Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial

J Hosp Med. 2009 Jan;4(1):16-27. doi: 10.1002/jhm.385.


Background: Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non-intensive care unit (ICU) setting.

Objective: To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia.

Design: Before-after trial.

Setting: Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists.

Patients: Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia.

Intervention: A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case-based educational workshops and lectures to nurses, physicians, and PAs.

Measurements: Mean percent of glucose readings per patient between 60 and 180 mg/dL; percent patient-days with hypoglycemia; insulin use patterns; and hospital length of stay.

Results: The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%-18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% CI, 0.6-2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% CI, 2.0-9.9) and adjusted length of stay decreased by 25% (95% CI, 9%-44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3.

Conclusions: This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin ordering practices and glycemic control among non-ICU medical patients.

Publication types

  • Clinical Trial
  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / drug therapy
  • Disease Management
  • Drug Therapy, Computer-Assisted / methods
  • Drug Therapy, Computer-Assisted / standards*
  • Female
  • Hospitalization*
  • Humans
  • Hyperglycemia / blood
  • Hyperglycemia / drug therapy*
  • Injections, Subcutaneous
  • Insulin / administration & dosage*
  • Male
  • Middle Aged
  • Patient Education as Topic / methods
  • Patient Education as Topic / standards*
  • Pilot Projects
  • Prospective Studies
  • Treatment Outcome


  • Insulin