Best Practices for Ordering Correctional Insulin for Acute, Non-Critically Ill Older Adults: An Expert Survey

Abstract

Background: Guidelines discourage correction only insulin for managing hyperglycemia in hospitalized non-critically ill adults in favour of basal-bolus-correction strategies. Older adults are at increased risk for harm from treatment but limited prospective data exists to guide practices in these patients. Appropriateness of extrapolating practices in younger adults to hospitalized older adults is unclear. Objectives: Our aims were to generate a list of best practices for ordering correctional insulin in acute, non-critically ill older adults and to evaluate the utility of a modified order set. Methods: Seventeen institutional experts at a Canadian teaching hospital were invited to participate in an online survey to assess their agreement with statements about correctional insulin use in acute, non-critically ill older adults and proposed modifications to an existing order set. Responses were captured using a Likert-type scale and analyzed descriptively. Survey items with unanimous agreement were identified as ‘best practice statements’ or ‘endorsed modifications’. Free text responses were analyzed qualitatively to identify themes. Results: The survey response rate was 47%. Six best practice statements focused on blood glucose targets and correction scale selection were identified. Themes included lenient blood glucose targets in frail adults, individualization of treatment, and correction insulin as a bridging strategy. There were seven endorsed modifications aimed at updating terminology, increasing standardization, and providing clinical decision support. Conclusions: Available literature can be applied to acute, non-critically ill older adults when ordering correctional insulin. However, strategies to reduce hypoglycemia risk and ongoing reassessment are required to optimize treatment efficacy and safety, particularly in frail adults.