Implementation of a Multihospital Electronic Medical Record-Based Insulin Order Set to Reduce Hypoglycemic Events

Glycemic control in hospitalized patients with diabetes is crucial yet remains challenging. Hypoglycemia poses an increased risk of complications, prolonged stays, and mortality. Strategies such as basal-bolus-correction insulin can help balance glycemic control and reduce hypoglycemic events. This study evaluated the impact of a mandatory electronic medical record-based insulin order set across a multihospital system.

This quality improvement project was implemented at 10 hospitals in North Carolina, including urban, rural, and community sites. The intervention introduced a standardized insulin order set with multiple fail-safes addressing insulin-to-nutrition mismatch, basal and bolus coverage, and dose accuracy. The primary outcome was hypoglycemia days per 1000 patient-days in nonpregnant adults. Secondary outcomes included hyperglycemia days and the rate of hemoglobin A1c orders.

Hypoglycemia days across all sites decreased from 13 to 10 per 1000 patient-days (24% reduction, P < .01), with 9 sites showing declines (7%-39%) and 1 site showing an increase. Hyperglycemia days decreased from 90 to 76 per 1000 patient-days (16% reduction, P < .01). Hemoglobin A1c ordering improved from 60% to 67% (12% increase, P < .01). The implementation of a system-wide electronic medical record-based insulin order set reduced hypoglycemia rates across 9 of 10 hospitals without adversely affecting hyperglycemia. The standardized protocol contributed to these improvements. Site-specific variations in outcomes suggest the need for tailored interventions in certain locations.

Implementation of a mandatory, standardized insulin order set with multiple fail-safes across a multihospital system effectively reduced hypoglycemic events, thus demonstrating their value in managing inpatient diabetes.