pract (Minneap). 2010;38:98-107.

Quinn JA, Snyder SL, Berghoff JL, Colombo CS, Jacobi J. A practical approach to hyperglycemia management in the intensive care unit: evaluation of an intensive insulin infusion protocol. Pharmacotherapy. 2006;26:1410-1420.

Reynolds LR, Cook AM, Lewis DA, et al. An institutional process to improve inpatient glycemic control. Qual Manag Health Care. 2007;16:239-249.

Schmeltz LR, Desantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia. Endocr Pract. 2006;12:641-650.

Schnipper JL, Liang CL, Ndumele CD, Pendergrass ML. Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial. Endocr Pract. 2010;16:209-218.

Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S. Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: The Updated Yale Insulin Infusion Protocol. Endocr Pract. 2012;18:363-370.

Shulman R, Finney SJ, O’Sullivan C, Glynne PA, Greene R. Tight glycaemic control: a prospective observational study of a computerised decision-supported intensive insulin therapy protocol. Crit Care. 2007;11:R75.

Tamler R, Green DE, Skamagas M, et al. Durability of the effect of online diabetes training for medical residents on knowledge, confidence, and inpatient glycemia. J Diabetes. 2012;4:281-290.

Trujillo JM, Barsky EE, Greenwood BC, et al. Improving glycemic control in medical inpatients: a pilot study. J Hosp Med. 2008;3:55-63.

Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine Hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab. 2009;94:564-569.

Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30:2181-2186.

Umpierrez GE. Basal versus sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes Care 2009;32:594-596.

Wexler DJ, Shrader P, Burns SM, Cagliero E. Effectiveness of a computerized insulin order template in general medical inpatients with type 2 diabetes: a cluster randomized trial. Diabetes Care. 2010;33:2181-2183.