Don’t Hold the Metformin! Enhancing the Inpatient Diabetes Order Set to Encourage Best Practices

From the 2021 HVPAA National Conference

Samantha Sanders (NYU School of Medicine), Michael Shen, Daniel Alaiev, Brianna Knoll, Michael Natter, Fiona Fitzgerald, Kayla Nunemacher, Mariah Schaflin, Meredith Ugell, Hyung (Harry) Cho, Ian Fagan, Amanda Klinger

Background

Studies have demonstrated that oral medications such as metformin are safe to continue in the hospital, and that when insulin is used in a hospital setting, a basal or basal-bolus regimen is more effective than sliding scale monotherapy. Despite mounting evidence and society guidelines, clinicians have been slow to adopt these practices in the medical inpatient setting.

Objective

We aimed to (1) increase appropriate use of oral diabetes medications and (2) increase basal insulin use in the inpatient setting across a 11-hospital safety net system.

Methods

The quality improvement initiative was implemented across an urban, 11-hospital safety net health system. We implemented a multifaceted intervention consisting of: (1) an education and awareness campaign, (2) local clinical consensus guidelines, and (3) electronic medical record order set enhancement.

To facilitate system-wide education, we sent materials to clinical leaders at each of our 11 sites, including a slide deck with guidelines for oral diabetes medications and insulin dosing, as well as a tip sheet for the enhanced order set. At select sites, we also facilitated lunchtime educational sessions for residents and students.

The order set we created nudges clinicians to continue a patient’s home oral medications (metformin and/or sitagliptin) when they are admitted to the hospital (Figure 1). It also encourages ordering of either basal-only regimens or basal-bolus regimens for patients who require insulin, rather than sliding scale monotherapy. We embedded dose calculators into each insulin order to help determine the appropriate initial dosing.

Results

Our primary outcome was use of metformin, sitagliptin, and basal insulin, which we measured for patients older than 18 years old hospitalized on a medical, surgical, or psychiatric service. We excluded patients hospitalized in an ICU setting. Pre-intervention data was from November 3, 2020 to February 9, 2021 (13 weeks), and post-intervention data was from February 10, 2021 to May 6, 2021 (12 weeks). The combined rate of metformin and sitagliptin orders increased by 9.3% (from 7.17 to 7.84 orders per 1000 patient days). The combined rate of basal insulin orders (insulin detemir and NPH) increased by 5.3% (from 37.9 to 39.9 orders per 1000 patient days).

We also assessed rates of hyperglycemia and hypoglycemia to monitor the safety of our intervention. Rate of hypoglycemia (glucose <70) was stable at 2.2% pre-intervention and 2.0% post-intervention. Similarly, the rate of hyperglycemia (glucose >200) was stable at 24.6% pre-intervention and 25.5% post-intervention.

Conclusions

The introduction of an inpatient diabetes order set resulted in increased use of metformin, sitagliptin, and basal insulin. Rates of hyperglycemia and hypoglycemia remained stable.

Clinical Implications

Shifting practice toward oral diabetes medications and basal insulin is achievable in large settings. It can deter use of unnecessary sliding scale insulin monotherapy regimens and may lead to improved glycemic control. This has the potential to encourage the use of inpatient diabetes medications that more readily translate into outpatient regimens for these patients.