Implementation of a protocol for postpartum diabetes medication management: effect on inpatient efficiency and...

Pregnancy is a state of insulin resistance. After delivery, insulin sensitivity rapidly increases, and total insulin requirements decline dramatically. This leaves obstetric clinicians with the difficult task of insulin dose reduction immediately following delivery. If postpartum insulin doses are not reduced sufficiently postpartum, then patients are at high-risk of hypoglycemia. These complex medical decisions can lead to delays in postpartum transfers. From February 2023 to February 2024, our institution observed increasing rates of delayed postpartum transfers and hypoglycemic events in postpartum patients due to overaggressive insulin regimens. In response to these observations, a postpartum medication protocol was designed to aid clinicians in the creation of postpartum insulin plans for patients with diabetes.

The objective of this study was to evaluate whether a postpartum medication protocol improved efficiency in postpartum patient transfers, inpatient glycemic control, and outpatient follow up rates for patients with diabetes.

This was a 2-cohort pre postintervention study with time series analysis at a tertiary-care academic hospital. The study included all delivering patients with pre-existing diabetes separated into 2 cohorts: pre- (February 2023-February 2024) and post- (April 2024-April 2025) protocol implementation. The primary outcome was delayed postpartum transfer, defined as postpartum transfer time exceeding one SD above the mean postpartum transfer time for our unit (postdelivery time on Labor and Delivery > 3.66 hours). To account for possible temporal variation within our data, an interrupted time series analysis was performed. Outcomes were compared between cohorts using bivariate analyses and logistic regression. Multivariable logistic regression with a backward stepwise selection was used to adjust for confounding variables.

There were 124 patients in each cohort, with 31% of patients in each cohort having type 1 diabetes. The time series analysis demonstrated an immediate decrease in the number of delayed postpartum transfers following protocol implementation (p-value .04). The postprotocol implementation cohort had decreased odds of delayed postpartum transfer compared to the preprotocol implementation cohort after adjusting for automatic insulin delivery (AID) system use (OR: 0.65 [0.37-1.13], aOR: 0.50 [0.27-0.93]).

Through this protocol implementation, we were able to improve efficiency of patient care delivery and improve patient outcomes in the postpartum period. This protocol serves as a model for other practices to potentially adopt or adapt to improve inpatient efficiency and to better serve their patients with diabetes.