TY - JOUR
AU - Oelschlaeger,, LaDonna
AB - Abstract Purpose The implementation of pharmacist-managed insulin dosing for selected hospitalized patients under a multimodal insulin protocol (MMIP) is described. Summary Hyperglycemia has been linked to increased thrombosis, decreased wound healing, and decreased immune response. Current recommendations support the use of multimodal (basal–bolus) insulin therapy in noncritically ill inpatients. As part of a systemwide quality-improvement initiative to improve glycemic management, the pharmacy department of a community hospital initiated a service to provide protocol-directed insulin dosing for selected patients under a pharmacist consultation model. An MMIP targeting patients with 2 blood glucose (BG) readings of >180 mg/dL within a 12-hour period was developed and approved. Pharmacist consultations, including patient assessment, entry of initial insulin orders, and ongoing insulin dosage adjustments, are performed pursuant to electronic notifications and computerized prescriber order entry. Noncritically ill patients who meet the criteria for protocol-guided insulin dosing are managed according to an approved weight-based MMIP for calculating and adjusting nutritional and basal insulin doses. Prior to the initiation of MMIP-guided insulin dosing, pharmacists were trained on the use of the protocol and passed a competency assessment. In the 90-day period after protocol implementation, 158 hyperglycemic patients received pharmacist-managed insulin dosing. Conclusion The goal of achieving a mean BG concentration of ≤180 mg/dL by day 3 of hyperglycemia management under a pharmacist-managed MMIP was attained in the second and third months after protocol implementation. basal–bolus insulin therapy, diabetes mellitus, hyperglycemia, inpatient, insulin, protocol Key Points Both the American Diabetes Association and the American Association of Clinical Endocrinologists recommend that non-critically ill hospitalized patients be treated with multimodal insulin therapy to prevent blood glucose concentrations from rising above 180 mg/dL. Implementation of a multimodal insulin protocol (MMIP) by the pharmacy department at a community hospital provided a valuable tool that gave pharmacists an opportunity to safely and effectively manage patients with hyperglycemia. Through optimization of readily available technology, the entire staff of pharmacists efficiently participated in MMIP service development. The American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), and the Endocrine Society (ES) discourage the use of sliding-scale insulin therapy alone for the management of hyperglycemia in the hospital setting.1,2 Multimodal insulin therapy, also referred to as basal–bolus insulin therapy, is the preferred treatment for hyperglycemia in noncritically ill hospitalized patients. In addition to recommending multimodal insulin therapy for treatment of inpatient hyperglycemia, ADA and ES recommend documenting a glycosylated hemoglobin (HbA1c) value in patients with diabetes and the timely initiation of blood glucose (BG) monitoring.2,3 Multimodal insulin therapy consists of a scheduled subcutaneous insulin regimen whose effects mimic the normal physiological response to glucose production. Basal–bolus insulin therapy is intentional, in contrast to sliding-scale therapy, which is reactive. A multimodal insulin regimen includes prandial insulin coverage with a rapid-acting insulin product to limit the increase in BG that occurs after a meal. Another hallmark is basal insulin coverage with a long-acting insulin product to cover BG production unrelated to meal intake. Finally, there is a correctional-scale insulin component consisting of rapid-acting insulin needed to treat hyperglycemia exceeding a specified BG concentration threshold (usually >140 mg/dL).1,4 It is worth noting that correctional-scale insulin alone is still considered multimodal therapy because a rise in the BG level will necessitate the addition of basal and nutritional insulin to bring the BG level under control. With sliding-scale insulin therapy, the dose-range instructions are still followed when BG concentrations are well above 180 mg/dL. In the RABBIT 2 trial, Umpierrez and colleagues4 collected data supporting the superior safety and efficacy of a structured inpatient basal–bolus insulin regimen relative to sliding-scale insulin monotherapy. Problem The office of clinical effectiveness of Adventist Health System, a healthcare organization that includes 45 hospital campuses in 9 states, identified hypoglycemia (i.e., a BG concentration of <70 mg/dL3) as the most common harm systemwide. Glycemic management was identified as an area for improvement. As part of the hospital system, Texas Health Huguley Hospital Fort Worth South (THH) is a 223-bed tertiary care hospital serving both a large urban county and a rural county. This community-based hospital has a wide array of specialists and subspecialists but only 1 endocrinologist for its large population of patients with diabetes. It was determined locally (through the hospital’s “hyperglycemia collaborative committee”) that intervention by a clinical pharmacist would be a viable option for providing the close monitoring and dosage adjustments required to meet ADA, AACE, and ES best-practice recommendations.5 This committee consisted of nurses, pharmacists, clinical dietitians, informaticists, hospital administrators, and a physician champion. The collaborative was developed to create solutions for attaining the hospital’s glycemic management goals. The dangers of inpatient hyperglycemia and hypoglycemia are well documented. Elevated BG levels have been associated with increased thrombosis, increased inflammation, and decreased immune response.6 In postoperative patients, consequences of hyperglycemia can include increased risks of sepsis, pneumonia, and surgical site infections.7,8 ADA and AACE recommend that noncritically ill hospitalized patients maintain BG concentrations under 180 mg/dL. Factors contributing to hyperglycemia include but are not limited to the use of corticosteroids, sepsis, renal dysfunction, infection, and parenteral nutrition; therefore, this recommendation applies to patients with or without a confirmed diabetes diagnosis.9 While hyperglycemia is a problem, hypoglycemia must be avoided. Severe hypoglycemia (a BG concentration of <40 mg/dL) has been studied as an independent risk factor for increased mortality.10 The NICE-SUGAR trial showed a link between increased mortality and hypoglycemia resulting from tight glucose control (i.e., BG concentrations of 81–108 mg/dL).11 These criteria led to the development of a protocol to address not only insulin requirements but appropriate laboratory testing and glucose monitoring to prevent hypoglycemia as well. Analysis and resolution Protocol development. A weight-based multimodal insulin protocol (MMIP) based on the basic tenets of the RABBIT 2 trial was developed by the THH pharmacy department. While Umpierrez and colleagues12 focused on noncritically ill, insulin-naive inpatients with type 2 diabetes, the protocol includes all patients exceeding inpatient hyperglycemia limits. The MMIP stratifies patients into 4 dosing groups: 0.3 unit/kg/day, 0.5 unit/kg/day, 0.6 unit/kg/day, and history-based dosing (Table 1).4,12 The calculated dose becomes the total daily dose (TDD) of insulin. The TDD is further divided 50:50 between basal and nutritional insulins. Long-acting insulin is used for the basal dose. Rapid-acting insulin is used for the nutritional and correctional-scale doses. The nutritional, or prandial, insulin doses constitute half of the TDD divided into 3 equal portions (subdoses are rounded to the nearest whole number). There are also 3 standard correctional scales available. Patients receive a low, medium, or high correctional-scale dose according to their TDD of insulin. Upon starting an MMIP consultation, the pharmacist orders glucose point-of-care (POC) testing and an HbA1c determination (if an HbA1c value has not been documented within the past 3 months). Once the MMIP is started, all previous medications for hyperglycemia are discontinued. The regimen is monitored and adjusted by a clinical pharmacist daily. Adjustments are made according to the MMIP (Table 2). The goal is a daily mean POC BG value of ≤180 mg/dL by day 3 of the pharmacy consultation, with day 0 being the day on which protocol criteria are met.13 Table 2 Point-of-Care Algorithm for Daily Insulin Adjustments According to Protocola Step 1 Step 2 Step 3 Step 4 Determine mean blood glucose value (mg/dL) for past 24 hrb Compare current TDDc and TDGd in past 24 hr Therapeutic adjustment per protocol Confirm dose adjustment   <120e TDG < TDD Decrease TDG by 20% Lower TDG   121–140 TDG < TDD Use TDG Equivalent TDG   141–180 TDG = TDD No change Use TDD   181–250 TDG > TDD Use TDG Equivalent TDG   251–350 TDG > TDD Increase TDG by 15% Higher TDG   >350 TDG > TDD Increase TDG by 20% Higher TDG Step 1 Step 2 Step 3 Step 4 Determine mean blood glucose value (mg/dL) for past 24 hrb Compare current TDDc and TDGd in past 24 hr Therapeutic adjustment per protocol Confirm dose adjustment   <120e TDG < TDD Decrease TDG by 20% Lower TDG   121–140 TDG < TDD Use TDG Equivalent TDG   141–180 TDG = TDD No change Use TDD   181–250 TDG > TDD Use TDG Equivalent TDG   251–350 TDG > TDD Increase TDG by 15% Higher TDG   >350 TDG > TDD Increase TDG by 20% Higher TDG a TDD = total daily dose, TDG = total dose given. b For any blood glucose value of <70 mg/dL, strongly consider recalculating regimen. c Total of basal and nutritional insulin doses documented in medication administration record for past 24 hours. d Total of basal, nutritional, and correctional units given in past 24 hours. e Discontinue scheduled insulin if necessary. Table 2 Point-of-Care Algorithm for Daily Insulin Adjustments According to Protocola Step 1 Step 2 Step 3 Step 4 Determine mean blood glucose value (mg/dL) for past 24 hrb Compare current TDDc and TDGd in past 24 hr Therapeutic adjustment per protocol Confirm dose adjustment   <120e TDG < TDD Decrease TDG by 20% Lower TDG   121–140 TDG < TDD Use TDG Equivalent TDG   141–180 TDG = TDD No change Use TDD   181–250 TDG > TDD Use TDG Equivalent TDG   251–350 TDG > TDD Increase TDG by 15% Higher TDG   >350 TDG > TDD Increase TDG by 20% Higher TDG Step 1 Step 2 Step 3 Step 4 Determine mean blood glucose value (mg/dL) for past 24 hrb Compare current TDDc and TDGd in past 24 hr Therapeutic adjustment per protocol Confirm dose adjustment   <120e TDG < TDD Decrease TDG by 20% Lower TDG   121–140 TDG < TDD Use TDG Equivalent TDG   141–180 TDG = TDD No change Use TDD   181–250 TDG > TDD Use TDG Equivalent TDG   251–350 TDG > TDD Increase TDG by 15% Higher TDG   >350 TDG > TDD Increase TDG by 20% Higher TDG a TDD = total daily dose, TDG = total dose given. b For any blood glucose value of <70 mg/dL, strongly consider recalculating regimen. c Total of basal and nutritional insulin doses documented in medication administration record for past 24 hours. d Total of basal, nutritional, and correctional units given in past 24 hours. e Discontinue scheduled insulin if necessary. Table 1 Multimodal Insulin Dosing Protocol Used by Pharmacists for Therapy Initiation Dosing Group Patient-Specific Condition Total Daily Dose  Low Thin or malnourished At risk for hypoglycemia Renal, cardiac, or severe hepatic dysfunction Elderly Hyperglycemia controlled on oral hypoglycemic Diagnosed type 1 diabetes Start at 0.3 unit/kg/day  Medium Normal body weight and/or hyperglycemia not controlled with low-dose therapy Start at 0.5 unit/kg/day  High Obese Infection Open wound Current corticosteroid use Hyperglycemia not controlled with medium-dose therapy Start at 0.6 unit/kg/daya Dosing Group Patient-Specific Condition Total Daily Dose  Low Thin or malnourished At risk for hypoglycemia Renal, cardiac, or severe hepatic dysfunction Elderly Hyperglycemia controlled on oral hypoglycemic Diagnosed type 1 diabetes Start at 0.3 unit/kg/day  Medium Normal body weight and/or hyperglycemia not controlled with low-dose therapy Start at 0.5 unit/kg/day  High Obese Infection Open wound Current corticosteroid use Hyperglycemia not controlled with medium-dose therapy Start at 0.6 unit/kg/daya a Morbidly obese patients may require 0.8 unit/kg/day. Table 1 Multimodal Insulin Dosing Protocol Used by Pharmacists for Therapy Initiation Dosing Group Patient-Specific Condition Total Daily Dose  Low Thin or malnourished At risk for hypoglycemia Renal, cardiac, or severe hepatic dysfunction Elderly Hyperglycemia controlled on oral hypoglycemic Diagnosed type 1 diabetes Start at 0.3 unit/kg/day  Medium Normal body weight and/or hyperglycemia not controlled with low-dose therapy Start at 0.5 unit/kg/day  High Obese Infection Open wound Current corticosteroid use Hyperglycemia not controlled with medium-dose therapy Start at 0.6 unit/kg/daya Dosing Group Patient-Specific Condition Total Daily Dose  Low Thin or malnourished At risk for hypoglycemia Renal, cardiac, or severe hepatic dysfunction Elderly Hyperglycemia controlled on oral hypoglycemic Diagnosed type 1 diabetes Start at 0.3 unit/kg/day  Medium Normal body weight and/or hyperglycemia not controlled with low-dose therapy Start at 0.5 unit/kg/day  High Obese Infection Open wound Current corticosteroid use Hyperglycemia not controlled with medium-dose therapy Start at 0.6 unit/kg/daya a Morbidly obese patients may require 0.8 unit/kg/day. During the course of the program, patients are also monitored for hypoglycemia, which may be caused by various factors, including changes in nutrition status, acute renal failure, and adjustments to corticosteroid therapy.14,15 Treatment to correct low BG levels follows the hospital’s hypoglycemia protocol. The MMIP incorporates the medication treatment portion of the protocol into the order-entry process. The pharmacist places orders for 50% dextrose injection, oral glucose gel, and glucagon in the medication administration record (MAR) in accordance with the hospital’s approved treatment protocol. The BG level must be reevaluated by the nurse 15 minutes after treatment until the goal of a BG concentration of >80 mg/dL is met. Dietary status changes are also built into the program, allowing the nurse to automatically convert to every-4-hour correctional-scale dosing for “nothing-by-mouth” and continuous enteral or parenteral nutrition modifications.16 Implementation. The hospital is equipped with a system for computerized prescriber order entry (CPOE). The pharmacy department operates 24 hours a day, with a total staff of 24 full-time equivalents (FTEs): 11 pharmacist FTEs, 12 certified pharmacy technician FTEs, and 1 clinical coordinator FTE. In addition, there is a clinical pharmacist diabetes specialist who reports to the director of pharmacy but whose position is budgeted through the hospital’s quality and patient safety department. This pharmacist acts as a liaison among patients, physicians, dietary staff, nurses, pharmacy department personnel, and the hospital administration. This individual coordinates the inpatient diabetes program, including the MMIP pharmacy service. The pharmacy department has an all-clinical-pharmacist paradigm. Each pharmacist must be able to start and adjust an insulin regimen using the protocol. At the time of protocol implementation, the training program included one-on-one instruction of each staff pharmacist by the clinical pharmacist diabetes specialist. All pharmacists completed this educational and clinical skills development program. All pharmacists passed a competency assessment before the program began. The first step in the MMIP pharmacy workflow is notification of pharmacists when patients are hyperglycemic, as defined in the protocol (i.e., 2 BG concentration readings of >180 mg/dL within a 12-hour period) through computerized hyperglycemia alerts sent to physicians through the computer system (the pharmacy is on the notification list). Pharmacists acquire MMIP consultations through follow-up phone calls or directly from orders in the CPOE. Next, the pharmacist who receives a new MMIP consultation initiates the patient assessment, completing data entry for laboratory testing and initial insulin orders. Patient names are then manually entered into a central list in the computer system. This central list makes it possible for all pharmacists to quickly identify MMIP patients when additional adjustments are needed. The final step is documentation of assessment findings and clinical decision-making in the electronic chart. Results. The MMIP was approved through both the pharmacy and therapeutics and medical executive committees. As the MMIP consultation service was a new clinical service created for quality improvement, institutional review board approval was not required. For the first 3 months after implementation, data were collected on non–critical care patients who were treated for hyperglycemia for at least 3 days. The hyperglycemia collaborative committee reviewed these data for continuous quality improvement. A total of 158 patients were treated under the MMIP by the pharmacy department over the 90-day period. Patient privacy was protected through adherence to Health Insurance Portability and Accountability Act guidelines during data collection. This information was compared with data on patients with hyperglycemia who had physician-managed insulin dosing during the same 90-day time frame. During the first month of the service, the mean BG value on day 3 of treatment among patients managed through the MMIP (n = 58) was 181 mg/dL, while the mean value among physician-managed patients (n = 42) was 203 mg/dL. In the second month of the evaluation period, the mean BG value on day 3 of treatment was 167 mg/dL with pharmacist-managed insulin dosing (n = 50), as compared with a mean value of 212 mg/dL in physician-managed patients (n = 35); in the third month, the values were 177 and 183 mg/dL among pharmacist-managed patients (n = 50) and physician-managed patients (n = 37), respectively. During the 3-month implementation period, the overall rate of documentation of HbA1c values among physician-managed patients and patients managed under the MMIP increased from 62% at baseline to 70%, 73%, and 74% in months 1, 2, and 3, respectively. The goal of an average BG concentration of ≤180 mg/dL on day 3 of pharmacy consultations was attained in the second and third months. Pharmacist-managed insulin dosing was found to be similar in effectiveness to physician-managed dosing when daily average BG values were used for comparisons (Table 3). Data reporting included hyperglycemic inpatients both with and without a confirmed diabetes diagnosis. Physicians were not permitted to adjust the insulin regimens of patients managed in the pharmacy consultation service. An order to discontinue a pharmacy consultation was entered if the responsible physician chose to manage a patient’s insulin therapy. Nurses were educated to notify the pharmacist first for BG-control issues. Only patients whose insulin dosing was managed by either a physician or the pharmacy service were included in the reported data. Table 3 Hyperglycemia Control With Pharmacist- Versus Physician-Managed Insulin Dosing Evaluation Period Mean ± S.D. Blood Glucose Concentration (mg/dL) Pharmacist-Managed Patients (n = 58)a Physician-Managed Patients (n = 42)b  Month 1   Day 0 233 ± 8 216 ± 10   Day 1 202 ± 24 206 ± 4   Day 2 174 ± 10 199 ± 4   Day 3 181 ± 11 203 ± 11  Month 2   Day 0 228 ± 9 220 ± 3   Day 1 202 ± 4 197 ± 16   Day 2 194 ± 8 192 ± 5   Day 3 167 ± 5 212 ± 6  Month 3   Day 0 230 ± 6 222 ± 15   Day 1 202 ± 7 206 ± 4   Day 2 181 ± 17 187 ± 4   Day 3 177 ± 3 183 ± 15 Evaluation Period Mean ± S.D. Blood Glucose Concentration (mg/dL) Pharmacist-Managed Patients (n = 58)a Physician-Managed Patients (n = 42)b  Month 1   Day 0 233 ± 8 216 ± 10   Day 1 202 ± 24 206 ± 4   Day 2 174 ± 10 199 ± 4   Day 3 181 ± 11 203 ± 11  Month 2   Day 0 228 ± 9 220 ± 3   Day 1 202 ± 4 197 ± 16   Day 2 194 ± 8 192 ± 5   Day 3 167 ± 5 212 ± 6  Month 3   Day 0 230 ± 6 222 ± 15   Day 1 202 ± 7 206 ± 4   Day 2 181 ± 17 187 ± 4   Day 3 177 ± 3 183 ± 15 a For months 2 and 3, n = 50. b For months 2 and 3, n = 35. Open in new tab Table 3 Hyperglycemia Control With Pharmacist- Versus Physician-Managed Insulin Dosing Evaluation Period Mean ± S.D. Blood Glucose Concentration (mg/dL) Pharmacist-Managed Patients (n = 58)a Physician-Managed Patients (n = 42)b  Month 1   Day 0 233 ± 8 216 ± 10   Day 1 202 ± 24 206 ± 4   Day 2 174 ± 10 199 ± 4   Day 3 181 ± 11 203 ± 11  Month 2   Day 0 228 ± 9 220 ± 3   Day 1 202 ± 4 197 ± 16   Day 2 194 ± 8 192 ± 5   Day 3 167 ± 5 212 ± 6  Month 3   Day 0 230 ± 6 222 ± 15   Day 1 202 ± 7 206 ± 4   Day 2 181 ± 17 187 ± 4   Day 3 177 ± 3 183 ± 15 Evaluation Period Mean ± S.D. Blood Glucose Concentration (mg/dL) Pharmacist-Managed Patients (n = 58)a Physician-Managed Patients (n = 42)b  Month 1   Day 0 233 ± 8 216 ± 10   Day 1 202 ± 24 206 ± 4   Day 2 174 ± 10 199 ± 4   Day 3 181 ± 11 203 ± 11  Month 2   Day 0 228 ± 9 220 ± 3   Day 1 202 ± 4 197 ± 16   Day 2 194 ± 8 192 ± 5   Day 3 167 ± 5 212 ± 6  Month 3   Day 0 230 ± 6 222 ± 15   Day 1 202 ± 7 206 ± 4   Day 2 181 ± 17 187 ± 4   Day 3 177 ± 3 183 ± 15 a For months 2 and 3, n = 50. b For months 2 and 3, n = 35. Open in new tab Discussion The rate of HbA1c value documentation peaked at only 74% during the 3-month initial implementation phase; this most likely occurred because there was some physician resistance to documenting those values during hospitalizations of patients they managed. Another reason was that the pharmacists were focused on the insulin dosing aspect of the protocol, and some might have neglected to enter an order for HbA1c measurement. Education regarding the need to order HbA1c determinations was continued, as HbA1c values were useful in diabetes education as well as clinical decision-making. The MMIP implemented by the THH pharmacy department has provided a valuable tool that gives pharmacists an opportunity to safely and effectively manage patients with hyperglycemia. The insulin regimens are monitored and adjusted daily by pharmacy personnel per protocol. This process also contributes valuable data to assist physicians in determining when adjustment of a patient’s discharge diabetes regimen is needed. An additional benefit of this type of service is that, because a pharmacist is typically more readily available than a physician to answer nurses’ questions, it promotes greater collaboration between pharmacy and nursing personnel in patient care. In physician-managed insulin dosing programs, it may be difficult to overcome clinical inertia and reach guideline adherence.16,17 While CPOE order sets guide evidence-based therapy, they can be cumbersome for physicians to navigate and require frequent updates to remain relevant. Greater deviation from formulary insulin products may also be expected with physician dosing. On the other hand, a pharmacy-led program using a pharmacy-based order set ensures that formulary items are used, standard MAR comments are present, and standard dosing schedules are kept. Through optimization of readily available technology, the entire staff of pharmacists can efficiently participate in this type of service. One weakness of the choice of mean BG concentrations to compare pharmacist- and physician-managed insulin dosing was that those values did not reflect the potential effect of hypoglycemia. The THH hyperglycemia collaborative committee reviewed all reports of severe hypoglycemic events biweekly, and an action plan was implemented to decrease future events. These interventions included increased education of staff on proper POC testing, an update to the hospital’s hypoglycemia protocol, and the rescheduling of dietary tray delivery times. About 2% of patients managed using the MMIP during the 90-day implementation period had a severe hypoglycemic event. The close monitoring provided for protocol-managed patients and the demonstrated safety of pharmacy-led insulin dosing service led several hospitalists to approve automatic pharmacy consultations for patients meeting MMIP criteria; this greatly increased the number of patients cared for through the service after the initial implementation phase. At the time of writing, pharmacists were regularly managing insulin dosing for more than 80% of inpatients meeting MMIP criteria. To our knowledge, this type of inpatient clinical service involving the entire staff of pharmacists has not been documented in the literature. It is important to note that the 90-day study described above was not designed to prove the superiority of a pharmacist-managed protocol over physician-ordered insulin dosing. The purpose of the analysis was to illustrate that pharmacists can safely manage patients with hyperglycemia using an approved MMIP. The data collected indicated that pharmacists and physicians maintained similar levels of BG control over 3 days of treatment of hyperglycemic patients in the acute care setting. As a result of these findings, a pharmacist-managed multimodal insulin service should be considered as an option for achieving insulin therapy consistent with ADA, AACE, and ES recommendations on inpatient glycemic management. Since implementation of the MMIP program, the hospital has benefited from a high level of adherence to evidence-based practice and a decreased risk of formulary variation. Physicians have benefited by being able to focus on other aspects of patient care while pharmacy personnel manage insulin dosing and adjustments. With the ongoing trend toward adoption of CPOE, full participation in the process of inpatient glycemic management should be a key area for expansion of the role of the hospital pharmacist. Conclusion The goal of achieving a mean BG concentration of ≤180 mg/dL by day 3 of hyperglycemia management under a pharmacist-managed MMIP was attained in the second and third months after protocol implementation. Disclosures The authors have declared no potential conflicts of interest. References 1 Moghissi ES Korytkowski MT DiNardo M . American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control . Endocr Pract . 2009 ; 15 : 353 – 69 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Umpierrez GE Hellman R Korytkowski MT . Management of hyperglycemia in hospitalized patients in non-critical care setting . J Clin Endocrinol Metab . 2012 ; 97 : 16 – 38 . Google Scholar Crossref Search ADS PubMed WorldCat 3 American Diabetes Association . Standards of medical care in diabetes . Diabetes Care . 2015 ; 38 ( suppl 1 ): S80 – 5 . PubMed WorldCat 4 Umpierrez GE Smiley D Zisman A . Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial) . Diabetes Care . 2007 ; 30 : 2181 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Rochester CD Leon N Dombrowski R Haines ST . Collaborative drug therapy management for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus . Am J Health-Syst Pharm . 2010 ; 67 : 42 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Clement S Braithwaite SS Magee MF . Management of diabetes and hyperglycemia in hospitals . Diabetes Care . 2004 ; 27 : 553 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Kwon S Thompson R Dellinger P . Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program . Ann Surg . 2013 ; 257 : 8 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Ata A Lee J Bestle SL . Postoperative hyperglycemia and surgical site infection in general surgery patients . Arch Surg . 2010 ; 145 : 858 – 64 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Hendrickson KC Bozzo JE Zimkus J . Evaluating inpatient glycemic management: the Quality Hyperglycemia Score . Diabetes Technol Ther . 2011 ; 13 : 753 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Finfer S Liu B Chittock DR , for the NICE-SUGAR Study investigators . Hypoglycemia and risk of death in critically ill patients . N Engl J Med . 2012 ; 367 : 1108 – 18 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Finfer S Chittock DR Su SY , for the NICE-SUGAR Study investigators . Intensive versus conventional glucose control in critically ill patients . N Engl J Med . 2009 ; 364 : 1283 – 97 . WorldCat 12 Umpierrez GE Smiley D Jacobs S . Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 surgery) . Diabetes Care . 2011 ; 34 : 256 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Smiley D Umpierrez GE . Management of hyperglycemia in hospitalized patients . Ann NY Acad Sci . 2010 ; 1212 : 1 – 11 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Rubin DJ Rybin D Doros G McDonnell ME . Weight-based, insulin dose–related hypoglycemia in hospitalized patients with diabetes . Diabetes Care . 2011 ; 34 : 1723 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Rubin DJ Golden SH . Hypoglycemia in non-critically ill, hospitalized patients with diabetes: evaluation, prevention and management . Hosp Pract . 2013 ; 41 : 109 – 16 . Google Scholar Crossref Search ADS WorldCat 16 Maynard G Wesorick DH O’Malley C Inzucchi SE . Subcutaneous insulin order sets and protocols: effective design and implementation strategies . J Hosp Med . 2008 ; 3 ( suppl 5 ): S29 – 41 . Google Scholar Crossref Search ADS WorldCat 17 Wei NJ Wexler DJ . Basal-bolus insulin protocols enter the computer age . Curr Diab Rep . 2012 ; 12 : 119 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Implementing a pharmacist consultation model for multimodal insulin therapy
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp150941
DA - 2017-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/implementing-a-pharmacist-consultation-model-for-multimodal-insulin-PMu2jFtAw6
SP - e224
VL - 74
IS - 9
DP - DeepDyve
ER -