Current Diabetes Reports

, 19:110 | Cite as

Timing of Insulin with Meals in the Hospital: a Systems Improvement Approach

  • Kathleen DunganEmail author
Health Care Delivery Systems and Implementation in Diabetes (ME McDonnell and AR Sadhu, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Health Care Delivery Systems and Implementation in Diabetes


Purpose of Review

Coordination of glucose monitoring, mealtimes, and insulin delivery in the hospital is complex, involving interactions between multiple key agents and overlapping workflows. The purpose of this review is to evaluate the scope of the problem as well as to assess evidence for interventions.

Recent Findings

In recent years, there has been an emphasis on systems-based approaches which address multiple contributing components of the problem at once in an effort to more seamlessly integrate workflows. Technological advances, such as decision support systems and advances in automated insulin delivery, and strategies that minimize the need for complex insulin regimens hold promise for future study.


Evaluation of the coordination of insulin delivery is limited by a lack of standardized metrics and systematically collected mealtimes. Nevertheless, successful efforts include system-wide multicomponent interventions, though advances in therapeutic approaches may be of value.


Hospital Diabetes Hyperglycemia Inpatient Meals Prandial insulin 


Compliance with Ethical Standards

Conflict of Interest

Kathleen Dungan reports research support from Eli Lilly, Sanofi Aventis, and Novo Nordisk; consulting activities with Eli Lilly, Mannkind; and royalties from UptoDate, DKBmed, and Elsevier.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011;17:853–61. Scholar
  2. 2.
    Fraze TK, Jiang HJ, Burgess J. Hospital stays for patients with diabetes, 2008. HCUP statistical brief #93. Rockville: Agency for Healthcare Research and Quality; 2010. Google Scholar
  3. 3.
    van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67. Scholar
  4. 4.
    Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34:256–61. Scholar
  5. 5.
    Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–82. Scholar
  6. 6.
    Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38. Scholar
  7. 7.
    Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists; American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32:1119–31. Scholar
  8. 8.
    American Diabetes Association. Standards of medical care in diabetes 2019. Diabetes Care. 2019;42:S173–81. Scholar
  9. 9.
    Wexler DJ, Meigs JB, Cagliero E, Nathan DM, Grant RW. Prevalence of hyper- and hypoglycemia among inpatients with diabetes. Diabetes Care. 2007;30:367–9. Scholar
  10. 10.
    Carey M, Boucai L, Zonszein J. Impact of hypoglycemia in hospitalized patients. Curr Diab Rep. 2013;13:107–13. Scholar
  11. 11.
  12. 12.
  13. 13.
    Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf. 2010;36:12–21.CrossRefGoogle Scholar
  14. 14.
    • Institute for Safe Medication Practices (ISMP). ISMP guidelines for optimizing safe subcutaneous insulin use in adults; 2017. Site accessed 5/26/2019. This publication identifies and defines insulin errors (including inadequate management strategies) and provides high-level systems-based strategies to address .
  15. 15.
    Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, et al. Enhancing insulin-use safety in hospitals: practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm. 2013;70:1404–13. Scholar
  16. 16.
  17. 17.
  18. 18.
    Jovanovic L, Giammattei J, Acquistapace M, Bornstein K, Sommermann E, Pettitt DJ. Efficacy comparison between preprandial and postprandial insulin aspart administration with dose adjustment for unpredictable meal size. Clin Ther. 2004;26:1492–7. Scholar
  19. 19.
    Ratner R, Wynne A, Nakhle S, Brusco O, Vlajnic A, Rendell M. Influence of preprandial vs. postprandial insulin glulisine on weight and glycaemic control in patients initiating basal-bolus regimen for type 2 diabetes: a multicenter, randomized, parallel, open-label study (NCT00135096). Diabetes Obes Metab. 2011;13:1142–8. Scholar
  20. 20.
    Schernthaner G, Wein W, Sandholzer K, Equiluz-Bruck S, Bates PC, Birkett MA. Postprandial insulin lispro: a new therapeutic option for type 1 diabetic patients. Diabetes Care. 1998;21:570–3. Scholar
  21. 21.
    Freeland B, Penprase BB, Anthony M. Nursing practice patterns: timing of insulin administration and glucose monitoring in the hospital. Diabetes Educ. 2011;37:357–62. Scholar
  22. 22.
    Lampe J, Penoyer DA, Hadesty S, Bean A, Chamberlain L. Timing is everything: results to an observational study of mealtime insulin practices. Clin Nurse Spec. 2014;28:161–7. Scholar
  23. 23.
    • Alwan D, Chipps E, Yen P, Dungan D. Evaluation of the timing and coordination of prandial insulin administration in the hospital. Diabetes Res and Clin Pract. 2017;131:18–32. This is the largest study (retrospective observational design) to date to characterize the timing of insulin relative to glucose monitoring and impact on glucose control. The study also assessed nursing perceptions. CrossRefGoogle Scholar
  24. 24.
  25. 25.
    • Bain A, Hasan SS, Babar ZU. Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review. Diabetes Med. 2019. This was a systematic review that assessed interventions which address insulin prescribing errors . CrossRefGoogle Scholar
  26. 26.
    McKibbon KA, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O'Reilly D, et al. The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. J Am Med Inform Assoc. 2012;19:22–30. Scholar
  27. 27.
    Kamarudin G, Penm J, Chaar B, Moles R. Educational interventions to improve prescribing competency: a systematic review. BMJ Open. 2013;3:e003291. Scholar
  28. 28.
    Houck PM, Tirumalasetty NN, Meadows RY. Insulin administration and meal delivery coordination for hospitalized patients. Ochsner J. 2013;13:327–33.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Wright K. Student nurses need more than math to improve their drug calculating skills. Nurse Educ Today. 2007;27:278–85. Scholar
  30. 30.
    • Engle M, Ferguson A, Fields W. A journey to improved inpatient glycemic control by redesigning meal delivery and insulin administration. Clin Nurse Spec. 2016;30:117–24. This retrospective study described a single institution’s approach to improve the timing of insulin delivery in the hospital via a nurse centric intervention. CrossRefPubMedGoogle Scholar
  31. 31.
    Pham JT, Schreiber P. Improving hyperglycemia management in the inpatient orthopaedic population with a special focus on mealtime insulin administration. University of California San Francisco School of Nursing. Accessed 5/26/2019.
  32. 32.
    Donihi AC, Abriola C, Hall R, Korytkowski MT. Getting the timing right in the hospital: synching insulin administration with meal tray arrival. American Diabetes Association 70th Scientific Sessions 2010. Abstract #1028P Accessed 5/26/2019.
  33. 33.
    Yamamoto J, Abraham D, Malatestinic B. Improving insulin distribution and administration safety using Lean Six Sigma Methodologies. Hosp Pharm. 2010;45:212–24.CrossRefGoogle Scholar
  34. 34.
    Yamamoto J, Abraham D, Malatestinic B. Facilitating process changes in meal delivery and radiological testing to improve inpatient insulin timing using Six Sigma method. Q Manage Health Care. 2010;19:189–200. Scholar
  35. 35.
    Nirantharakumar K, Chen YF, Marshall T, Webber J, Coleman JJ. Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: systematic review. Diabet Med. 2012;29:698–708. Scholar
  36. 36.
    • Donsa K, Beck P, Höll B, Mader JK, Schaupp L, Plank J, et al. Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. Int J Med Inform. 2016;90:58–67. This was a post hoc analysis of a randomized study of a computerized insulin management system. The timing of glucose monitoring and insulin delivery did not impact glucose control though the interval was < 1 hour on average. CrossRefPubMedGoogle Scholar
  37. 37.
    Campion TR Jr, Waitman LR, Lorenzi NM, May AK, Gadd CS. Barriers and facilitators to the use of computer-based intensive insulin therapy. Int J Med Inform. 2011;80:863–71. Scholar
  38. 38.
    Campion TR Jr, Waitman LR, May AK, Ozdas A, Lorenzi NM, Gadd CS. Social, organizational, and contextual characteristics of clinical decision support systems for intensive insulin therapy: a literature review and case study. Int J Med Inform. 2010;79:31–43. Scholar
  39. 39.
    • Thabit H, Hovorka R. Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non-critical care settings. Diabetes Med. 2018;35:460–71. This review characterizes the role of novel treatments and technologies under study in the hospital, including novel automated insulin dosing strategies. CrossRefGoogle Scholar
  40. 40.
    Neubauer KM, Mader JK, Höll B, Aberer F, Donsa K, Augustin T, et al. Standardized glycemic management with a computerized workflow and decision support system for hospitalized patients with type 2 diabetes on different wards. Diabetes Technol Ther. 2015;17:685–92. Scholar
  41. 41.
    • Umpierrez GE, Klonoff DC. Diabetes technology update: use of insulin pumps and continuous glucose monitoring in the hospital. Diabetes Care. 2018;41:1579–89. This is a recent review article which describes the appropriate use of continuous glucose monitoring systems in the hospital. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    • Wallia A, Umpierrez GE, Rushakoff RJ, Klonoff DC, Rubin DJ, Hill Golden S, et al. Consensus statement on inpatient use of continuous glucose monitoring. J Diabetes Sci Technol. 2017;11:1036–44. This is an expert consensus statement describes the appropriate use of continuous glucose monitoring systems in the hospital and future areas for research. CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Thabit H, Hovorka R. Glucose control in non-critically ill in patients with diabetes: towards closed-loop. Diabetes Obes Metab. 2014;16:500–9. Scholar
  44. 44.
    • Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, et al. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label,non-inferiority randomised trial. Lancet Diabetes Endocrinol. 2017;5:125–33. This was a randomized multi-center study that demonstrated similar safety and efficacy of Sitagliptin + basal + correction insulin as an alternative strategy to basal + prandial + correction insulin. CrossRefPubMedGoogle Scholar
  45. 45.
    Pasquel FJ, Gomez-Huelgas R, Anzola I, Oyedokun F, Haw JS, Vellanki P, et al. Predictive value of admission hemoglobin A1c on inpatient glycemic control and response to insulin therapy in medicine and surgery patients with type 2 diabetes. Diabetes Care. 2015;38:e202–3. Scholar
  46. 46.
    • Heise T, Pieber TR, Danne T, Erichsen L, Haahr H. A pooled analysis of clinical pharmacology trials investigating the pharmacokinetic and pharmacodynamic characteristics of fast-acting insulin aspart in adults with type 1 diabetes. Clin Pharmacokinet. 2017;56:551–9. This was a pooled analysis of studies indicating the potential utility of faster acting insulins for post-meal insulin administration, which is relevant for the hospitalized patient who is getting post-meal insulin. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    • Russell-Jones D, Bode BW, De Block C, Franek E, Heller SR, Mathieu C, et al. Fast-acting insulin aspart improves glycemic control in basal-bolus treatment for type 1 diabetes: results of a 26-week multicenter, active-controlled, treat-to-target, randomized, parallel-group trial (onset 1). Diabetes Care. 2017;40:943–50. This was a randomized controlled trial using CGM to demonstrate the potential utility of faster acting insulins for post-meal insulin administration, which is relevant for the hospitalized patient who is getting post-meal insulin. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Endocrinology, Diabetes and MetabolismThe Ohio State UniversityColumbusUSA

Personalised recommendations