A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline for the Management of Hyperglycemia in Adults Hospitalized for Noncritical Illness or Undergoing Elective Surgical Procedures.

CONTEXT: Individuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging. OBJECTIVE: To support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures. METHODS: We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS: We included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level < 7% was associated with shorter length of stay, lower postoperative BG and a lower number of neurological complications and infections, but a higher number of reoperations (very low certainty). Treatment with glucagon-like peptide-1 agonists or dipeptidyl peptidase-4 inhibitors in hospitalized patients with type 2 diabetes and mild hyperglycemia was associated with lower frequency of hypoglycemic events than insulin therapy (low certainty). Caloric oral fluids before surgery in adults with diabetes undergoing surgical procedures did not affect outcomes (very low certainty). Counting carbohydrates for prandial insulin dosing did not affect outcomes (very low certainty). Compared with scheduled insulin (basal-bolus or basal insulin + correctional insulin), correctional insulin was associated with higher mean daily BG and fewer hypoglycemic events (low certainty). CONCLUSION: The certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.

Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline.

BACKGROUND: Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management. OBJECTIVE: To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. METHODS: A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS: The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes. CONCLUSION: The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

Sex differences in glycemic measures, complications, discharge disposition, and postdischarge emergency room visits and readmission among non-critically ill, hospitalized patients with diabetes.

INTRODUCTION: The purpose of this prospective observational cohort study was to examine sex differences in glycemic measures, diabetes-related complications, and rates of postdischarge emergency room (ER) visits and hospital readmissions in non-critically ill, hospitalized patients with diabetes. RESEARCH DESIGN AND METHODS: Demographic data including age, body mass index, race, blood pressure, reason for admission, diabetes medications at admission and discharge, diabetes-related complications, laboratory data (hematocrit, creatinine, hemoglobin A1c, point-of-care blood glucose measures), length of stay (LOS), and discharge disposition were collected. Patients were followed for 90 days following hospital discharge to obtain information regarding ER visits and readmissions. RESULTS: 120 men and 100 women consented to participate in this study. There were no sex differences in patient demographics, diabetes duration or complications, or LOS. No differences were observed in the percentage of men and women with an ER visit or hospital readmission within 30 (39% vs 33%, p=0.40) or 90 (60% vs 49%, p=0.12) days of hospital discharge. More men than women experienced hypoglycemia prior to discharge (18% vs 8%, p=0.026). More women were discharged to skilled nursing facilities (p=0.007). CONCLUSIONS: This study demonstrates that men and women hospitalized with an underlying diagnosis of diabetes have similar preadmission glycemic measures, diabetes duration, and prevalence of diabetes complications. More men experienced hypoglycemia prior to discharge. Women were less likely to be discharged to home. Approximately 50% of men and women had ER visits or readmissions within 90 days of hospital discharge. TRIAL REGISTRATION NUMBER: NCT03279627.

Patient Understanding of Discharge Instructions for Home Diabetes Self-Management and Risk for Hospital Readmission and Emergency Department Visits.

OBJECTIVE: The primary objective of this study was to examine the patient comprehension of diabetes self-management instructions provided at hospital discharge as an associated risk of readmission. METHODS: Noncritically ill patients with diabetes completed patient comprehension questionnaires (PCQ) within 48 hours of discharge. PCQ scores were compared among patients with and without readmission or emergency department (ED) visits at 30 and 90 days. Glycemic measures 48 hours preceding discharge were investigated. Diabetes Early Readmission Risk Indicators (DERRIs) were calculated for each patient. RESULTS: Of 128 patients who completed the PCQ, scores were similar among those with 30-day (n = 31) and 90-day (n = 54) readmission compared with no readmission (n = 72) (79.9 ± 14.4 vs 80.4 ± 15.6 vs 82.3 ± 16.4, respectively) or ED visits. Clarification of discharge information was provided for 47 patients. PCQ scores of 100% were achieved in 14% of those with and 86% without readmission at 30 days (P = .108). Of predischarge glycemic measures, glycemic variability was negatively associated with PCQ scores (P = .035). DERRIs were significantly higher among patients readmitted at 90 days but not 30 days. CONCLUSION: These results demonstrate similar PCQ scores between patients with and those without readmission or ED visits despite the need for corrective information in many patients. Measures of glycemic variability were associated with PCQ scores but not readmission risk. This study validates DERRI as a predictor for readmission at 90 days.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

ADDRESSING PITFALLS IN MANAGEMENT OF DIABETIC KETOACIDOSIS WITH A STANDARDIZED PROTOCOL.

Objective: To determine the efficacy and safety of a diabetic ketoacidosis (DKA)-Power Plan (PP) for guiding intravenous (IV) insulin infusions prior to anion gap (AG) closure and administering subcutaneous (SC) insulin ≥1 hour before discontinuing IV insulin. Methods: Retrospective chart review of patients with DKA before (pre-PP) (n = 60) and following (post-PP) (n = 60) implementation of a DKA-PP. Groups were compared for percentage of patients for whom IV insulin therapy was continued until AG closure, the percentage of patients receiving SC insulin ≥1 hour before discontinuation of IV insulin, and percentage of patients with rebound DKA during the index hospitalization. Results: Admission plasma glucose (514 mg/dL vs. 500 mg/dL; P = .36) and venous pH (7.2 vs. 7.2; P = .57) were similar in pre- and post-PP groups. Inappropriate discontinuation of IV insulin occurred less frequently in post-PP patients (28% vs. 7%; P = .007), with a lower frequency of rebound DKA (40% vs. 8%; P = .001) following acute management. More post-PP patients received SC insulin ≥1 hour before discontinuation of IV insulin (65% vs. 78%; P = .05). Conclusion: Implementation of a DKA-PP was associated with appropriate discontinuation of IV insulin in more patients, more frequent administration of SC insulin ≥1 hour prior to discontinuation of IV insulin, and fewer episodes of rebound DKA. Abbreviations: ADA = American Diabetes Association; AG = anion gap; BG = blood glucose; DKA = diabetic ketoacidosis; DKA-PP = DKA-Power Plan; ICU = intensive care unit; IQR = interquartile range; IV = intravenous; IVF = IV fluid; LOS = length of stay; SC = subcutaneous.

Practical Recommendations for Transitioning Patients with Type 2 Diabetes from Hospital to Home.

PURPOSE OF REVIEW: The purpose of this review is to provide practical evidence-based recommendations for transitioning hospitalized patients with type 2 diabetes (T2DM) to home. RECENT FINDINGS: Hospitalized patients who have newly diagnosed or poorly controlled T2DM require initiation or intensification of their outpatient diabetes regimen. Potential barriers to medication access and continuity of care should be identified early in the hospitalization. Throughout hospitalization, patients should receive diabetes education focused on basic survival skills and tailored to learning needs. Patients should leave the hospital with personalized discharge instructions that include a list of all medications and follow-up appointments with both the outpatient diabetes provider and a diabetes educator whenever possible. An approach to transitioning patients with T2DM from hospital to home that focuses on optimizing the patient's discharge diabetes regimen, anticipating patients' needs during the immediate post-discharge period, providing survival skills education, and ensuring continuation of diabetes care and education following hospital discharge has the potential to improve glycemic control and reduce emergency department visits and hospital readmissions.

Blended Simulation Progress Testing for Assessment of Practice Readiness.

Objective. To design an assessment of practice readiness using blended-simulation progress testing. Design. A five-station, blended simulation assessment was developed to evaluate patient care outcomes in first- and third-year pharmacy (P1 and P3) students, as well as first-year postgraduate (PGY1) pharmacy residents. This assessment of practice readiness included knowledge and performance evaluations administered as a progress test. Assessment. Eighteen PGY1 residents, 108 P3 students, and 106 P1 students completed the assessment. P3 students scored significantly higher than P1 students across all evaluations. Third-year pharmacy students scored significantly lower than PGY1 residents in interprofessional communications and attitudes of ownership in a standardized colleague/mannequin model station, and in patient communication in a standardized patient station. Conclusion. Learners demonstrated evolving skills as they progressed through the curriculum. A blended simulation integrated progress test provides data for improvement of individual student clinical skills, informs curricular advancement, and aligns curricular content, process, and outcomes with accreditation standards.

Combination of a Flipped Classroom Format and a Virtual Patient Case to Enhance Active Learning in a Required Therapeutics Course.

Objective. To design and evaluate the integration of a virtual patient activity in a required therapeutics course already using a flipped-classroom teaching format. Design. A narrative-branched, dynamic virtual-patient case was designed to replace the static written cases that students worked through during the class, which was dedicated to teaching the complications of liver disease. Students completed pre- and posttests before and after completing the virtual patient case. Examination scores were compared to those in the previous year. Assessment. Students' posttest scores were higher compared to pretest scores (33% vs 50%). Overall median examination scores were higher compared to the historical control group (70% vs 80%), as well as scores on questions assessing higher-level learning (67% vs 83%). A majority of students (68%) felt the virtual patient helped them apply knowledge gained in the pre-class video lecture. Students preferred this strategy to usual in-class activities (33%) or indicated it was of equal value (37%). Conclusion. The combination of a pre-class video lecture with an in-class virtual patient case is an effective active-learning strategy.

The Nurse Education and Transition (NEAT) model: educating the hospitalized patient with diabetes.

BACKGROUND: The number of patients with a diabetes mellitus (DM)-related diagnosis is increasing, yet the number of hospital-based diabetes educators is being reduced. Interest in determining effective ways for staff nurses to deliver diabetes education (DE) is mounting. The purpose of this multi-phase feasibility study was to develop and evaluate the Nurse Education and Transition (NEAT) inpatient DM education model. METHODS: Exploratory focus groups were conducted with staff nurses from inpatient units at academic tertiary and community hospitals to gain insight into barriers, content, delivery and support mechanisms related to providing DE to hospitalized patients. Findings informed the development of the NEAT model, which included a delivery protocol and toolkit with brief educational videos on key diabetes topics uploaded onto iPads, patient assessments and "teach back" tools, a discharge survival skills summary sheet, and guidelines for electronic medical record documentation and scheduling outpatient DE visits. Trained staff nurses used NEAT to deliver DE to hospitalized patients with DM and then participated in follow-up focus groups to assess their experiences, with particular attention to the usefulness of NEAT in meeting the needs of nurses related to the delivery of diabetes survival skill education. Information generated was analyzed to identify emerging key themes. RESULTS: Exploratory focus groups revealed that staff nurses view teaching patients with DM as part of their job, but report barriers. Nurses agreed that inpatient DE should be designed to assure safety after discharge and advised that it be patient-centered, targeted, assessment-based and user friendly. Nurses who participated in the delivery of NEAT found that the process and tools met the majority of the basic DE needs of their patients while relieving their workload. In particular, they reported that video and iPad technology provided a convenient and standardized method for facilitating teaching at the bedside, but requested that an interactive feedback mechanism be added to encourage patient self-knowledge assessment. CONCLUSIONS: This study presents challenges staff nurses face in providing DE to hospitalized patients and identifies opportunities and strategies for improving content and delivery to ensure safe transition of patients with DM from hospital to outpatient setting.

SAFETY AND EFFICACY OF A PERI-OPERATIVE PROTOCOL FOR PATIENTS WITH DIABETES TREATED WITH CONTINUOUS SUBCUTANEOUS INSULIN INFUSION WHO ARE ADMITTED FOR SAME-DAY SURGERY.

OBJECTIVE: The number of people with diabetes using continuous subcutaneous insulin infusions (CSII) with an insulin pump has risen dramatically, creating new challenges when these patients are admitted to the hospital for surgical or other procedures. There is limited literature guiding CSII use during surgical procedures. METHODS: The study was carried out in a large, urban, tertiary care hospital. We enrolled 49 patients using insulin pump therapy presenting for 57 elective surgeries. We developed a CSII peri-operative glycemic management protocol (PGMP) to standardize insulin pump management in patients admitted to a same-day surgery unit (SDSU). The purpose was evaluate the safety (% capillary blood glucose (CBG) <70 mg/dL and/or pump incidents) and efficacy (first postoperative CBG ≤200 mg/dL) of the CSII PGMP. We determine the contribution of admission CBG, type of anesthesia, surgery length, and peri-operative steroid use on postoperative glycemic control. RESULTS: Overall, 63% of patients treated according to the CSII PGMP had a first postoperative CBG ≤200 mg/dL. There were no episodes of intra- or postoperative hypoglycemia. For patients treated with the CSII PGMP, the mean postoperative CBG was lower in patients with anticipated or actual surgical length ≤120 minutes (158.1 ± 53.9 vs. 216 ± 77.7 mg/dL, P<.01). No differences were observed with admission CBG, type of anesthesia, or steroid use. CONCLUSIONS: This study demonstrates that a CSII PGMP is both safe and effective for patients admitted for elective surgical procedures and provides an example of a standardized protocol for use in clinical practice.

Use of an iPad to Provide Warfarin Video Education to Hospitalized Patients.

OBJECTIVE: To evaluate the effectiveness of a warfarin educational video in the hospital setting and to determine patients' satisfaction with using an iPad to view a warfarin educational video. METHODS: This prospective quality improvement project included adult (≥18 years of age) patients on warfarin in the hospital. All patients completed pre-video and post-video knowledge tests on the iPad before and after viewing the educational video on warfarin therapy. Patients also completed a patient satisfaction survey. RESULTS: Forty hospitalized patients were educated using the warfarin video and included for analysis. The majority of patients were new to warfarin therapy (65%). Forty-three percent of patients passed the pre-video knowledge test, and 90% passed the post-video knowledge test (P < 0.001). No significant differences were observed among knowledge test scores when compared by age, sex, level of education, and use of central nervous system depressant medications. Most patients (82.5%) reported they liked using the iPad and found it easy to use. Patients who were younger (< 65 years) and female subjects reported they liked using the iPad more than older patients (P = 0.01) and male subjects (P = 0.02), respectively. Also, younger patients found the iPad easier to use compared with patients who were older (P = 0.01). CONCLUSION: Educating hospitalized patients about warfarin by using a video on an iPad was effective. Video education on an iPad may be an alternative to traditional education in the hospital setting.

Pilot trial of diabetes self-management education in the hospital setting.

AIMS: Diabetes self-management education (DSME) is recommended for all patients with diabetes. Current estimates indicate that <50% of patients receive DSME, increasing risk for hospitalization which occurs more frequently with diabetes. Hospitalization presents opportunities to provide DSME, potentially decreasing readmissions. To address this, we investigated the feasibility of providing DSME to inpatients with diabetes. METHODS: Patients hospitalized on four medicine units were randomized to receive DSME (Education Group) (n=9) prescribed by a certified diabetes educator and delivered by a registered nurse, or Usual Care (n=12). Participants completed Diabetes Knowledge Tests (DKT), Medical Outcomes Short Form (SF-36), Diabetes Treatment Satisfaction Questionnaire (DTSQ), and the DTSQ-inpatient (DTSQ-IP). Bedside capillary blood glucoses (CBG) on day of admission, randomization and discharge were compared. RESULTS: There were no group differences in demographics, diabetes treatment, admission CBG (186±93 mg/dL vs. 219±84 mg/dL, p=0.40), DKT scores (Education vs. Usual Care 48±25 vs. 68±19, p=0.09), SF-36, and DTSQ scores (28±6 vs. 25±7, p=0.41). Patients receiving education reported more satisfaction with inpatient treatment (83±13 vs. 65±19, p=0.03), less hyperglycemia prior to (2.7±4.5 vs. 4.5±1.4, p=0.03) and during hospitalization (3.9±1.9 vs. 5.5±1.2, p=0.04); and had lower mean discharge CBG (159±38 mg/dL vs. 211±67 mg/dL, p=0.02). CONCLUSIONS: Inpatient diabetes education has potential to improve treatment satisfaction, and reduce CBG.

Glycemic management in medical and surgical patients in the non-ICU setting.

Hyperglycemia is commonly observed in hospitalized patients with and without previously known diabetes and is associated with adverse outcomes. For this reason, measurement of blood glucose (BG) is recommended for all patients at admission. Measurement of an A1C identifies patients with either newly recognized diabetes or uncontrolled diabetes. Current guidelines advise fasting and premeal BG <140 mg/dl, with maximal random BG <180 mg/dl for the majority of noncritically ill patients. Rational use of basal bolus insulin (BBI) regimens is effective in achieving these glycemic goals, with low risk for hypoglycemia. The safety of BBI relies upon provider knowledge for initiation and adjustment of insulin doses for changes in nutritional status or use of medications affecting glucose metabolism. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin, as well as education in basic skills for home management.

Comparison of insulin infusion protocols targeting 110-140 mg/dL in patients after cardiac surgery.

BACKGROUND: Continuous intravenous insulin infusion (CII) following coronary artery bypass graft (CABG) surgery reduces postoperative complications and hospitalization duration. Because of limited data evaluating outcomes of CII with revised glycemic targets (110-140 mg/dL) in cardiac surgery, this study compared efficacy and safety of two different CII protocols having revised targets. SUBJECTS AND METHODS: This is a retrospective study comparing two different protocols between August 2009 and March 2010. Protocol 1 consists of four algorithms, and Protocol 2 is a table to adjust CII. Blood glucose (BG) and CII rates were recorded for 48 h postoperatively or CII discontinuation. Efficacy was defined by the percentage of BG values in the target range, and safety was defined by the percentage of BG values<40 and 40-69 mg/dL. RESULTS: Protocol 1 (n=117) patients were older (65 vs. 61 years; P=0.006) and had more CABG and fewer valve procedures compared with Protocol 2 (n=130). There were no differences in baseline BG level (149±40.6 vs. 151±38.1 mg/dL), body mass index (30±6.3 vs. 30±6.4 kg/m(2)), hematocrit (28% vs. 28%), percentage of diabetes patients (32% vs. 31%), percentage of patients with glomerular filtration rate of <30 mL/min (5% vs. 6%), CII duration (42 [9-48] vs. 40 [14-48] h), total insulin units received (99 [15-376] vs. 114 [12-457]), hourly insulin rate (median of average rate [range], 2.59 [0-21) vs. 2.96 [0-25] units/h), percentage of BG values 110-140 mg/dL, <40 mg/dL, 40-69 mg/dL, and >180 mg/dL, and BG coefficient of variation (21±6.5 vs. 21±6.1). Shorter time to goal (3.32 [0.22-19.35] vs. 5.03 [0.92-19.80] h; P=0.018) and lower mean BG level (127±12.2 vs. 133±12.1 mg/dL; P<0.001) were noted with Protocol 1. DISCUSSION: CII protocols targeting 110-140 mg/dL were effective in achieving revised targets with low hypoglycemia. Despite differences in mean BG level and time to target, each hospital continued using its existing protocols and identified areas for improvement.

Hypoglycemia in hospitalized patients treated with sulfonylureas.

STUDY OBJECTIVE: To identify the incidence of and risk factors associated with hypoglycemia in hospitalized patients taking sulfonylureas. DESIGN: Nested case-control study. SETTING: Tertiary care academic medical center. PATIENTS: Adults who received a sulfonylurea during hospitalization between November 1, 2008, and October 31, 2009. Case patients were those who experienced at least one episode of hypoglycemia, defined as a blood glucose level less than 70 mg/dl; potential control patients were those who did not experience hypoglycemia. One hundred seventeen cases were matched in a 1:1 ratio with controls based on sex and the number of days treated with a sulfonylurea in the hospital. For case patients, the index date was defined as the date of first blood glucose level less than 70 mg/dl. The number of days that the patient was taking the sulfonylurea before the index date was determined, and this same number was used to define the index date for the matched controls. MEASUREMENTS AND MAIN RESULTS: Overall, 19% of patients who received a sulfonylurea experienced at least one episode of hypoglycemia: 22% receiving glyburide, 19% receiving glimepiride, and 16% receiving glipizide. Variables included in the multivariate regression were age 65 years or older, glomerular filtration rate (GFR)≤ 30 ml/min/1.73 m(2) , and treatment with glipizide, glyburide, or concurrent intermediate- or long-acting insulin. Age 65 years or older (odds ratio [OR] 3.07, p < 0.001), intermediate- or long-acting insulin (OR 3.01, p=0.002), and GFR of 30 ml/minute/1.73 m(2) or lower (OR 3.64, p=0.006) were predictors of hypoglycemia. Cases were less likely than controls to receive glipizide (OR 0.44, p=0.005). CONCLUSION: Hospitalized patients at increased risk for sulfonylurea-related hypoglycemia were those aged 65 years or older, those with a GFR of 30 ml/minute/1.73 m(2) or lower, and those who received concurrent intermediate- or long-acting insulin during inpatient sulfonylurea therapy. Sulfonylureas should be avoided or used with caution in these patients.

Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: a randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of an Inpatient Diabetes Management Program (IDMP) on physician knowledge and inpatient glycemic control. METHODS: Residents assigned to General Internal Medicine inpatient services were randomized to receive the IDMP (IDMP group) or usual education only (non-IDMP group). Both groups received an overview of inpatient diabetes management in conjunction with reminders of existing order sets on the hospital Web site. The IDMP group received print copies of the program and access to an electronic version for a personal digital assistant (PDA). A Diabetes Knowledge Test (DKT) was administered at baseline and at the end of the 1-month rotation. The frequency of hyperglycemia among patients under surveillance by each group was compared by using capillary blood glucose values and a dispersion index of glycemic variability. IDMP users completed a questionnaire related to the program. RESULTS: Twenty-two residents participated (11 in the IDMP group and 11 in the non-IDMP group). Overall Diabetes Knowledge Test scores improved in both groups (IDMP: 69% ± 1.7% versus 83% ± 2.1%, P = .003; non-IDMP: 76% ± 1.2% versus 84% ± 1.4%, P = .02). The percentage of correct responses for management of corticosteroid-associated hyperglycemia (P = .004) and preoperative glycemic management (P = .006) improved in only the IDMP group. The frequency of hyperglycemia (blood glucose level >180 mg/dL) and the dispersion index (5.3 ± 7.6 versus 3.7 ± 5.6; P = .2) were similar between the 2 groups. CONCLUSION: An IDMP was effective at improving physician knowledge for managing hyperglycemia in hospitalized patients treated with corticosteroids or in preparation for surgical procedures. Educational programs directed at improving overall health care provider knowledge for inpatient glycemic management may be beneficial; however, improvements in knowledge do not necessarily result in improved glycemic outcomes.

U-500 insulin as a component of basal bolus insulin therapy in type 2 diabetes.

BACKGROUND: Changes in hemoglobin A1c (A1C), weight, and total daily insulin dose (TDD) were investigated following initiation of insulin U-500 (U500) alone or as part of a basal/bolus insulin (BBI) regimen. SUBJECTS AND METHODS: Records of patients with type 2 diabetes who were prescribed U500 were retrospectively reviewed. Logistic regression analysis was used to investigate relationships between changes in A1C and use of U500 alone or as BBI. RESULTS: Twelve patients were identified as using U500 alone (n=2) or in combination with long-acting (LAI) (n=7) or rapid-acting (RAI) (n=3) insulin. Reductions in A1C (9.5% at baseline vs. 7.7% at 6-9 months, P<0.0001) and increases in weight (128.8±32.7 vs. 131.5±31.3 kg, P<0.014) and TDD (260±111 to 333±106 units/day, P<0.0002) were observed. Concurrent use of LAI or RAI with U500 did not predict improvements in A1C. CONCLUSIONS: U500 resulted in improvements in A1C and weight gain and increased TDD when used alone or as part of combination insulin therapy. Further investigations to define the optimal use of U500 are recommended.