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 Jan;4(1):3-15. doi: 10.1002/jhm.391.


Background: Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported.

Objective: Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control.

Design: Prospective observational.

Setting: 400-bed academic center.

Patients: Adult non-critical care inpatients with diabetes or hyperglycemia and point-of-care (POC) glucose testing.

Interventions: Structured insulin orders, insulin management algorithm.

Measurements: Percent of insulin orders with basal insulin. Percent uncontrolled patient-stays (day-weighted mean glucose >or=180 mg/dL) and uncontrolled patient-days (patient-day mean glucose >or=180 mg/dL). Percent of monitored patient-days and patient-stays with hypoglycemia (glucose <or=60 mg/dL) and severe hypoglycemia (glucose <or=40 mg/dL).

Results: The percent sliding scale only insulin regimens decreased (72% versus 26% with structured insulin orders, P < 0.0001 chi square). The percent of uncontrolled patient-days was 37.8% versus 33.9% versus 30.1% (P < 0.005) (TP1-Baseline; TP2-Structured insulin orders; TP3-Orders plus Algorithm). Expressed as relative risk with 95% confidence interval (RR with CI), the RR of an uncontrolled patient-stay was reduced from baseline to 0.91 (CI 0.85-0.96) in TP2, and to 0.84 (CI 0.77-0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 POC values. The percent of patient-days with hypoglycemia was 3.8%, 2.9%, and 2.6% in 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59-0.78). Similar reductions were seen in risk for hypoglycemic patient-stays.

Conclusions: Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms.

Publication types

  • Comparative Study

MeSH terms

  • Algorithms*
  • Blood Glucose / metabolism
  • Disease Management
  • Drug Administration Schedule
  • Glycemic Index / drug effects*
  • Glycemic Index / physiology
  • Hospitalization*
  • Humans
  • Hypoglycemia / blood
  • Hypoglycemia / drug therapy*
  • Injections, Subcutaneous
  • Insulin / administration & dosage
  • Insulin / analogs & derivatives*
  • Insulin, Long-Acting
  • Prospective Studies


  • Blood Glucose
  • Insulin
  • Insulin, Long-Acting