Individualization through standardization: electronic orders for subcutaneous insulin in the hospital

The objective was to design electronic order sets that would promote safe, effective, and individualized order entry for subcutaneous insulin in the hospital, based on a review of best practices.

Saint Francis Hospital in Evanston, Illinois, a community teaching hospital, was selected as the pilot site for 6 hospitals in the Health Care System to introduce an electronic medical record. Articles dealing with management of hospital hyperglycemia, medical order entry systems, and patient safety were reviewed selectively.

In the published literature on institutional glycemic management programs and insulin order sets, features were identified that improve safety and effectiveness of subcutaneous insulin therapy. Subcutaneous electronic insulin order sets were created, designated in short: "patients eating", "patients not eating", and "patients receiving overnight enteral feedings." Together with an option for free text entry, menus of administration instructions were designed within each order set that were applicable to specific insulin orders and expressed in standardized language, such as "hold if tube feeds stop" or "do not withhold."

Two design features are advocated for electronic order sets for subcutaneous insulin that will both standardize care and protect individualization. First, within the order sets, the glycemic management plan should be matched to the carbohydrate exposure of the patients, with juxtaposition of appropriate orders for both glucose monitoring and insulin. Second, in order to convey precautions of insulin use to pharmacy and nursing staff, the prescriber must be able to attach administration instructions to specific insulin orders.