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Eliminating Inpatient Sliding-Scale Insulin

A reeducation project with medical house staff

Rush University Medical Center, Chicago, Illinois

Address correspondence and reprint requests to David Baldwin, MD, Section of Endocrinology, Rush University Medical Center, 1725 W. Harrison St., Suite 250, Chicago, IL 60612. E-mail: david_baldwin{at}rush.edu

OBJECTIVE—We studied a systematic program to reeducate our medical house officers on how to manage inpatient hyperglycemia without the use of sliding-scale insulin (SSI).

RESEARCH DESIGN AND METHODS—Patients admitted to the general medical service with diabetes or a blood glucose >140 mg/dl were included. HbA_1c was measured in all patients, and therapy was modified if the HbA_1c was >7.0%. For each 24 h on call, two house officers were responsible for all glucose management for their team’s patients and rounded with a teaching endocrinologist twice daily for 2 weeks. Oral agent or insulin therapy was modified using blood glucoses and HbA_1c. All patients who required insulin therapy were treated with basal and bolus insulin, usually NPH and regular, adjusted twice daily.

RESULTS—During 8 weeks, 88 patients were identified and 16 house officers were instructed. The mean duration of diabetes was 10.4 years. Mean HbA_1c level was 8.7%, and 48% of patients had HbA_1c >8%. All patients with HbA_1c >7% had diabetes therapy intensified. Overall 80% had their diabetes therapy changed by discharge. Compared with 98 historical control subjects, significantly fewer study patients had episodes of hyperglycemia, and a subgroup followed for 12 months showed a decrease in HbA_1c from 10.1 to 8%.

CONCLUSIONS—Medical history, blood glucose, and HbA_1c testing can effectively identify patients with inpatient hyperglycemia. Using direct ward-based teaching and a widely disseminated pocket set of guidelines, house officers can be taught to effectively and safely manage inpatient hyperglycemia without the use of SSI.

Abbreviations: SSI, sliding-scale insulin

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