SC Insulin Order Sets and Protocols

Choose a Total Daily Dose

Clinicians need guidance on how much subcutaneous insulin they should give a patient. These doses are well known from clinical experience and the published literature. The fear of hypoglycemia usually results in substantial underdosing of insulin, or total avoidance of scheduled insulin on admission. Your team should provide guidance for how much insulin to start a patient on when it is unclear from past experience how much insulin the patient needs. Waiting a few days to see how much insulin is required via sliding‐scale‐only regimens is a bad practice that should be discouraged for patients whose glucose values are substantially above the glycemic target. The total daily dose (TDD) can be estimated in several different ways (as demonstrated in Appendix 1 and 2), and protocols should make this step very clear for clinicians. Providing a specific location on the order set to declare the TDD may help ensure this step gets done more reliably. Some institutions with computer physician order entry (CPOE) provide assistance with calculating the TDD and the allocation of basal and nutritional components, based on data the ordering physician inputs into the system.

Select and Dose a Basal Insulin

Your protocol should describe how the TDD should be divided between basal and nutritional insulin. We generally recommend 50% of the TDD be given as basal insulin, with the other 50% administered on a scheduled basis to cover glycemic excursions from nutritional intake. The 50/50 rule is simple and generally works well, and should be widely promoted. However, there are exceptions to this rule that should be incorporated into your full protocol and educational programs. The order set should have separate steps for ordering basal insulin, nutritional insulin, and correction insulin. The advantage to providing these insulin components separately is that it allows them to be independently manipulated (eg, if a patient is unable to tolerate a meal, nutritional insulin is held, but basal insulin and correction insulin are continued).

The SHM GCTF specifically endorses long acting insulin (glargine and detemir) as the preferred basal insulin in the hospital setting, thus discouraging the use of neutral protamine Hagedorn (NPH) insulin and fixed combination insulin formulations (Table 2). In the absence of randomized controlled trials demonstrating superiority of the glargine or detemir to NPH insulin in the hospital, this endorsement deserves some further explanation. Although we believe that correctly dosed NPH containing insulin regimens can attain effective and safe glycemic control in the hospital setting, it is more difficult to standardize their use and adjust for fluctuations in nutritional intake. Glargine and detemir have much less pronounced spikes in their effect than NPH, rendering them relatively peakless in comparison. This pharmacokinetic profile allows for continued dosing with minimal or no correction when nutrition intake is variable, and allow for consistent reinforcement of the basal‐nutritional‐correction insulin concept.

There are some caveats to this general recommendation. First, patients who are well controlled on home regimens with NPH basal insulin can (and sometimes should) stay on the regimen that has worked well for them. However, extra vigilance in reducing the dose for reductions in nutrition is required, because NPH is generally used to cover both nutritional and basal requirements. Second, extensive experience with glargine and detemir are not available in obstetric populations. They are not U.S. Food and Drug Administration (FDA) approved for use in pregnant patients and formally carry a Class C rating, whereas NPH insulin has been used safely in obstetric populations for decades. Third, the insulin regimen used as an inpatient is not necessarily the preferred regimen to prescribe at discharge: cost, patient preferences, HbA1c level, and other factors should be considered in making this choice.

Select and Dose a Nutritional (Prandial) Insulin

The step for ordering nutritional insulin should assist the clinician in matching the insulin to the type of nutrition that the patient is receiving. For example, rapid‐acting insulin analogs are preferred over regular insulin in the eating patient, in view of their more physiologic profile, which averts the insulin stacking that can occur with regular insulin. If regular insulin is used as the preferred institutional choice for eating patients, the lunchtime dose should be reduced or eliminated altogether, to eliminate insulin stacking.

Table 2 outlines the SHM GCTF preferred regimens for different nutritional situations.

There should be a standing order for nutritional insulin to be held when nutrition is interrupted, whether intentional or unintentional. Patients with interrupted tube feedings could have standing orders for a dextrose infusion to replace the tube feeding carbohydrate load and prevent hypoglycemia. Ideally, there should also be a standing order allowing for real‐time management of the patient with uncertain nutritional intake. For example, when a patient's premeal assessment reveals that she may not tolerate the meal, the patient should be allowed to attempt to eat, and then the nutritional insulin should be given after the meal, in proportion to the amount of food that was eaten. This type of order will require significant nursing education and process redesign in many hospitals, but is essential for matching nutritional insulin to actual intake.

Add Correction Insulin

There is no convincing evidence for the benefit of correction (sliding‐scale) insulin in the inpatient setting, although a randomized trial demonstrating the superiority of basal/nutritional insulin regimens to sliding‐scale only regimens did incorporate a correction insulin scale as an adjunct to the superior basal/nutritional regimen.4 The SHM GCTF again emphasizes that control of hyperglycemia should be proactive and anticipatory of insulin needs, rather than reactive to hyperglycemia. Nonetheless, unexpected hyperglycemic excursions are common, and the use of correction insulin remains a pervasive and arguably logical practice. If correction insulin is used, it should be ordered as a separate step after considering basal and nutrition insulin needs. The doses of scheduled insulin should be adjusted regularly if correction insulin is consistently being required. Ideally, the prescriber should choose a preformatted corrective insulin scale, based on the patient's insulin sensitivity (Appendix 2). There should be a prompt to use the same type of insulin that is being used for nutritional insulin, and there should be instructions that this insulin is given in addition to the basal and nutritional insulin to correct for hyperglycemia. Nocturnal correction‐dose scales should be reduced in the eating patient.

Even after limiting insulin regimens to those in Table 2, multidisciplinary glycemic control teams are still left with several options within these SHM‐preferred regimens. We recommend that your team choose a single, institutionally‐preferred basal‐nutritional‐correction insulin combination for each situation.

Choosing one preferred option for these situations is advantageous because:

• 1

  You can communicate preferred regimens more simply and succinctly to all staff.

• 2

  You eliminate all inappropriate choices for insulin regimens for that situation, as well as some other less preferred, but acceptable choices.

• 3

  You can encourage regimens that are most economical (by promoting the insulin regimens that reflect your hospital formulary choices).

• 4

  Staff members can become very familiar with a few regimens, instead of being confused by a multitude of them. They can identify variations from your preferred choices and target these patients for extra scrutiny and actions should they fail to meet glycemic targets.

Although virtually every institution can provide specific guidance on insulin management in a protocol, there are tradeoffs inherent in how restrictive you can be in pushing these preferred choices in your order sets. Should you eliminate alternate basal or nutritional insulin choices from your order sets? As you integrate more and more of your preferred algorithm and regimens into your order set, you will gain incremental improvement in the standardization of inpatient insulin management. However, you reduce not only variability in ordering, but also the choices available to your prescribers and patients, and in effect you are pushing the providers to use an insulin regimen that often differs from the patient's outpatient regimen. If your institution is not yet ready to go with a single preferred insulin, simply listing your preferred insulin first with the annotation preferred can be enough to increase the use of the preferred insulin.

We endorse building the most protocol‐driven, proscriptive, insulin order set that the Glycemic Control Steering Committee believes their medical staff will accept. There are some caveats to this endorsement. First, there must be extra efforts on the backend of the admission, to ensure that the antihyperglycemic regimen is tailored to the unique needs of the patient (this is discussed further below). Second, a protocol‐driven approach is not a substitute for a good educational program for health care providers or well‐informed clinical judgment. Education should reinforce major concepts driving the protocol and should also highlight exceptions to the rule. Variance from the protocol endorsed choices should be allowed (and even encouraged) when the variance is driven by patient factors (as opposed to provider whim). Learning from this variance is a key concept in refining protocols. Education ideally should not be limited to only protocol‐endorsed choices, as staff should be familiar with the full range of antihyperglycemia regimens seen in inpatient and outpatient settings.

Patient on Continuous Tube Feeding

The SHM GCTF endorses glargine or detemir as the basal insulin of choice for this setting. The nutritional and correction insulin of choice is either an RAA‐I every 4 hours (q4h), or regular insulin every 6 hours (q6h). We endorse this choice because it retains the basal‐nutritional‐correction dose concept, generally allows for continued basal insulin use if the tube feedings become interrupted, and is amenable to building a consistent institutional protocol.

There are some important caveats to this recommendation. First, realize that almost any regimen that provides a stable insulin supply would be acceptable, and many institutions will use glargine or detemir to cover both basal and nutritional needs. The downside to using large boluses of long‐acting insulin in this clinical situation is that any unexpected interruption of the feedings will necessitate prolonged infusions of dextrate 10% solution (D10) to avoid hypoglycemia

Second, because of the glycemic load inherent in tube feedings, maintenance of glycemic control in the setting of enteral feeding may be best managed by providing a higher percentage of the TDD as nutritional insulin. In these cases, ratios of basal to nutritional insulin of 40:60, or even less basal insulin, may be appropriate.

Glucocorticoid Therapy

High‐dose glucocorticoids are strongly associated with increased insulin requirements. The degree of hyperglycemia induced by steroids varies significantly from patient to patient, and the pattern of hyperglycemia will vary depending on the pattern of steroid administration. The general principle to keep in mind is that the hyperglycemia induced by a steroid dose will peak 8‐12 hours after it is given, so insulin regimens to address this should take this effect into account. For example, giving a long‐acting basal insulin like glargine to accommodate the hyperglycemic effect of a steroid bolus given in the morning would be inappropriate because the steroid effect would wane and then disappear overnight, leading to insulin‐induced hypoglycemia. NPH insulin can be ideal in this setting, either by itself, or by layering it on top of an existing regimen.

Another caveat: glucocorticoids exert their predominate effect on insulin sensitivity in muscle (as opposed to the liver), and as a result, have their most notable effect on postprandial glucose. For this reason, the best insulin regimens for this situation may use proportionally less basal insulin and more nutritional insulin. One common regimen calls for keeping the basal insulin dose the same as the preglucocorticoid dose, while escalating the RAA insulin dose at lunch and dinner.

Given the complexities of covering steroid‐induced hyperglycemia and its high prevalence in certain populations (such as transplantation patients and patients undergoing chemotherapy), this would be an excellent area on which to focus expertise. Examples include routine endocrinology consultation, intervention by a special glycemic control team, or incorporating routine glucose monitoring and triggers for initiating insulin infusion into the protocols for chemotherapy and transplantation patients.

Choose a Total Daily Dose

Clinicians need guidance on how much subcutaneous insulin they should give a patient. These doses are well known from clinical experience and the published literature. The fear of hypoglycemia usually results in substantial underdosing of insulin, or total avoidance of scheduled insulin on admission. Your team should provide guidance for how much insulin to start a patient on when it is unclear from past experience how much insulin the patient needs. Waiting a few days to see how much insulin is required via sliding‐scale‐only regimens is a bad practice that should be discouraged for patients whose glucose values are substantially above the glycemic target. The total daily dose (TDD) can be estimated in several different ways (as demonstrated in Appendix 1 and 2), and protocols should make this step very clear for clinicians. Providing a specific location on the order set to declare the TDD may help ensure this step gets done more reliably. Some institutions with computer physician order entry (CPOE) provide assistance with calculating the TDD and the allocation of basal and nutritional components, based on data the ordering physician inputs into the system.

Select and Dose a Basal Insulin

Your protocol should describe how the TDD should be divided between basal and nutritional insulin. We generally recommend 50% of the TDD be given as basal insulin, with the other 50% administered on a scheduled basis to cover glycemic excursions from nutritional intake. The 50/50 rule is simple and generally works well, and should be widely promoted. However, there are exceptions to this rule that should be incorporated into your full protocol and educational programs. The order set should have separate steps for ordering basal insulin, nutritional insulin, and correction insulin. The advantage to providing these insulin components separately is that it allows them to be independently manipulated (eg, if a patient is unable to tolerate a meal, nutritional insulin is held, but basal insulin and correction insulin are continued).

The SHM GCTF specifically endorses long acting insulin (glargine and detemir) as the preferred basal insulin in the hospital setting, thus discouraging the use of neutral protamine Hagedorn (NPH) insulin and fixed combination insulin formulations (Table 2). In the absence of randomized controlled trials demonstrating superiority of the glargine or detemir to NPH insulin in the hospital, this endorsement deserves some further explanation. Although we believe that correctly dosed NPH containing insulin regimens can attain effective and safe glycemic control in the hospital setting, it is more difficult to standardize their use and adjust for fluctuations in nutritional intake. Glargine and detemir have much less pronounced spikes in their effect than NPH, rendering them relatively peakless in comparison. This pharmacokinetic profile allows for continued dosing with minimal or no correction when nutrition intake is variable, and allow for consistent reinforcement of the basal‐nutritional‐correction insulin concept.

There are some caveats to this general recommendation. First, patients who are well controlled on home regimens with NPH basal insulin can (and sometimes should) stay on the regimen that has worked well for them. However, extra vigilance in reducing the dose for reductions in nutrition is required, because NPH is generally used to cover both nutritional and basal requirements. Second, extensive experience with glargine and detemir are not available in obstetric populations. They are not U.S. Food and Drug Administration (FDA) approved for use in pregnant patients and formally carry a Class C rating, whereas NPH insulin has been used safely in obstetric populations for decades. Third, the insulin regimen used as an inpatient is not necessarily the preferred regimen to prescribe at discharge: cost, patient preferences, HbA1c level, and other factors should be considered in making this choice.

Select and Dose a Nutritional (Prandial) Insulin

The step for ordering nutritional insulin should assist the clinician in matching the insulin to the type of nutrition that the patient is receiving. For example, rapid‐acting insulin analogs are preferred over regular insulin in the eating patient, in view of their more physiologic profile, which averts the insulin stacking that can occur with regular insulin. If regular insulin is used as the preferred institutional choice for eating patients, the lunchtime dose should be reduced or eliminated altogether, to eliminate insulin stacking.

Table 2 outlines the SHM GCTF preferred regimens for different nutritional situations.

There should be a standing order for nutritional insulin to be held when nutrition is interrupted, whether intentional or unintentional. Patients with interrupted tube feedings could have standing orders for a dextrose infusion to replace the tube feeding carbohydrate load and prevent hypoglycemia. Ideally, there should also be a standing order allowing for real‐time management of the patient with uncertain nutritional intake. For example, when a patient's premeal assessment reveals that she may not tolerate the meal, the patient should be allowed to attempt to eat, and then the nutritional insulin should be given after the meal, in proportion to the amount of food that was eaten. This type of order will require significant nursing education and process redesign in many hospitals, but is essential for matching nutritional insulin to actual intake.

Add Correction Insulin

There is no convincing evidence for the benefit of correction (sliding‐scale) insulin in the inpatient setting, although a randomized trial demonstrating the superiority of basal/nutritional insulin regimens to sliding‐scale only regimens did incorporate a correction insulin scale as an adjunct to the superior basal/nutritional regimen.4 The SHM GCTF again emphasizes that control of hyperglycemia should be proactive and anticipatory of insulin needs, rather than reactive to hyperglycemia. Nonetheless, unexpected hyperglycemic excursions are common, and the use of correction insulin remains a pervasive and arguably logical practice. If correction insulin is used, it should be ordered as a separate step after considering basal and nutrition insulin needs. The doses of scheduled insulin should be adjusted regularly if correction insulin is consistently being required. Ideally, the prescriber should choose a preformatted corrective insulin scale, based on the patient's insulin sensitivity (Appendix 2). There should be a prompt to use the same type of insulin that is being used for nutritional insulin, and there should be instructions that this insulin is given in addition to the basal and nutritional insulin to correct for hyperglycemia. Nocturnal correction‐dose scales should be reduced in the eating patient.

Even after limiting insulin regimens to those in Table 2, multidisciplinary glycemic control teams are still left with several options within these SHM‐preferred regimens. We recommend that your team choose a single, institutionally‐preferred basal‐nutritional‐correction insulin combination for each situation.

Choosing one preferred option for these situations is advantageous because:

• 1

  You can communicate preferred regimens more simply and succinctly to all staff.

• 2

  You eliminate all inappropriate choices for insulin regimens for that situation, as well as some other less preferred, but acceptable choices.

• 3

  You can encourage regimens that are most economical (by promoting the insulin regimens that reflect your hospital formulary choices).

• 4

  Staff members can become very familiar with a few regimens, instead of being confused by a multitude of them. They can identify variations from your preferred choices and target these patients for extra scrutiny and actions should they fail to meet glycemic targets.

Although virtually every institution can provide specific guidance on insulin management in a protocol, there are tradeoffs inherent in how restrictive you can be in pushing these preferred choices in your order sets. Should you eliminate alternate basal or nutritional insulin choices from your order sets? As you integrate more and more of your preferred algorithm and regimens into your order set, you will gain incremental improvement in the standardization of inpatient insulin management. However, you reduce not only variability in ordering, but also the choices available to your prescribers and patients, and in effect you are pushing the providers to use an insulin regimen that often differs from the patient's outpatient regimen. If your institution is not yet ready to go with a single preferred insulin, simply listing your preferred insulin first with the annotation preferred can be enough to increase the use of the preferred insulin.

We endorse building the most protocol‐driven, proscriptive, insulin order set that the Glycemic Control Steering Committee believes their medical staff will accept. There are some caveats to this endorsement. First, there must be extra efforts on the backend of the admission, to ensure that the antihyperglycemic regimen is tailored to the unique needs of the patient (this is discussed further below). Second, a protocol‐driven approach is not a substitute for a good educational program for health care providers or well‐informed clinical judgment. Education should reinforce major concepts driving the protocol and should also highlight exceptions to the rule. Variance from the protocol endorsed choices should be allowed (and even encouraged) when the variance is driven by patient factors (as opposed to provider whim). Learning from this variance is a key concept in refining protocols. Education ideally should not be limited to only protocol‐endorsed choices, as staff should be familiar with the full range of antihyperglycemia regimens seen in inpatient and outpatient settings.

Patient on Continuous Tube Feeding

The SHM GCTF endorses glargine or detemir as the basal insulin of choice for this setting. The nutritional and correction insulin of choice is either an RAA‐I every 4 hours (q4h), or regular insulin every 6 hours (q6h). We endorse this choice because it retains the basal‐nutritional‐correction dose concept, generally allows for continued basal insulin use if the tube feedings become interrupted, and is amenable to building a consistent institutional protocol.

There are some important caveats to this recommendation. First, realize that almost any regimen that provides a stable insulin supply would be acceptable, and many institutions will use glargine or detemir to cover both basal and nutritional needs. The downside to using large boluses of long‐acting insulin in this clinical situation is that any unexpected interruption of the feedings will necessitate prolonged infusions of dextrate 10% solution (D10) to avoid hypoglycemia

Second, because of the glycemic load inherent in tube feedings, maintenance of glycemic control in the setting of enteral feeding may be best managed by providing a higher percentage of the TDD as nutritional insulin. In these cases, ratios of basal to nutritional insulin of 40:60, or even less basal insulin, may be appropriate.

Glucocorticoid Therapy

High‐dose glucocorticoids are strongly associated with increased insulin requirements. The degree of hyperglycemia induced by steroids varies significantly from patient to patient, and the pattern of hyperglycemia will vary depending on the pattern of steroid administration. The general principle to keep in mind is that the hyperglycemia induced by a steroid dose will peak 8‐12 hours after it is given, so insulin regimens to address this should take this effect into account. For example, giving a long‐acting basal insulin like glargine to accommodate the hyperglycemic effect of a steroid bolus given in the morning would be inappropriate because the steroid effect would wane and then disappear overnight, leading to insulin‐induced hypoglycemia. NPH insulin can be ideal in this setting, either by itself, or by layering it on top of an existing regimen.

Another caveat: glucocorticoids exert their predominate effect on insulin sensitivity in muscle (as opposed to the liver), and as a result, have their most notable effect on postprandial glucose. For this reason, the best insulin regimens for this situation may use proportionally less basal insulin and more nutritional insulin. One common regimen calls for keeping the basal insulin dose the same as the preglucocorticoid dose, while escalating the RAA insulin dose at lunch and dinner.

Given the complexities of covering steroid‐induced hyperglycemia and its high prevalence in certain populations (such as transplantation patients and patients undergoing chemotherapy), this would be an excellent area on which to focus expertise. Examples include routine endocrinology consultation, intervention by a special glycemic control team, or incorporating routine glucose monitoring and triggers for initiating insulin infusion into the protocols for chemotherapy and transplantation patients.

Choose a Total Daily Dose

Clinicians need guidance on how much subcutaneous insulin they should give a patient. These doses are well known from clinical experience and the published literature. The fear of hypoglycemia usually results in substantial underdosing of insulin, or total avoidance of scheduled insulin on admission. Your team should provide guidance for how much insulin to start a patient on when it is unclear from past experience how much insulin the patient needs. Waiting a few days to see how much insulin is required via sliding‐scale‐only regimens is a bad practice that should be discouraged for patients whose glucose values are substantially above the glycemic target. The total daily dose (TDD) can be estimated in several different ways (as demonstrated in Appendix 1 and 2), and protocols should make this step very clear for clinicians. Providing a specific location on the order set to declare the TDD may help ensure this step gets done more reliably. Some institutions with computer physician order entry (CPOE) provide assistance with calculating the TDD and the allocation of basal and nutritional components, based on data the ordering physician inputs into the system.

Select and Dose a Basal Insulin

Your protocol should describe how the TDD should be divided between basal and nutritional insulin. We generally recommend 50% of the TDD be given as basal insulin, with the other 50% administered on a scheduled basis to cover glycemic excursions from nutritional intake. The 50/50 rule is simple and generally works well, and should be widely promoted. However, there are exceptions to this rule that should be incorporated into your full protocol and educational programs. The order set should have separate steps for ordering basal insulin, nutritional insulin, and correction insulin. The advantage to providing these insulin components separately is that it allows them to be independently manipulated (eg, if a patient is unable to tolerate a meal, nutritional insulin is held, but basal insulin and correction insulin are continued).

The SHM GCTF specifically endorses long acting insulin (glargine and detemir) as the preferred basal insulin in the hospital setting, thus discouraging the use of neutral protamine Hagedorn (NPH) insulin and fixed combination insulin formulations (Table 2). In the absence of randomized controlled trials demonstrating superiority of the glargine or detemir to NPH insulin in the hospital, this endorsement deserves some further explanation. Although we believe that correctly dosed NPH containing insulin regimens can attain effective and safe glycemic control in the hospital setting, it is more difficult to standardize their use and adjust for fluctuations in nutritional intake. Glargine and detemir have much less pronounced spikes in their effect than NPH, rendering them relatively peakless in comparison. This pharmacokinetic profile allows for continued dosing with minimal or no correction when nutrition intake is variable, and allow for consistent reinforcement of the basal‐nutritional‐correction insulin concept.

There are some caveats to this general recommendation. First, patients who are well controlled on home regimens with NPH basal insulin can (and sometimes should) stay on the regimen that has worked well for them. However, extra vigilance in reducing the dose for reductions in nutrition is required, because NPH is generally used to cover both nutritional and basal requirements. Second, extensive experience with glargine and detemir are not available in obstetric populations. They are not U.S. Food and Drug Administration (FDA) approved for use in pregnant patients and formally carry a Class C rating, whereas NPH insulin has been used safely in obstetric populations for decades. Third, the insulin regimen used as an inpatient is not necessarily the preferred regimen to prescribe at discharge: cost, patient preferences, HbA1c level, and other factors should be considered in making this choice.

Select and Dose a Nutritional (Prandial) Insulin

The step for ordering nutritional insulin should assist the clinician in matching the insulin to the type of nutrition that the patient is receiving. For example, rapid‐acting insulin analogs are preferred over regular insulin in the eating patient, in view of their more physiologic profile, which averts the insulin stacking that can occur with regular insulin. If regular insulin is used as the preferred institutional choice for eating patients, the lunchtime dose should be reduced or eliminated altogether, to eliminate insulin stacking.

Table 2 outlines the SHM GCTF preferred regimens for different nutritional situations.

There should be a standing order for nutritional insulin to be held when nutrition is interrupted, whether intentional or unintentional. Patients with interrupted tube feedings could have standing orders for a dextrose infusion to replace the tube feeding carbohydrate load and prevent hypoglycemia. Ideally, there should also be a standing order allowing for real‐time management of the patient with uncertain nutritional intake. For example, when a patient's premeal assessment reveals that she may not tolerate the meal, the patient should be allowed to attempt to eat, and then the nutritional insulin should be given after the meal, in proportion to the amount of food that was eaten. This type of order will require significant nursing education and process redesign in many hospitals, but is essential for matching nutritional insulin to actual intake.

Add Correction Insulin

There is no convincing evidence for the benefit of correction (sliding‐scale) insulin in the inpatient setting, although a randomized trial demonstrating the superiority of basal/nutritional insulin regimens to sliding‐scale only regimens did incorporate a correction insulin scale as an adjunct to the superior basal/nutritional regimen.4 The SHM GCTF again emphasizes that control of hyperglycemia should be proactive and anticipatory of insulin needs, rather than reactive to hyperglycemia. Nonetheless, unexpected hyperglycemic excursions are common, and the use of correction insulin remains a pervasive and arguably logical practice. If correction insulin is used, it should be ordered as a separate step after considering basal and nutrition insulin needs. The doses of scheduled insulin should be adjusted regularly if correction insulin is consistently being required. Ideally, the prescriber should choose a preformatted corrective insulin scale, based on the patient's insulin sensitivity (Appendix 2). There should be a prompt to use the same type of insulin that is being used for nutritional insulin, and there should be instructions that this insulin is given in addition to the basal and nutritional insulin to correct for hyperglycemia. Nocturnal correction‐dose scales should be reduced in the eating patient.

Even after limiting insulin regimens to those in Table 2, multidisciplinary glycemic control teams are still left with several options within these SHM‐preferred regimens. We recommend that your team choose a single, institutionally‐preferred basal‐nutritional‐correction insulin combination for each situation.

Choosing one preferred option for these situations is advantageous because:

• 1

  You can communicate preferred regimens more simply and succinctly to all staff.

• 2

  You eliminate all inappropriate choices for insulin regimens for that situation, as well as some other less preferred, but acceptable choices.

• 3

  You can encourage regimens that are most economical (by promoting the insulin regimens that reflect your hospital formulary choices).

• 4

  Staff members can become very familiar with a few regimens, instead of being confused by a multitude of them. They can identify variations from your preferred choices and target these patients for extra scrutiny and actions should they fail to meet glycemic targets.

Although virtually every institution can provide specific guidance on insulin management in a protocol, there are tradeoffs inherent in how restrictive you can be in pushing these preferred choices in your order sets. Should you eliminate alternate basal or nutritional insulin choices from your order sets? As you integrate more and more of your preferred algorithm and regimens into your order set, you will gain incremental improvement in the standardization of inpatient insulin management. However, you reduce not only variability in ordering, but also the choices available to your prescribers and patients, and in effect you are pushing the providers to use an insulin regimen that often differs from the patient's outpatient regimen. If your institution is not yet ready to go with a single preferred insulin, simply listing your preferred insulin first with the annotation preferred can be enough to increase the use of the preferred insulin.

We endorse building the most protocol‐driven, proscriptive, insulin order set that the Glycemic Control Steering Committee believes their medical staff will accept. There are some caveats to this endorsement. First, there must be extra efforts on the backend of the admission, to ensure that the antihyperglycemic regimen is tailored to the unique needs of the patient (this is discussed further below). Second, a protocol‐driven approach is not a substitute for a good educational program for health care providers or well‐informed clinical judgment. Education should reinforce major concepts driving the protocol and should also highlight exceptions to the rule. Variance from the protocol endorsed choices should be allowed (and even encouraged) when the variance is driven by patient factors (as opposed to provider whim). Learning from this variance is a key concept in refining protocols. Education ideally should not be limited to only protocol‐endorsed choices, as staff should be familiar with the full range of antihyperglycemia regimens seen in inpatient and outpatient settings.

Patient on Continuous Tube Feeding

The SHM GCTF endorses glargine or detemir as the basal insulin of choice for this setting. The nutritional and correction insulin of choice is either an RAA‐I every 4 hours (q4h), or regular insulin every 6 hours (q6h). We endorse this choice because it retains the basal‐nutritional‐correction dose concept, generally allows for continued basal insulin use if the tube feedings become interrupted, and is amenable to building a consistent institutional protocol.

There are some important caveats to this recommendation. First, realize that almost any regimen that provides a stable insulin supply would be acceptable, and many institutions will use glargine or detemir to cover both basal and nutritional needs. The downside to using large boluses of long‐acting insulin in this clinical situation is that any unexpected interruption of the feedings will necessitate prolonged infusions of dextrate 10% solution (D10) to avoid hypoglycemia

Second, because of the glycemic load inherent in tube feedings, maintenance of glycemic control in the setting of enteral feeding may be best managed by providing a higher percentage of the TDD as nutritional insulin. In these cases, ratios of basal to nutritional insulin of 40:60, or even less basal insulin, may be appropriate.

Glucocorticoid Therapy

High‐dose glucocorticoids are strongly associated with increased insulin requirements. The degree of hyperglycemia induced by steroids varies significantly from patient to patient, and the pattern of hyperglycemia will vary depending on the pattern of steroid administration. The general principle to keep in mind is that the hyperglycemia induced by a steroid dose will peak 8‐12 hours after it is given, so insulin regimens to address this should take this effect into account. For example, giving a long‐acting basal insulin like glargine to accommodate the hyperglycemic effect of a steroid bolus given in the morning would be inappropriate because the steroid effect would wane and then disappear overnight, leading to insulin‐induced hypoglycemia. NPH insulin can be ideal in this setting, either by itself, or by layering it on top of an existing regimen.

Another caveat: glucocorticoids exert their predominate effect on insulin sensitivity in muscle (as opposed to the liver), and as a result, have their most notable effect on postprandial glucose. For this reason, the best insulin regimens for this situation may use proportionally less basal insulin and more nutritional insulin. One common regimen calls for keeping the basal insulin dose the same as the preglucocorticoid dose, while escalating the RAA insulin dose at lunch and dinner.

Given the complexities of covering steroid‐induced hyperglycemia and its high prevalence in certain populations (such as transplantation patients and patients undergoing chemotherapy), this would be an excellent area on which to focus expertise. Examples include routine endocrinology consultation, intervention by a special glycemic control team, or incorporating routine glucose monitoring and triggers for initiating insulin infusion into the protocols for chemotherapy and transplantation patients.