Assessing Patterns of Insulin Use and Order Set Utilization

As you implement new order sets, algorithms, and guidelines, your team will need to assess if your efforts are leading to the desired changes in practice.

1. ICU and perioperative settings
   For ICU and perioperative settings, it will be important to track the use of your insulin infusion order set. Designation of BG levels that trigger insulin infusion in these settings should be agreed on. You may want to skew the definition toward giving leeway to style, so that nearly all would agree with the criteria you put forward for initiating insulin infusions. The number of patients who meet the criteria would make up the denominator, and the number of patients on the insulin infusion order set would make up the numerator.
   Alternately, you could just monitor how many order forms are used each month as a rough measure of how much your protocol is being used, or you could work with your pharmacy to determine how many unique patients had insulin infusions prepared.
2. Non–critical care units
   On the non–critical care wards, measuring the percentage of subcutaneous insulin regimens that contain a basal insulin is a useful way to monitor the impact of your intervention. A more detailed analysis could examine the percentage of patients on sliding-scale insulin alone (ie, without basal or scheduled nutritional insulin) or on simultaneous basal, nutritional (if not NPO), and correction-dose insulin. Or you could trend the percentage of patients who had changes in their insulin regimens on days after hypo- or hyperglycemic excursions. Indicators of insulin use to be tracked will depend on the ability of your data system (or chart review) to capture specifics of the insulin orders and/or dose adjustments.

The introduction of a simple standardized subcutaneous insulin order set, as shown in the run chart below, can decrease the exclusive use of sliding-scale insulin regimens by 50% or more, as shown by the chart from UCSD.

You should also monitor how widely your standardized order set is being used. Remember that it is important to determine periodically that prescribers are using all components of the order set, that is, orders for basal, nutritional, and correction-dose insulin, as the order set cannot be expected to have a successful impact on glycemic control if it is not being used appropriately. Also obtain feedback on the ease with which people can use your form or order set. If it’s not easy to use, more education about your form or exhortations to use it will likely fail.

Your team may also wish to monitor the use of oral antidiabetes agents at your medical center, especially by patients for whom their use is contraindicated (eg, patients with congestive heart failure who are on thiazolidinediones and patients with renal insufficiency or receiving intravenous contrast continued on metformin).