Designing and implementing insulin infusion protocols and order sets

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children

OBJECTIVE

Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.

METHODS

Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.

RESULTS

After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.

CONCLUSIONS

Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.

Near-euglycemia can be achieved safely in pediatric total pancreatectomy islet autotransplant recipients using an adapted intravenous insulin infusion protocol

BACKGROUND

Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in β-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant.

SUBJECTS AND METHODS

Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]).

RESULTS

During IIP, the mean patient BG level was 116±27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n=16) had a lower mean BG and less variability than the early era (first 16 patients) (P≤0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P<0.0001).

CONCLUSIONS

Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.

Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics

Insulin is a top source of adverse drug events in the hospital, and glycemic control is a focus of improvement efforts across the country. Yet, the majority of hospitals have no data to gauge their performance on glycemic control, hypoglycemia rates, or hypoglycemic management. Current tools to outsource glucometrics reports are limited in availability or function. Society of Hospital Medicine (SHM) faculty designed and implemented a web-based data and reporting center that calculates glucometrics on blood glucose data files securely uploaded by users. Unit labels, care type (critical care, non-critical care), and unit type (eg, medical, surgical, mixed, pediatrics) are defined on upload allowing for robust, flexible reporting. Reports for any date range, care type, unit type, or any combination of units are available on demand for review or downloading into a variety of file formats. Four reports with supporting graphics depict glycemic control, hypoglycemia, and hypoglycemia management by patient day or patient stay. Benchmarking and performance ranking reports are generated periodically for all hospitals in the database. In all, 76 hospitals have uploaded at least 12 months of data for non-critical care areas and 67 sites have uploaded critical care data. Critical care benchmarking reveals wide variability in performance. Some hospitals achieve top quartile performance in both glycemic control and hypoglycemia parameters. This new web-based glucometrics data and reporting tool allows hospitals to track their performance with a flexible reporting system, and provides them with external benchmarking. Tools like this help to establish standardized glucometrics and performance standards.

Effectively identifying the inpatient with hyperglycemia to increase patient care and lower costs

Recent years have seen an increased focus on merging quality care and financial results. This focus not only extends to the inpatient setting but also is of major importance in assuring effective transitions of care from hospital to home. Inducements to meld the 2 factors include tying payment to quality standards, investing in patient safety, and offering new incentives for providers who deliver high-quality and coordinated care. Once seen as the purview of primary care or specific surgical screening programs, identification of patients with hyperglycemia or undiagnosed diabetes mellitus now presents providers with opportunities to improve care. Part of the new focus will need to address the length of stay for patients with diabetes mellitus. These patients are proven to require longer hospital stays regardless of the admission diagnosis. With reducing length of stay as a major objective, efficiency combined with improved quality is the desired outcome. Even with the mounting evidence supporting the benefits of improving glycemic control in the hospital setting, institutions continue to struggle with inpatient glycemic control. Multiple national groups have provided recommendations for blood glucose assessment and glycated hemoglobin testing. This article identifies the key benefits in identifying patients with hyperglycemia and reviews possible ways to identify, monitor, and treat this potential problem area and thereby increase the level of patient care and cost-effectiveness.

Improving glycemic control in the acute care setting through nurse education

Patients with a primary or secondary diagnosis of diabetes present unique challenges during an inpatient hospital stay to treat an acute or chronic illness. Upon review of current hospital practice, an interprofessional team embarked on a performance improvement project to improve outcomes for the complex medical-surgical diabetic patient. The methods detailed herein--a comprehensive education plan, preceptorship and peer accountability, active engagement and support by the unit nursing leadership team, and interprofessional collaboration--offer strategies any organization can implement to positively impact diabetes care.

Development of a computerized intravenous insulin application (AutoCal) at Kaiser Permanente Northwest, integrated into Kaiser Permanente HealthConnect: impact on safety and nursing workload

CONTEXT

The electronic medical record, HealthConnect, at the Kaiser Sunnyside Medical Center in the Northwest used scanned paper protocols for intravenous insulin administration. A chart review of 15 patients on intravenous insulin therapy using state-of-the-art paper-based column protocols revealed 40% deviation from the protocol. A time study of experienced nurses computing the insulin dose revealed an average of 2 minutes per calculation per hour to complete.

OBJECTIVE

To improve patient safety and to reduce nursing workload burden with a computerized intravenous insulin calculator application connected to HealthConnect.

SOLUTION

Using Kaiser iLab developers through innovation funding, a computerized protocol was developed and integrated into HealthConnect, with a computerized tracking system used to store and to analyze intravenous insulin data.

OUTCOME

A review of 35 patient charts using computerized insulin infusion tool indicated 100% accuracy in computations with a reduction of nursing workload from 2 minutes to 30 seconds per calculation.

CONCLUSION

Development and operationalizing an integrated intravenous insulin calculator into HealthConnect was successfully completed at the Kaiser Sunnyside Medical Center, with 97% nursing satisfaction scores and a promise to generate data on intravenous insulin therapy to refine the protocol.

2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level

BACKGROUND

The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions).

METHODS

More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center.

RESULTS

Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams.

CONCLUSIONS

Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Provision of balanced nutrition protects against hypoglycemia in the critically ill surgical patient

BACKGROUND

Intensive insulin therapy lowers blood glucose and improves outcomes but increases the risk of hypoglycemia. Typically, insulin protocols require a dextrose solution to prevent hypoglycemia. The authors hypothesized that the provision of balanced nutrition (enteral nutrition [EN] or parenteral nutrition [PN]) would be more protective against hypoglycemia (≤50 mg/dL) than carbohydrate alone.

METHODS

A retrospective analysis was performed of patients treated with intensive insulin therapy and surviving ≥24 hours. The computer-based insulin protocol requires infusion of D10W at 30 mL/h if EN or PN is not provided. Nutrition provision was assessed in 2-hour increments, comparing periods of blood glucose control with and without balanced nutrition. The risk of hypoglycemia for each blood glucose measurement was estimated by multivariable regression.

RESULTS

In total, 66,592 glucose measurements were collected on 1392 patients. Hypoglycemic events occurred in 5.8/1000 glucose tests after 2 hours without balanced nutrition compared to 2.2/1000 tests when balanced nutrition was given in the preceding 2 hours. In multivariable regression models, balanced nutrition was the strongest protective factor against hypoglycemia. Patients who did not receive balanced nutrition in the preceding 2 hours had a 3 times increase in the odds of a hypoglycemic event at their next glucose check (odds ratio = 3.6, P < .001). Providing carbohydrate alone was not protective.

CONCLUSIONS

Balanced nutrition is associated with reduced risk of hypoglycemia. These results suggest that balanced nutrition should be given when insulin therapy is initiated. Future studies should evaluate the efficacy of EN vs PN in preventing hypoglycemia.