Prevention of Hospital Hypoglycemia by Algorithm Design: A Programming Pathway for Electronic Order Entry

Abstract

Caregivers treating hospitalized patients are confronted with the necessity both to control hyperglycemia and also to avoid iatrogenic hypoglycemia. Despite controversy about optimal glycemic targets, a large body of evidence associates uncontrolled hyperglycemia with adverse outcomes, both in the intensive care unit and also on general hospital wards (American Diabetes Association, 2011; Moghissi et al., 2009). On general wards, glycemic control during use of scheduled subcutaneous insulin is superior to that seen during use of sliding scale regimens (Baldwin et al., 2005; Umpierrez et al., 2007). When scheduled insulin was compared to sliding scale treatment among general surgical patients, glycemic control was improved (mean blood glucose 145 ± 32 mg/dL vs. 172 ± 47 mg/dL, p < 0.01), and a composite outcome of complications was reduced from 24.3 to 8.6%with odds ratio 3.39 (95% CI 1.50-7.65), p = 0.003 (Umpierrez et al., 2011). Nevertheless, the problem of hypoglycemia is a barrier to successful control of hospital hyperglycemia. Among 1718 adult patients admitted at academic medical centers and having hyperglycemia or receiving insulin therapy, hypoglycemia occurred on 2.8% of all hospital days (Boord et al., 2009). Predisposing factors and adverse outcomes associated with hypoglycemia have been examined in observational studies and in clinical trials studying the effect of glycemic control upon nonglycemic outcomes (Bagshaw et al., 2009; Fischer et al., 1986; Finfer et al., 2009; Kagansky et al., 2003; Krinsley et al., 2007; Maynard et al., 2008; Smith et al., 2005; Stagnaro-Green et al., 1995; Turchin et al., 2009; Van den Berghe et al., 2006; Varghese et al., 2007; Vriesendorp et al., 2006; Wexler et al., 2007). Mortality of patients having myocardial infarction is higher at the lowest as well as the highest ranges glucose, such that the relationship between mortality and glucose is described by a J-shaped curve (Kosiborod et al., 2008). Outcomes of hospitalized patients that have been linked to hypoglycemia include increased ICU mortality or hospital mortality rates, adverse events such as seizures, and increased length of stay. In the intensive care unit and on general wards, associated factors