Overcoming clinical inertia in the management of postoperative patients with diabetes

Objective: To assess the impact of an intervention designed to increase basal-bolus insulin therapy administration in postoperative patients with diabetes mellitus.Methods: Educational sessions and direct support for surgical services were provided by a nurse practitioner (NP). Outcome data from the intervention were compared to data from a historical (control) period. Changes in basal-bolus insulin use were assessed according to hyperglycemia severity as defined by the percentage of glucose measurements >180 mg/dL.Results: Patient characteristics were comparable for the control and intervention periods (all P≥.15). Overall, administration of basal-bolus insulin occurred in 9% (8/93) of control and in 32% (94/293) of intervention cases (P<.01). During the control period, administration of basal-bolus insulin did not increase with more frequent hyperglycemia (P = .22). During the intervention period, administration increased from 8% (8/96) in patients with the fewest number of hyperglycemic measurements to 60% (57/95) in those with the highest frequency of hyperglycemia (P<.01). The mean glucose level was lower during the intervention period compared to the control period (149 mg/dL vs. 163 mg/dL, P<.01). The proportion of glucose values >180 mg/dL was lower during the intervention period than in the control period (21% vs. 31% of measurements, respectively, P<.01), whereas the hypoglycemia (glucose >70 mg/dL) frequencies were comparable (P = .21).Conclusion: An intervention to overcome clinical inertia in the management of postoperative patients with diabetes led to greater utilization of basal-bolus insulin therapy and improved glucose control without increasing hypoglycemia. These efforts are ongoing to ensure the delivery of effective inpatient diabetes care by all surgical services.