Sliding scale insulin for non-critically ill hospitalised adults with diabetes mellitus

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

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“…Optimizing for patients with unstable diabetes could target (i) wound healing; (ii) SSI; and (iii) re-admission rate [60][61][62][63].…”

Section: Description Of Effectmentioning

confidence: 99%

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Gallo

Nieslanikova

2020

JCM

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“… 2–4 A Cochrane study suggests that the evidence in favor of either SSI or basal-bolus therapy is equivocal. 40 Sliding scale monotherapy was inferior to basal-bolus insulin in controlling glycemia and was associated with worse clinical outcomes among surgical patients with hyperglycemia. 37 Using SSI alone is strongly discouraged for patients with type 2 diabetes or those with stress hyperglycemia given association with increased risk of hospital complications.…”

Section: Discussionmentioning

confidence: 98%

Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes

Pichardo-Lowden

Umpiérrez

Lehman

et al. 2021

BMJ Open Diab Res Care

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IntroductionInnovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations.Research design and methodsThe tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9–4.4 mmol/L (70–80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods.ResultsWhen active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized.ConclusionEMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.

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“…Outside the 2 small, randomized, controlled RABBIT 2 trials, the advantages of BB have not been clearly established in noncritically ill patients with respect to glycemic control and patient outcomes. In a systematic review, Colunga-Lozano and colleagues included 8 randomized, controlled trials of 1048 individuals with type 2 diabetes in noncritically ill medical and surgical adults [ 31 ]. They found increased severe hypoglycemia (defined as blood glucose < 40 mg/dL) in the BB group at a rate of 24 per 1000 people compared to 5 per 1000 people in the SS group.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of “Real-World” Insulin Strategies in the Management of Hospital Hyperglycemia

Sadhu

Patham

Vadhariya

et al. 2021

Journal of the Endocrine Society

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Context Guidelines recommend scheduled long acting basal and short acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world”, insulin therapy is complicated, with limited data on comparative effectiveness of different insulin strategies. Objective Evaluate the association of different insulin strategies with glucose control and hospital outcomes, after adjustment for patient and physician factors that influence choice of therapy. Design Retrospective, observational. Setting Academic hospital. Patients Non-critically ill hospitalized medical/surgical patients (n=4,558) receiving subcutaneous insulin ≥75% of the admission. Interventions Insulin therapy was grouped into 3 strategies within the first 48 hours: basal-bolus (BB: scheduled long and short/rapid n=2,358), sliding scale (SS: short/rapid acting n=1,855), or basal only (BO: long only: n=345). Main Outcome Measure(s) Glucose control: hypo-, hyper-, euglycemic days, mean glucose. Hospitalization: mortality, length of stay (LOS), readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40 (CI:2.04,2.82) (P< 0.001)) and fewer euglycemic days (0.90 (CI:0.85,0.97) (P=0.003)) than SS, whereas BO was associated with fewer hyperglycemic days ((0.70 (0.62,0.79) (P<0.001)), lower mean glucose (-18.03 (CI:-22.46, -12.61) (P< 0.001)) and more euglycemic days (1.22 (CI:1.09,1.37), (P< 0.001)) compared to SS. No difference in mortality, LOS and readmissions was found. However, decreased LOS was observed in the subgroup with a medical DRG (0.93 (CI:0.89,0.97) (P<0.001)). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

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Sliding scale insulin for non-critically ill hospitalised adults with diabetes mellitus

Cited by 32 publications

References 77 publications

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes

Outcomes of “Real-World” Insulin Strategies in the Management of Hospital Hyperglycemia

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