Reducing hyperglycemia hospitalwide: the basal-bolus concept.

BACKGROUND: Hyperglycemia has been identified as potent and independent risk factor for adverse outcomes for patients. An initiative was undertaken to reduce hyperglycemia hospitalwide in adults. METHODS: In a multistep process, insulin protocols were implemented hospitalwide via an electronic provider order entry system. Education regarding basal bolus insulin delivery preceded implementation. Protocols were modified in an ongoing manner on the basis of clinical staff feedback and blood glucose monitoring. Key practice changes included intravenous insulin for initial management in ICU patients, insulin replacement based on the basal bolus approach, elimination of sliding-scale insulin, standardization of blood glucose monitoring before meals, adjustment of prandial dose insulin based on food consumed, administration of prandial dose after the meal, evening snacks ordered based on insulin type, and a glycosolated hemoglobin (A1C) determination for patients with admission glucose > 180 mg/dL. Median inpatient glucose levels in patients with diabetes were assessed using statistical process control methodology. RESULTS: Between January 2004 and September 2007, median glucose for all inpatients with diabetes decreased 15% from 159 mg/dL to < 135 mg/dL. The percentage of inpatients with diabetes who experienced a day with a glucose measurement above 180 mg/dl decreased from 66% to 53%. Frequency of hypoglycemia (< 60 mg/dL) did not change following protocol implementation. DISCUSSION: Major improvements in hospitalwide blood glucose control are feasible and safe, employing standard protocols based on the basal-bolus concept. Improvement was sustained during a four-year period with ongoing institutional support, multidisciplinary education, collaboration between clinical services, and monitoring of clinical outcomes on a quarterly basis.

Daily physical movement and bone mineral density among a mixed racial cohort of women.

PURPOSE: The impact of lifestyle physical activity on bone mineral density (BMD) is unclear. We examined the influence of physical activities typical of everyday life on BMD among 151 women (52.0 +/- 0.9 yr). These women were of low socioeconomic status, and 57.6% were Hispanic, 17.2% black, and 24.5% white. METHODS: BMD was measured at the calcaneus by ultrasound with a Hologic Sahara sonometer. We measured physical activity with two questions from the Yale Physical Activity Survey that assessed h x d(-1) spent in motion typical of the past month and number of flights of stairs climbed up daily. Multivariate ANCOVA adjusted for adiposity and nutrients and medications known to influence BMD determined whether BMD differed between categories of physical activity (<2 vs > or = 2 flights x d(-1) and <7 vs > or = 7 h x d(-1)), menopausal status (pre- vs post-), and ethnic group (white vs nonwhite). RESULTS: Among the premenopausal women (N = 63, 43.2+/-0.9 yr), adjusted mean calcaneal BMD and BMD T-score were similar between categories of stair climbing and accumulated daily movement regardless of ethnic origin (P > 0.05). Among the postmenopausal women (N = 88, 58.1 +/- 1.0 yr), adjusted mean calcaneal BMD (0.561 +/- 0.019 g x cm(-2) vs 0.503 +/- 0.016) (P = 0.022) and BMD T-score (-0.172 +/- 0.166 vs -0.695 +/- 0.143) (P = 0.020) were higher with more flights of stairs climbed daily in the Hispanic and black women only. Similarly, calcaneal BMD (0.579 +/- 0.023 g x cm(-2) vs 0.505 +/- 0.014) (P = 0.010) and BMD T-score (-0.020 +/- 0.209 vs -0.678 +/- 0.129) (P = 0.010) were higher with greater amounts of daily movement in only the older Hispanic and black women. CONCLUSION: Lifestyle physical activity positively impacted BMD indicators in a mixed racial cohort of postmenopausal women. Older Hispanic and black women should be encouraged to engage in physical activities typical of everyday life to attenuate age-related bone loss.