Safety and efficacy of hyperglycemia urgency order set.

Serious hyperglycemia, defined as blood glucose (BG) greater than 300 mg/dL, is a common occurrence in hospitalized patients, and can be challenging to manage. Subcutaneous insulin may provide less desirable pharmacokinetics in these urgent situations and intravenous continuous infusions present a significant safety concern in areas with less nursing coverage. Regular insulin given intravenously as a bolus dose offers a unique advantage in treating these urgent elevations in BG due to its quick onset of action and short duration of action. Based on these characteristics, we developed a Hyperglycemia Urgency Order Set that was implemented into our electronic order entry system at Barnes-Jewish Hospital. The intent of this order set was to provide an option for the treatment of serious hyperglycemia that was not associated clinical deterioration or any of the following: potassium < 4 mEq/L, bicarbonate < 15 mEq/L, or severe symptoms such as coma, metabolic compromise, or hypotension. Secondarily, the hyperglycemia order set was designed to prevent the need for higher levels of care, such as transfer to an ICU. Components of the order set include narrative on the intent of the order set, description of patients in need of higher level of care, instructions to hold dextrose fluids or tube feeds, an order for nothing by mouth (NPO) status, an order for a basic metabolic panel, an order for a 1-time bolus dose of intravenous regular insulin along with dosing recommendations (see Table 1), and follow-up BG monitoring. Table 1. Recommended IV Push Doses of Insulin for Hyperglycemia Urgency. Following the implementation of this order set, we reviewed the use of this protocol during the first 6 months using a retrospective chart review. The order set was used to provide 31 doses of insulin in 24 patients (median weight 82 kg). The order set was used by internal medicine (n = 9), neurology (n = 6), surgery (n = 5), and oncology (n = 4) services. The reasons for hyperglycemia were due to corticosteroid use (n = 13), inadequate dose titration (n = 7), missed doses of insulin (n = 3), and unknown (n = 8). The median glucose value immediately prior to order set use was 439 mg/dL (range 215-549 mg/dL). Doses of insulin (range 2-15 units) were in line with the recommended doses in 23 of 31 cases. No orders for IV regular insulin were completed among patients outside of the intent of the Hyperglycemia Urgency Order Set. The median glucose value 4 hours following administration of IV push bolus insulin was 238 mg/dL (range 138-478 mg/dL). No patients experienced hypoglycemia, but 4 patients required repeat doses of IV insulin. Only 1 patient treated with IV regular insulin, but who received less than recommended dose of IV push insulin, subsequently required escalation of care including transfer to an intensive care unit for continuous intravenous infusion of insulin. Two patients had glucose values >350mg/dL at 9 and 12 hours after the original order set was utilized. Overall, this approach to managing hyperglycemia urgency in non–critically ill patients seems safe and effective in this cohort. We would suggest this approach for other institutions wishing to reduce the use of intravenous insulin by continuous infusion in this patient population.