Timing of Insulin with Meals in the Hospital: a Systems Improvement Approach
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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.
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.
KeywordsHospital 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
- 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. https://doi.org/10.2337/dc10-1407.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1210/jc.2011-2098.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.2337/dc09-9029.CrossRefPubMedPubMedCentralGoogle Scholar
- 12.http://www.ihi.org/explore/highalertmedicationsafety/pages/default.aspx. Accessed 5/26/2019.
- 14.• Institute for Safe Medication Practices (ISMP). ISMP guidelines for optimizing safe subcutaneous insulin use in adults; 2017. https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP138-Insulin%20Guideline-051517-2-WEB.pdf. 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 .
- 16.http://www.jointcommission.org/assets/1/6/DSC_teleconference__IPD_111213.pdf. Accessed 5/26/2019.
- 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. https://doi.org/10.1016/j.clinthera.2004.09.001.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1111/j.1463-1326.2011.01478.x.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1016/j.diabres.2017.06.021 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.https://psnet.ahrq.gov/primers/primer/42/patient-safety-101. Accessed 5/26/2019.
- 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. https://doi.org/10.1111/dme.13982 This was a systematic review that assessed interventions which address insulin prescribing errors . CrossRefGoogle Scholar
- 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. https://doi.org/10.1136/amiajnl-2011-000304.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1097/NUR.0000000000000190 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.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. http://dne2.ucsf.edu/public/cripc/ebpabstract/pham-abst.pdf. Accessed 5/26/2019.
- 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 https://professional.diabetes.org/abstract/getting-timing-right-hospital-synching-insulin-administration-meal-tray-arrival. Accessed 5/26/2019.
- 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. https://doi.org/10.1016/j.ijmedinf.2016.03.007 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
- 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. https://doi.org/10.1016/j.ijmedinf.2009.09.004.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1111/dme.13563 This review characterizes the role of novel treatments and technologies under study in the hospital, including novel automated insulin dosing strategies. CrossRefGoogle Scholar
- 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. https://doi.org/10.1089/dia.2015.0027.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.2337/dci18-0002 This is a recent review article which describes the appropriate use of continuous glucose monitoring systems in the hospital. CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1177/1932296817706151 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
- 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. https://doi.org/10.1016/S2213-8587(16)30402-8 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.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. https://doi.org/10.2337/dc15-1835.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1007/s40262-017-0514-8 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.• 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. https://doi.org/10.2337/dc16-1771 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