Standardized inpatient insulin therapy based on electronic insulin dose calculation

The necessity of an optimal blood glucose control in hospitalized diabetic patients with avoidance of hypoglycemic episodes is well-known among physicians. However, insulin sliding scales without consideration of ingested carbohydrates (CH) are still frequently used in many hospital departments, even for patients with type 1 diabetes

In 2009, we therefore introduced a standardized, paper-based insulin scheme in all our medical and surgical departments. This scheme accounts for actual blood sugar, ingested CH and the estimated insulin resistance. Meals for diabetic patients are routinely ordered with a defined CH content so that nurse staff could evaluate the amount of CH the patient would eat. Comparison of this standardized scheme with the former sliding scales has shown a faster and more consistent hyperglycemia correction with a lower risk for hypoglycemia in our diabetic inpatients.

With the implementation of an electronic health record system (KISIM, Cistec AG) in 2013, we also changed our paper based insulin scheme to an electronic scheme. We developed a bolus calculator for this software, using correction factors for blood sugar outside the target range, CH factors for ingested CH and a resistance factor. Based on the prescribed resistance factor, the blood sugar and the amount of CH intake the program calculates the appropriate dose of short-acting insulin. In the case of hypoglycemia or hyperglycemia the nurse gets advice how to react and is told to ask the resident to adjust the dose of basal or prandial insulin. Lists of all hyperglycemic (> 180 mg/dl) or hypoglycemic (< 60 mg/dl) patients can be generated, so patients who need an adaptation of their insulin dose can easily be identified by their attending physicians and the endocrinologists – diabetologists.

Herein, we present an electronic insulin scheme which has shown major benefits in clinical practice in our medical department and which may also prove to be useful in in other non-medical departments.