Improving Reliability of Care across Transitions and Perioperative Settings

Cheryl O’Malley, Maryann Emanuel, Greg Maynard

Why Worry about Safe Transitions?

The position statement of the Inpatient Diabetes and Glycemic Control: A Call to Action Consensus Conference identified one of the barriers to inpatient glycemic control:
“Patients frequently move across a spectrum of care providers and geographic locations during a single inpatient stay, entailing multiple handoffs, communication challenges, and opportunities for error. The complexity of the task of achieving safe handoffs and consistency in the approach across this spectrum of care is a significant challenge.”¹

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified the same challenge, and in its 2007 National Patient Safety Goals Hospital Version, it defines several important areas to consider broadly as an organization and more specifically with your multidisciplinary team when implementing an inpatient hyperglycemia control program.

JCAHO 2007 National Patient Safety Goal 2
— is to improve the effectiveness of communication among caregivers, with requirement 2E specifically calling for hospitals to implement a standardized approach to handoff communications.
Some well-known approaches are “SBAR,” “5 P’s,” and “I PASS THE BATON.”^2–5

Issues for your team to consider:

• What kind of standardized approach for handoffs is used in your institution?
  Does it include standard prompts specific for patients with hyperglycemia. This should include recent doses of insulin, recent blood glucose values, prior hypoglycemia, and predisposing factors for hypoglycemia (specifically, recent change in caloric intake or oral hypoglycemic medications or new renal failure; see previous sections of the resource room for a full description).
• How is report given? Consider all areas of transition. Some important ones are:
  1. Emergency department to inpatient unit.
  2. From emergency department or ward to procedures (eg, cardiac catheterization, radiology services, endoscopy).
  3. Perioperative transitions (the pre-op holding area, then to the operating room, to the postanesthesia care unit, and finally to the surgical/medical ward or intensive care unit).
  4. During nursing shift change.
  5. From physician to physician (at change of shift, at change of a rotation, before vacation).
  6. Discharge to outpatient primary care follow-up, skilled nursing facility, rehabilitation facility, or transfer to another hospital.

JCAHO 2007 National Patient Safety Goal 8
— is to accurately and completely reconcile medications across the continuum of care. This is essential in the care of hyperglycemic patients because the total daily dose of insulin in a day is used to determine the following day’s dose. Caregivers should be aware of recent medication changes as a patient transfers from one care setting to another so they can anticipate new hypo- or hyperglycemia. In addition, physicians consider the home regimen and prior glycemic control to determine if changes in medications are necessary at discharge.

Issues for your team to consider:

• How are medications reconciled throughout a hospitalization?
• Who does it?
• Are there organization-wide documents that govern consistent practice and articulates the hospital’s expectation that staff will cooperate with that practice?
• Do such documents specifically prompt caregivers to report recent insulin doses (or other diabetic medications), recent blood glucose values, history of hypoglycemia, and risk factors for hypoglycemia?

Steps to Improve the Safety of Insulin Use throughout Entire Hospital

Helpful tools came out of the joint project of the American Society of Health System Pharmacists and the Hospital and Health-System Association of Pennsylvania, which convened a panel of experts from medicine, pharmacy, and nursing in October 2004 to discuss best practices related to safe insulin use in hospitals.6 Their summary recommendations have been covered in the appropriate sections, but important ones to be sure you have built in or have considered are:

• Determine if your organization has clear, comprehensive, and coordinated policies and procedures related to insulin use. Policies should include educational and competence requirements for all involved staff (across all transitions) with easy access to these policies and a plan to monitor compliance. If you don’t have a set policy, then your multidisciplinary team will need to create one.
• Determine if insulin is designated a “high-alert” medication within the organization and that the staff is educated continually. With insulin considered a high-alert medication, strategies to reduce errors need to be in place (eg, double-checks at error-prone stages).
• Ensure there is a standard protocol for managing hypoglycemia that is uniform across all locations of care within the organization. Hypoglycemia “rescue” agents (IV dextrose or glucagon) need to be available throughout the organization.

Specific transitions that put patients at increased risk for hypoglycemia
One of the final recommendations in the “Safe Use of Insulin” document is that protocols for high-risk transitions including conversion from insulin infusion to intermittent subcutaneous insulin be built into standard infusion orders and that protocols also include standard orders for notifying providers and adjusting insulin if continuous IV or enteral nutrition is interrupted, possibly with separate protocols for any perioperative procedure.

Protocols should include alerts to appropriate caregivers and instructions on steps to take when factors associated with hypoglycemia are present: Specific areas to address are sudden reduction in oral intake or NPO status, discontinuing enteral feeding or parenteral nutrition, reduction or discontinuation of dextrose-containing intravenous fluids, failure of a patient to eat after administration of a prandial insulin dose, or unexpected transport from a unit after prandial insulin has been given. Actions that should be included on the protocol include holding prandial insulin if patients are unable to eat more than 50% of their meal, notifying the physician or substituting new dextrose-containing fluids if the patient was on basal insulin and continuous tube feeds or parenteral nutrition that was discontinued.

A. Transitioning from IV to subcutaneous insulin
Effective options to standardize the transition from IV to subcutaneous insulin include:

1. Have a separate order set for the IV to subcutaneous transition (see “Transition from IV insulin to sub Q insulin protocol” — Clinical Tools).
2. Include conversion instructions on the original IV insulin order (see “Banner cardiac surgery intravenous insulin orders” — Clinical Tools).
3. The conversion orders and/or dosing guidelines may also be part of the standard subcutaneous protocol your team develops for general medical ward patients (see examples in Clinical Tools>Subcutaneous Insulin Order Forms).
4. Some institutions choose to have an order that triggers a phone call to a pharmacist or the diabetes management team to handle conversion.

Whichever option you choose, be sure to review the policies, guidelines, and algorithms to ensure that all areas are given uniform instructions (also see “Choosing insulin regimens for patients with different forms of nutritional intake”).

Important areas to consider when building your orders for transitioning:

• What sources of carbohydrate does the patient receive — IV dextrose, TPN, oral intake, or tube feeds?
• Have there been recent changes in insulin need?
• Generally, 2–3 consecutive hourly blood glucoses without a change in the IV insulin rate is a preferred definition of stability.
• Level of blood glucose control at this point should be closer to your non-ICU glycemic target.
• Despite these allowances, some experts advocate limiting the initial dose of glargine to <60 units. This provides a measure of safety when the insulin infusion may have overestimated actual needs (ie, infusion delivery problems, increased insulin sensitivity because of improving illness, and decreasing dextrose-containing IV fluids).
• Does the patient have known diabetes versus new hyperglycemia? Have the patient required a large amount of insulin?
• Nondiabetic patients with an HbA1c < 6 who require less than 0.5 units/hour IV at transition may not need basal insulin with their transition.
• How stable is the patient clinically?
• In general, the motivation for making this transition should be that the patient has become clinically stable, with transfer out of the ICU planned in the next 12–24 hours or that oral intake has reached reliable levels.
• Patients who are still intubated, on pressors, critically ill, or have a poorly controlled blood glucose level should have the transition delayed.

One option that would design reliability into this process is having checklists as part of the order to ensure that some key points in the timing and dosing of transitions have been adequately considered. Following is an example, the decision tree for an adult IV-to-subcutaneous transition that is part of the Adult Transition from IV to Subcutaneous Insulin Orders at the Medical Uni­ver­sity of South Carolina. The order is specific to DKA and hyperglycemic hyperosmolar syndromes, but this same method could be used to prompt clinicians to ask the questions we just posed.

At this point, review the guidelines you have given providers in making these transitions and build them into the order set and policies you have chosen. In general when a stable drip rate is reached around the time of transition, this hourly rate can be multiplied by 20.

If the patient has been receiving significant calories from tube feeds, TPN, or oral intake, this result is about 80% of the total daily dose of insulin. If they have received negligible nutrition, this total is only the basal component of the total daily insulin dose.

Be sure that your protocol includes orders for the first dose of basal insulin and for when to turn the drip off. In general, discontinuation of insulin infusion should take place 2–3 hours after scheduled injection of basal insulin or 1 hour after injection of regular or rapid-acting insulin.

Additional way to ensure safety during transitions of patients on IV insulin infusions:

• Include orders to stop the insulin infusion if there is an interruption of the glucose source
  (eg, TPN, D5W, or enteral tube feeds) and to check blood glucose every hour.
• Include orders to reduce insulin drip rate if patient leaves the unit for a test or procedure and the glucose source continues to flow. Recheck BG when patient returns and restart.

B. Anticipating transitions surrounding tube feedings
Several effective options to standardize the transitions during tube feeding are:

• Include tube feeding instructions on the same insulin protocol form as that used for patients who are eating, with additional instructions for tube feedings.
• Have a separate order set for continuous tube feeds. Some hospitals then transition them to a protocol for various other scenarios (ie, insulin protocols for planned stop of tube feeding, for adult receiving continuous tube feed plus liquid diet, and for adult receiving continuous tube feed plus solid oral diet). Adding additional orders provides specific instructions for unique situations but also adds complexity that will require more education of users.

• Instructions that basal insulin should not exceed 50% of the total daily dose of insulin. This provides a measure of safety if tube feedings are stopped.
• Do your orders include a plan for stopping tube feedings when on basal insulin? Some protocols differentiate between unplanned and planned cessation. Because of the tendency for providers to forget about the effect of basal insulin given the day before, one way to possibly build in more safety is to include automatic substitution of IV dextrose in place of enteral feedings. Some methods for doing this are:
  
  • Begin D10 intravenous fluids at the same rate as tube feedings if the latter are interrupted and glargine has been given within the last 24 hours.
  • Notify primary service of this plan so patient’s fluid status and prior glucose control may be considered.
  • Discontinue IV dextrose-containing fluids 24 hours after last dose of glargine and 12 hours after last dose of NPH or when enteral nutrition is restarted.
  • Check blood glucose 2 hours after tube feeds are discontinued, do not cover with supplemental insulin, and call physician to adjust rate or concentration of dextrose drip.
  • Continue blood glucose monitoring every 4 hours.

Perioperative settings — a series of transitions and linked protocols
Patients undergoing surgery present a special challenge. They are faced with not only the physiologic and mental stress of surgery, but also the hazards of multiple handoffs across several care teams, all with different priorities and cultures. The importance of following principles of performance improvement and effective implementation cannot be overstated. We will echo some points made elsewhere in the resource room as we lay out the steps of effective implementation of perioperative glycemic control protocols.

Identify key players and engage them in the process
Surgeons, anesthesiologists, hospitalists, intensivists, cardiologists, endocrinologists, and primary care physicians may all be involved in the care of the perioperative patient. Engaging these physicians is of vital importance, whether they are part of your core glycemic control steering committee or not. Nursing, pharmacy, and nonphysician providers must also be a part of the process. It particularly important to get the assistance of the nursing staffs from the multiple clinical settings the typical patient will see during the perioperative period. Although you do want involvement from all key areas, be selective in the individuals you choose to be on your core team in order to improve the efficiency of your efforts.

Understand the process: How do patients get from home to the OR and back again?
There is marked variability across institutions (and often within institutions) in how a patient moves between surgical, anesthesiology, and medical providers and between inpatient and outpatient settings. Your team needs to understand your own perioperative flow and procedures and to improve it when possible by answering several questions:

• Who does most preoperative medical evaluations?
• Do you have an integrated, single-site clinic that the great majority of patients go through (eg, Cleveland Clinic model)? Or do you have multiple clinics? Or are the preoperative evaluations done in a variety of private offices?
• Is there a standardized process for triaging surgical patients who need more thorough pre­operative anesthesiology, cardiology, or medical evaluations? Or is it left to individual judgment?
• Are all the surgeries done at one site?
• How many and what types of surgeries are performed at your institution per month?
• Is there a perioperative/OR committee in place? How has it addressed patient flow, safety, and standardization? Are protocols in place for perioperative antibiotics, beta-blockers, VTE prophylaxis, and the like? If so, you can leverage the committee’s efforts and integrate your glycemic control protocol with the broader perioperative protocol.
• Does anesthesia administer and monitor insulin infusions in the OR?
• What is the routine for monitoring glucose values in different care settings?

Focus on leverage: Do most patients have to travel a common pathway to the OR?
Drawing a process flow map can be very helpful (see Process Flow Mapping in the Analyze Care Delivery section of the resource room) and may suggest areas where you can most efficiently focus your efforts. For example, you may find that 80% of patients going to the OR go through a pre-op anesthesiology clinic, whereas only half undergo a pre-op “clearance” evaluation in a variety of offices. The obvious implication would be to focus your efforts on early identification and mitigation of pre-op hyperglycemia in the common pathway areas, where you can initiate a standardized protocol more easily. The preanesthesia area and operative check-in areas are the last line of defense and a safety net for any patient who may have gotten through earlier evaluations without a glycemic control assessment.

If possible, identify and adjust therapy of patients with diabetes and hyperglycemia early
Patients with a history of diabetes or hyperglycemia on screening should have an A1C drawn or available and a history taken to assess their long-term glycemic control. Virtually all patients should be screened for hyperglycemia before they go to the OR, even if they are asymptomatic and have no history.

Ideally, patients would be diagnosed and treated for hyperglycemia for weeks to months before elective surgery, but obviously this is not always possible. Although no randomized controlled trials of this practice have occurred, many centers defer elective surgery of hyperglycemic patients with A1C elevated above a given level and even perform point-of-care A1C tests on hyperglycemic patients on the day of surgery (if not previously obtained). Under this construct, a patient observed to have hyperglycemia on the day of surgery could still go to the OR after acute hyperglycemia was controlled with an insulin infusion, whereas a patient with a markedly elevated A1C and hyperglycemia would have surgery deferred.

For patients whose diabetes is new or suboptimally controlled, the communication process with the responsible caregivers and the mechanism to start and follow up on therapy are important.

The process of screening patient populations doesn’t end when patients enter the system, as the stress of surgery, medications, TPN, and other factors can initiate hyperglycemia after admission. Your team needs to make sure it is part of the routine to check glucose levels at transitions in care or when factors that can change insulin requirements are introduced.

Introduce and implement perioperative glycemic management protocol
The bare bones of a perioperative glycemic control protocol are not unduly complicated, as you can see by the sample protocol, which fits on the next page. The difficult part of the protocol is not writing it, but trying to make its steps happen with a high degree of reliability. Also, your team needs to work on linking this protocol to all the other protocols in your institution, such as the insulin infusion and subcutaneous insulin protocols, all while coaching and educating patients on their role. Achieving glycemic control in the OR is of less value when rampant hyperglycemia is allowed when the patient goes to the PACU, ICU, or noncritical ward or leaves the hospital. So paying attention to all these areas and the transitions between them is critical. Integrate the guidance from your protocol into order sets, check sheets, and the fabric of frontline care.

See sample perioperative guideline

Focus on handoffs and communication issues at all transitions
Most errors occur during transitions in care. The team should really focus on all areas where information is exchanged and the patient changes hands from one care team to the next. Put a lot of thought into the processes around these handoffs, looking for methods to make the communication as reliable as possible.

Work at making everybody’s job easier, as you ask them to do more
Perioperative glycemic monitoring and ensuring the protocol is followed can be labor intensive. Your team should spend at least as much time on making this work simpler to do, understand, and document as you do in creating the protocol in the first place. Ask your frontline workers for feedback and suggestions on how to make this happen. Pilot various parts of your protocol before rolling it out on a wide scale.

Layer interventions and use high-reliability design
A quick review of Reliable Interventions sections Protocols and Reliability and Advance Reliability may be useful, as you try to enhance the effectiveness of your protocol by layering interventions using QI strategies and high-reliability design. Patient and provider education programs, nested prompts, and feedback on performance may help significantly.

Triggers for involvement of a hyperglycemia hit squad or for automatic consultation with endocrinology or internal medicine may be appropriate, especially for high-risk patients such as transplant patients or CABG patients.

Monitor reliability of your protocol and the glycemic control obtained with it; identify and mitigate oversights
As we’ve stressed throughout the resource room, implementing your protocols is really just a starting point. If you wish to achieve excellent perioperative glycemic control, you will need to monitor your results for glycemic control, safety, and compliance with recommended protocol strategies. When variation or poor results occur, the team should scrutinize the incident and look for the root systemic causes of the problems. Does there need to be focused education, a change in process, or the addition of a redundant double-check to make sure a key step occurs? Or is the variation from your protocol happening because some aspect of it is not user friendly or because the needs of a particular patient were not met?

D. Transitioning to home
The final important transition is discharge to home. All the information gathered during the hospitalization will be used to determine the optimal home regimen. Important considerations are the HbA1C at admission, home medications, current medical problems, new contraindications to oral medications, goals of care/life expectancy, and resources. This is an area that is poorly studied and was specifically identified by the AACE as an area of need for future research.

1. Many patients with new hyperglycemia (unrecognized diabetes or hospital-related hyper­glycemia), will indeed have diabetes or prediabetes, but others will return to normal after attain­ing metabolic stability after discharge. An HbA1C can be helpful but is not part of the ADA’s cur­rent diagnostic criteria. (Note: If the patient has received a transfusion of red blood cells prior to HbA1C measurement or has a hemoglobinopathy, the HbA1C will not be accurate). So although the HbA1C may give some initial guidance in discharge planning, all patients with new hyper­glycemia need to have short- and long-term plans to for a follow-up fasting blood glucose or a 75-g oral glucose tolerance test (OGTT) to establish the diagnosis. If diabetes or pre­diabetes is identified early, implementation of a treatment plan may delay or prevent it or its complications.
2. For patients with known diabetes, the discharge regimen may be different from admission because new medical issues may affect the safety of the prior home oral regimen, or an elevated HbA1C measurement at admission may indicate the need for an improved therapeutic regimen.

The following are some general guidelines for discharge planning according to specific HbA1C values. There are currently no ADA diagnostic thresholds for the HbA1C; the values used here were demonstrated in the study by Greci et al. (2003).⁷

• HbA1C < 5.2
  New hyperglycemia: These patients do not have diabetes. Repeat screening should be done in the future with fasting blood glucose or OGTT.
  Known diabetes: Continue home regimen if no significant hypoglycemia or new contraindications.
• HbA1C 5.2–6
  New hyperglycemia: May have diabetes. Repeat screening in the near future with fasting blood glucose or OGTT.
  Known diabetes: Continue home regimen if no significant hypoglycemia or new contraindications.
• HbA1C 6–7
  New hyperglycemia: Likely will have diabetes diagnosed in the future but should be discharged home on a diabetic diet and have a fasting blood glucose or OGTT as soon as metabolically stable
  Known diabetes: Continue home regimen if no significant hypoglycemia or new contraindications.
• HbA1C 7–8:
  New hyperglycemia: Likely will have diabetes diagnosed in the future. Possible treatment options include diet and exercise or a low-dose oral agent (in general, each oral agent can decrease the A1C by 1%–2%).
  Known diabetes: Increase dose of home oral agents, add a third agent, or add basal insulin at bedtime.
• HbA1C > 8
  New hyperglycemia: Same as for HbA1C 7–8.
  Known diabetes: If already on two oral agents at home, add once-a-day basal insulin at bedtime (see instructions below for starting doses). If adding insulin to TZDs, only pioglitazone is FDA approved, and so patient will need to be switched to this particular agent.

Once HbA1C > 9–10, most patients should be on basal/bolus insulins at discharge.

Restarting oral antidiabetes drugs: Oral antidiabetes drugs are usually held while a patient is admitted to the hospital because of the transient occurrence of contraindications and the inability to rapidly titrate to achieve glycemic goals. Once medical conditions are improved, oral intake is established, and renal function stabilized, oral agents can be restarted. If a patient has a new contraindication to metformin or sulfonylureas but does not need insulin, consider a thiazolidinedione (TZD). Note that they are not recommended for patients with NYHA III and NYHA IV congestive heart failure and should be used with caution for patients with NYHA 1-II. Elderly patients and those with renal or liver disease are at increased risk of developing hypoglycemia, and doses of oral medications should be adjusted with this in mind. Other options include sitagliptin (Januvia) and exenatide (Byetta) in place of a sulfonylurea. Close follow-up is imperative when any changes in medication are made. Blood glucose initially should be measured at least twice a day to help minimize the risks. If restarting oral agents while in the hospital:

1. If patients are going to be discharged on basal insulin in addition to oral agents, discontinue mealtime bolus insulin but continue the same dose of basal insulin and correction factor. The dose of basal insulin should be no more than 50% of the total daily dose of insulin, and if recent changes have occurred in nutritional intake or medical condition that place the patient at increased risk of hypoglycemia, this basal insulin dose may need to be reduced and gradually titrated back up.
2. Once discharged, the long-acting insulin dose can be safely increased in patients with creatinine < 2 mg/dL every 3 days by 2 units if blood glucose is still >100 mg/dL.7 Other dose titration regimens with proven safety start at 10 units of NPH insulin or glargine at bedtime and increase weekly based on the average fasting morning glucose. In this regimen, for fasting blood glucose between 100 and 120 mg/dL, the total dose is increased by 2 units, 120–140 mg/dL increased by 4 units, 140–180 mg/dL increased by 6 units, and >180 mg/dL increased by 8 units.8 If patients are discharged on oral agents only, discontinue the basal insulin 12–24 hours prior to restarting the oral diabetic medications and discontinue the scheduled nutritional insulin at the same time pills are started. Continuing a low dose of the rapid-acting correction-factor insulin until discharge will ensure that extreme excursions in blood glucose levels that might occur during this transition do not persist.

Transitioning Insulin for the Outpatient Setting
Common options for insulin initiation include treatment with an intermediate or long-acting basal insulin or with a biphasic insulin formulation containing both basal and rapid-acting components.

• On insulin prior to admission:
1. Keep usual home dose and regimen if patient’s BG was well controlled and the regimen is acceptable to the patient.
2. A conservative option if a patient has multiple risk factors for hypoglycemia is to start 10 units at bedtime of NPH or glargine and adjust.
3. If patient’s BG was not controlled as an outpatient or a change is desired:
1. Use the amount of basal insulin required in the hospital (50% of the TDD) as once-daily glargine or bid NPH (generally two-thirds in the morning and one-third at bedtime).
2. If the home regimen was once-a-day NPH as the basal insulin and there is a desire to change, use the same dose as the once-a-day glargine.
3. If the preadmission insulin was twice a day, then use 80% of the total daily NPH as the once-daily glargine dose.
4. Continue multiple daily dose insulin as started in the hospital. This is more labor intensive but can lead to a potential freedom in the timing and composition of meals and has been proven to reduce HbA1C better than once-daily basal insulin. Outpatient follow-up about advanced carbohydrate counting is desirable.
• Never been on insulin as an outpatient:
1. Use the amount of basal insulin required in the hospital (50% of the TDD) as once-daily glargine or bid NPH (generally two-thirds in the morning and one-third at bedtime).
2. A conservative option if patient has multiple risk factors for hypoglycemia is to start 10 units at bedtime of NPH or glargine and adjust.

Follow-up for patients started on new insulin regimens:

• Bedtime insulin should be given at 9 pm, with fasting blood glucose checked each morning.
• Proven dose titration rules include increasing basal insulin by 2 units every 3 days if FBG > 110 mg/dL.
• Regardless of the discharge medical regimen, plans should include call parameters that would intercept a downward or upward trend of blood glucose (see the Comprehensive Educational Programs section).
• A return visit shortly after discharge to discuss diabetes control and ongoing outpatient education is appropriate. This should occur quickly if the patient has been started on a new regimen or has predisposing factors for hypo- or hyperglycemia.

Discharge Documentation
At the time of discharge, complete written documentation to safely and effectively facilitate change in care environments and communicate with care providers is essential. Medication lists with changes introduced during hospitalization, reference to the patient’s glycemic control, and suggestions for outpatient treatment and follow-up should all be part of the discharge information. The patient’s readiness and capability to assume an active role in his or her care should be evaluated and shared with the outpatient provider (see the Comprehensive Educational Programs section).

1. Garber AJ, Moghissi ES, Bransome ED Jr, et al., American College of Endocrinology Task Force on Inpatient Diabetes Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10:77–82.
2. SBAR technique for communication: a situational briefing model. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm.
3. Yates G. Promising quality improvement initiatives: reports from the field. AHRQ Summit — Improving Health Care Quality for All Americans: Celebrating Success, Measuring Progress, Moving Forward 2004, Available at: http://www.ahrq.gov/qual/qsummit/qsummit4.htm#sentara,
4. Strategies and tools to improve healthcare handoffs and transitions. Department of Defense.
5. Recommendations for safe use of insulin in hospitals. American Society of Health System Pharmacists and the Hospital and Health System Association of Pennsylvania. 2005. Available at: http://www.premierinc.com/all/safety/publications/01-06-downloads/01-safe-use-insulin-ashp.pdf. Accessed December 23, 2006. http://www.ashp.org/s_ashp/docs/files/Safe_Use_of_Insulin.pdf Accessed August 6, 2008.
6. Greci LS, Kailasam M, Malkani S, et al. Utility of HbA1C levels for diabetes case finding in hospitalized patients with hyperglycemia. Diabetes Care. 2003;26:1064–1068.
7. Davies M, Storms F, Shutler S, Bianchi-Biscay M, Gomis R. Improvement of glycemic control in subjects with poorly controlled type 2 diabetes. Diabetes Care. 2005;28:1282–1288.
8. Riddle M, Rosenstock J, Gerich J, Investigators IGS. The treat-to target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetes patients. Diabetes Care. 2003;26:3080–3086.