Safe and Effective Use of Insulin

During a hospital stay, the problem is two-fold; hospitalized patients with diabetes who are taking insulin may be unable to manage their glucose readings and insulin administration, and health care providers may not be available or have the right training to help these patients.

Glycemic control is not only fundamental to the management of diabetes, but is also essential to help prevent hyper- or hypoglycemic events induced by critical illness, stress, and medical treatment. Hypoglycemic events can result in a patient suffering symptoms ranging from moderate confusion to severe convulsions, coma and death. Untreated hyperglycemia can also result in ketoacidosis and other serious adverse clinical outcomes as well as a prolonged hospital stay. Strong glycemic control also has a financial benefit: The Centers for Medicare & Medicaid Services includes poor glycemic management on its 2013 list of 15 hospital-acquired conditions and will no longer reimburse hospitals for additional costs associated with these preventable events.

The safe use of insulin to achieve optimal blood glucose has been directly associated with improved patient outcomes. The occurrence of these preventable adverse drug reactions and events can be reduced, and insulin can be used safely to achieve optimal glycemic control for hospitalized patients.

The Joint Commission Center for Transforming Healthcare uses Robust Process Improvement^® (RPI^®) methods and tools to identify causes and develop solutions to reduce incidences of poor glycemic control. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates tools and concepts from Lean Six Sigma and change management methodologies. Using RPI, the project teams developed solutions to reduce incidences of poor glycemic control.

The hospitals and health centers participating in this project worked with the Center to identify the root causes that led to poor glycemic control related to insulin administration and other factors. The participating organizations found solutions that were unique to their organization’s specific causes. These solutions were tested and validated, and then spread to other organizations.

Project Team 
Morristown Medical Center (Atlantic Health System), New Jersey 
New York-Presbyterian Hospital, New York 
Sharp HealthCare, California 
Texas Health Resources, Texas 
VA Connecticut Healthcare System, Connecticut

Pilot Team
Rush Copley Medical Center, Illinois
JPS Health Network, Texas
Kaiser Permanente Vallejo Medical Center, California
Kaiser Permanente San Diego Medical Center, California

The Safe and Effective Use of Insulin project focused on the administration of insulin to adult inpatients with active insulin orders to ensure they maintained glycemic control.  The project team defined control as having a blood glucose level between 70 mg d/L and 180 mg d/L.  The group also established secondary metrics focused on reducing the number of extreme hyperglycemia (>300 mg d/L) test results and maintaining or reducing the number of hypoglycemic (<70 mg d/L) test results.

The hospitals in this phase saw:

• A reduction in their aggregate out of control results from 34.94% to 31.46%, a relative reduction of 9.76%.
• A reduction in their extreme hyperglycemia test results from 6.89% to 4.84%, a relative reduction of 29.75%.
• A reduction in their hypoglycemia test rests from 1.52% to 1.38%, a 9.18% relative reduction.

These teams achieved these results by focusing on a wide range of issues including standardizing insulin orders, establishing target glucose control ranges for patients, staff education, coordinating glucose testing with insulin administration and meal delivery, and developing and deploying standard order sets for patients receiving insulin and steroids.

After these solutions are tested and validated, the Center will share the project results and solutions with other health care organizations.

The following additional resources are available for the Safe and Effective Use of Insulin project:

• Safe and Effective Use of Insulin Fact Sheet