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Olsen MT, Rasmussen LM, Bach E, Demir C, Klarskov CK, Pedersen-Bjergaard U, Hansen KB, Molsted S, Lommer Kristensen P. Healthcare professionals' competencies and confidence in managing hospitalized patients with type 2 diabetes. Diabet Med 2024:e15392. [PMID: 38924549 DOI: 10.1111/dme.15392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
AIMS In hospitals, 15%-20% of patients have diabetes. Therefore, all healthcare professionals (HCPs) must have a basic knowledge of in-hospital diabetes management. This survey assessed the knowledge of diabetes among HCPs in Denmark. METHODS A 27-item questionnaire was developed and reviewed independently before the survey was distributed. The questionnaire contained seven baseline questions on the HCPs' current workplace, educational level, usual shift routines and years of experience, 18 multiple-choice questions and 2 cases. RESULTS A total of 252 completed questionnaires were returned by 133 (52.8%) physicians, 101 (40.1%) nurses and 18 (7.1%) healthcare assistants. HCPs answered 50% of the questions correctly. Having experience from endocrinological departments increased the correct response score (0%-100%) by 6.2% points (95% CI 0.3-12.1) (p = 0.039) and 3.1% points (95% CI 1.5-4.7) for every increase in confidence level on a scale from 1 to 10 (p < 0.001). HCPs scored 8 out of 10 on a confidence level scale on average. In a fictive case, 50% of HCPs administered the correct bolus insulin dose. Hyperglycaemia (>10.0 mmol/L) and hypoglycaemia (<3.9 mmol/L) were correctly identified by around 40% of HCPs. Hypoglycaemia was rated more important than hyperglycaemia by most HCPs. CONCLUSION Significant gaps in identifying hypo- and hyperglycaemia and correct administration of bolus insulin have been identified, which could be targeted in future education for HCPs. HCPs answered 50% of questions related to in-hospital diabetes management correctly. Experience from endocrinological departments and self-rated confidence levels are associated with HCPs' in-hospital diabetes competencies.
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Affiliation(s)
- Mikkel Thor Olsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Louise Mathorne Rasmussen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Ermina Bach
- Steno Diabetes Center Aarhus, Regionshospitalet Viborg, Viborg, Denmark
| | - Ceren Demir
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Carina Kirstine Klarskov
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Katrine Bagge Hansen
- Steno Diabetes Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stig Molsted
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Research, Copenhagen University Hospital - North Zealand, Hillerod, Denmark
| | - Peter Lommer Kristensen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Sanders SF, Shen MS, Alaiev D, Knoll B, Cho HJ, Tsega S, Krouss M, Fagan I, Klinger A. Don't hold the metformin: Enhancing inpatient diabetes education to encourage best practices in a public hospital. J Hosp Med 2024; 19:551-556. [PMID: 38695331 DOI: 10.1002/jhm.13269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/01/2023] [Accepted: 12/12/2023] [Indexed: 06/04/2024]
Affiliation(s)
- Samantha F Sanders
- Department of Medicine, NYC Health + Hospitals/Bellevue, New York, New York, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael S Shen
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
- Department of Medicine, NYC Health + Hospitals/Woodhull, Brooklyn, New York, USA
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
| | - Brianna Knoll
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
- Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Surafel Tsega
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
- Department of Medicine, NYC Health + Hospitals/Kings, Brooklyn, New York, USA
| | - Mona Krouss
- Department of Quality and Safety, NYC Health + Hospitals, New York, New York, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Fagan
- Department of Medicine, NYC Health + Hospitals/Bellevue, New York, New York, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Amanda Klinger
- Department of Medicine, NYC Health + Hospitals/Bellevue, New York, New York, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
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Singh LG, Ntelis S, Siddiqui T, Seliger SL, Sorkin JD, Spanakis EK. Association of Continued Use of SGLT2 Inhibitors From the Ambulatory to Inpatient Setting With Hospital Outcomes in Patients With Diabetes: A Nationwide Cohort Study. Diabetes Care 2024; 47:933-940. [PMID: 38051789 DOI: 10.2337/dc23-1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/24/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE Limited data are available on the continuation of outpatient sodium glucose cotransporter 2 inhibitors (SGLT2is) during hospitalization. The objective was to evaluate associations of SGLT2i continuation in the inpatient setting with hospital outcomes. RESEARCH DESIGN AND METHODS This nationwide cohort study used Veterans Affairs health care system data of acute care hospitalizations between 1 April 2013 and 31 August 2021. A total of 36,505 admissions of patients with diabetes with an outpatient prescription for an SGLT2i prior to hospitalization were included. The exposure was defined as SGLT2i continuation during hospitalization. Admissions where SGLT2i was continued were compared with admissions where it was discontinued. The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury (AKI) and length of stay (LOS). Negative binomial propensity score-weighted and zero-truncated analyses were used to compare outcomes and adjusted for multiple covariates, including demographics and comorbidities. RESULTS Mean (SE) age was 67.2 (0.1) and 67.5 (0.1) years (P = 0.03), 97.0% and 96.6% were male (P = 0.1), 71.3% and 72.1% were White, and 20.8% and 20.5% were Black (P = 0.52) for the SGLT2i continued and discontinued groups, respectively. After adjustment for covariates (age, sex, race, BMI, Elixhauser comorbidity index, procedures/surgeries, and insulin use), the SGLT2i continued group had a 45% lower mortality rate (incidence rate ratio [IRR] 0.55, 95% CI 0.42-0.73, P < 0.01), no difference in AKI (IRR 0.96, 95% CI 0.90-1.02, P = 0.17), and decreased LOS (4.7 vs. 4.9 days) (IRR 0.95, 95% CI 0.93-0.98, P < 0.01) versus the SGLT2i discontinued group. Similar associations were observed across multiple sensitivity analyses. CONCLUSIONS Continued SGLT2i during hospitalization among patients with diabetes was associated with lower mortality, no increased AKI, and shorter LOS.
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Affiliation(s)
- Lakshmi G Singh
- Division of Endocrinology, Baltimore VA Medical Center, Baltimore, MD
- Department of Pharmacy, Baltimore VA Medical Center, Baltimore, MD
| | - Spyridon Ntelis
- Division of Endocrinology, Baltimore VA Medical Center, Baltimore, MD
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD
| | - Tariq Siddiqui
- Division of Endocrinology, Baltimore VA Medical Center, Baltimore, MD
- Division of Endocrinology, University of Maryland School of Medicine, Baltimore, MD
| | - Stephen L Seliger
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD
- Medical Care Clinical Service, Baltimore VA Medical Center, Baltimore, MD
| | - John D Sorkin
- Geriatric Research, Education, and Clinical Center, Baltimore VA Medical Center, Baltimore, MD
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Elias K Spanakis
- Division of Endocrinology, Baltimore VA Medical Center, Baltimore, MD
- Division of Endocrinology, University of Maryland School of Medicine, Baltimore, MD
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Alassaf A, Gharaibeh L, Abuna'meh L, Odeh R. Adequacy of knowledge of new medical graduates about diagnosis and management of children and adolescents with type 1 diabetes in a developing country. BMC MEDICAL EDUCATION 2023; 23:234. [PMID: 37046268 PMCID: PMC10100482 DOI: 10.1186/s12909-023-04234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 04/05/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Knowledge of diabetes by the graduate physicians had been reported to be deficient in many aspects of diagnosis and management of type 1 diabetes (T1D). This will reflect on patient care and quality of health services especially in limited-resources countries. Our aim was to assess knowledge of basic management of T1D in new medical graduates in Jordan. METHODS A questionnaire was developed to collect information concerning demographics and knowledge and was distributed in paper form and online using google forms. The knowledge was assessed using 28 questions on different aspects of the disease. RESULTS A total of 358 new medicine graduates responded to the survey and female respondents were significantly higher than male respondents. Average number of lectures concerning diabetes during the medical school years was 3.92 ± 1.37. High knowledge scores were on pathophysiology of T1D, hypoglycemia, and certain aspects of diabetic ketoacidosis. Female gender, higher number of persons with T1D the participant had encountered during medical school, and good or excellent expected degree of self-knowledge of diabetes were associated with high knowledge score, p values = 0.01, 0.009, and < 0.001, respectively. Female gender and good or excellent expected degree of knowledge of diabetes predicted high knowledge score, p value = 0.008, and < 0.001, respectively. CONCLUSION Gaps in knowledge of new medical graduates in certain T1D subjects exist. This can be corrected by many strategies including changes in curricula, elective courses, more clinical exposure, and interprofessional education. These measures must be evaluated for their short and long-term benefits.
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Affiliation(s)
- Abeer Alassaf
- Department of Pediatrics, University of Jordan, Queen Rania Street, Amman, 11942, Jordan.
| | - Lobna Gharaibeh
- Pharmacological and Diagnostic Research Center, Faculty of Pharmacy, Al-Ahliyya Amman University, Amman, Jordan
| | - Lina Abuna'meh
- Department of Pediatrics, University of Jordan, Queen Rania Street, Amman, 11942, Jordan
| | - Rasha Odeh
- Department of Pediatrics, University of Jordan, Queen Rania Street, Amman, 11942, Jordan
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Porter ME, Litchman ML, Grigorian EG, Blanchette JE, Allen NA. Who Needs Diabetes Education? A Qualitative Analysis of Emerging Adults With Type 1 Diabetes. Sci Diabetes Self Manag Care 2021; 47:436-446. [PMID: 34935540 DOI: 10.1177/26350106211051297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study is to explore the diabetes self-management education (DSME) needs of emerging adults with type 1 diabetes mellitus (T1DM) because addressing these needs may facilitate optimal glycemic management during this challenging transitional period. METHODS A hybrid qualitative design was utilized. Emerging adults and parents of emerging adults were recruited from endocrinology and primary care clinics and through a Utah-specific T1DM online community. Interviews were conducted to asses needs to achieve target A1C. Data were interpreted thematically. RESULTS Emerging adults with T1DM (N = 33) and parents of emerging adults with T1DM (N = 17) were interviewed. Three main themes emerged: (1) mixed desire for personal DSME; (2) I don't need the education, others do; and (3) health care provider (HCP) attributes that make a difference. Associated subthemes were reported. CONCLUSIONS Emerging adults reported that further education for themselves was not needed, although newly diagnosed individuals would benefit from increased training in diabetes management. Although many emerging adults had a supportive social network, they endorsed the need for greater public education to avoid diabetes misinformation. Emerging adults felt more connected with HCPs that had diabetes-specific training (ie, endocrinologist) or those who personally live with T1DM.
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Affiliation(s)
| | - Michelle L Litchman
- Utah Diabetes and Endocrinology Center, Salt Lake City, Utah.,University of Utah College of Nursing, Salt Lake City, Utah
| | | | | | - Nancy A Allen
- University of Utah College of Nursing, Salt Lake City, Utah
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Jinjing W, Kang C, Xufei L, Xueqiong L, Xinye J, Miao Y, Jinping Z, Zhaohui L, Jingtao D, Yaolong C, Linong J, Yiming M. Chinese clinical practice guidelines for perioperative blood glucose management. Diabetes Metab Res Rev 2021; 37:e3439. [PMID: 33605539 DOI: 10.1002/dmrr.3439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 12/20/2022]
Abstract
With the increased incidence of diabetes, the number of diabetic patients who require surgical treatment is also increasing. Unfortunately, practices in this area lack standardisation. The purpose of this multidisciplinary, evidence-based guidelines for perioperative blood glucose management is to provide a comprehensive set of recommendations for clinicians treating diabetes with different types of surgery. The intended audience comprises Chinese endocrinologists, surgeons, anaesthetists, clinical pharmacists, nurses and professionals involved in perioperative blood glucose management. The guidelines were formulated as follows. First, a multidisciplinary expert group was established to identify and formulate key research questions on topics of priority according to the Population, Intervention, Comparator and Outcomes (PICO) process. We conducted a meta-analysis of available studies using Review Manager version 5.3, as appropriate. We pooled crude estimates as odds ratios with 95% confidence intervals using a random-effects model, and used the Grading of Recommendations Assessment, Development, and Evaluation methods to assess the quality of the retrieved evidence. Finally, 32 recommendations were gathered that covered 11 fields-management and coordination, endocrinologists' consultation, diabetes diagnosis, surgery timing and anaesthesia method, blood glucose target values and monitoring frequency, hypoglycaemia treatment, oral administration of blood glucose lowering drugs, use of insulin, enteral and parenteral nutritional, postoperative treatment and medication and education and training. Twenty-five systematic reviews and meta-analyses were conducted for these guidelines to address the PICO questions. These guidelines are intended to improve perioperative blood glucose management and help doctors in specifying medical diagnosis and treatment, and will be implemented / disseminated extensively in China.
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Affiliation(s)
- Wang Jinjing
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chen Kang
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Luo Xufei
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Li Xueqiong
- Department of Dry Therapy, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jin Xinye
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Nephrology, Hainan Hospital of Chinese PLA General Hospital, the Hainan Academician Team Innovation Center, Hainan, China
| | - Yu Miao
- Department of EndocrinologyKey Laboratory of EndocrinologyNational Health Commission, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhang Jinping
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Lv Zhaohui
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Dou Jingtao
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chen Yaolong
- Institute of Health Data Science, Lanzhou University, Lanzhou, China
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
| | - Ji Linong
- Department of Endocrinology and Metabolism, Peking University people's Hospital, Peking University Diabetes Center, Beijing, China
| | - Mu Yiming
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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Improving Management of Type 2 Diabetes Mellitus in Hospitalized Adults: A Quality Initiative. J Healthc Qual 2021; 43:e20-e25. [PMID: 33560047 DOI: 10.1097/jhq.0000000000000298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ABSTRACT The American Diabetes Association recommends scheduled basal and nutritional insulin doses as the preferred treatment for noncritically ill hospitalized patients with type 2 diabetes; however, the adoption of these practices remains suboptimal. We sought to understand current diabetes management practices and improve glycemic control in patients with type 2 diabetes on the Hospital Medicine Services at our academic medical center. We surveyed resident and attending physicians to understand barriers to guideline-based practice. We conducted educational sessions, developed pocket-card decision aids, encouraged discussion on rounds, and provided periodic performance feedback to attending physicians. Results of the barriers survey identified "fear of causing hypoglycemia" as the most common barrier to guideline-based practice. Compared with the preintervention 12-month period, these interventions were associated with doubling of the use of guideline-based insulin therapy regimens, a significant reduction in the rate of severe hyperglycemia days, and a nonsignificant reduction in the rate of hypoglycemia days over a 12-month period. These results demonstrate that a simple, low-cost intervention can be associated with an increase in guideline-concordant insulin ordering with improvement in glycemic outcomes for patients with type 2 diabetes.
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Pichardo-Lowden A, Umpierrez G, Lehman EB, Bolton MD, DeFlitch CJ, Chinchilli VM, Haidet PM. Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes. BMJ Open Diabetes Res Care 2021; 9:9/1/e001557. [PMID: 33462075 PMCID: PMC7816906 DOI: 10.1136/bmjdrc-2020-001557] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Innovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations. RESEARCH DESIGN AND METHODS The tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9-4.4 mmol/L (70-80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods. RESULTS When active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized. CONCLUSION EMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Matthew D Bolton
- Department of Information Services, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christopher J DeFlitch
- Department of Emergency Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Paul M Haidet
- Department of Medicine, Public Health Sciences, and Humanities, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Evaluating the Impact of Inadequate Meal Consumption on Insulin-Related Hypoglycemia in Hospitalized Patients. Endocr Pract 2020; 27:443-448. [PMID: 33934753 DOI: 10.1016/j.eprac.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/09/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Meal intake is sometimes reduced in hospitalized patients. Meal-time insulin administration can cause hypoglycemia when a meal is not consumed. Inpatient providers may avoid ordering meal-time insulin due to hypoglycemia concerns, which can result in hyperglycemia. The frequency of reduced meal intake in hospitalized patients remains inadequately determined. This quality improvement project evaluates the percentage of meals consumed by hospitalized patients with insulin orders and the resulting risk of postmeal hypoglycemia (blood glucose [BG] <70 mg/dL, <3.9 mmol/L). METHODS This was a retrospective quality improvement project evaluating patients with any subcutaneous insulin orders hospitalized at a regional academic medical center between 2015 and 2017. BG, laboratory values, point of care, insulin administration, diet orders, and percentage of meal consumed documented by registered nurses were abstracted from electronic health records. RESULTS Meal consumption ≥50% was observed for 85% of meals with insulin orders, and bedside registered nurses were accurate at estimating this percentage. Age ≥65 years was a risk factor for reduced meal consumption (21% of meals 0%-49% consumed, P < .05 vs age < 65 years [12%]). Receiving meal-time insulin and then consuming only 0% to 49% of a meal (defined here as a mismatch) was not rare (6% of meals) and increased postmeal hypoglycemia risk. However, the attributable risk of postmeal hypoglycemia due to this mismatch was low (4 events per 1000) in patients with premeal BG between 70 and 180 mg/dL. CONCLUSION This project demonstrates that hospitalized patients treated with subcutaneous insulin have a low attributable risk of postmeal hypoglycemia related to inadequate meal intake.
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Horton WB, Law S, Darji M, Conaway MR, Akbashev MY, Kubiak NT, Kirby JL, Thigpen SC. A MULTICENTER STUDY EVALUATING PERCEPTIONS AND KNOWLEDGE OF INPATIENT GLYCEMIC CONTROL AMONG RESIDENT PHYSICIANS: ANALYZING THEMES TO INFORM AND IMPROVE CARE. Endocr Pract 2019; 25:1295-1303. [PMID: 31412227 DOI: 10.4158/ep-2019-0299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control. Abbreviations: DM = diabetes mellitus; Emory = Emory University Healthcare; IGC = inpatient glycemic control; IGCQ = Inpatient Glycemic Control Questionnaire; IRB = Institutional Review Board; PGY = postgraduate year; UMMC = University of Mississippi Medical Center; UVA = University of Virginia Health System; UL = University of Louisville Health Sciences Center.
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Horton WB, Law S, Darji M, Conaway MR, Kubiak NT, Kirby JL, Thigpen SC. Construction and preliminary evaluation of the inpatient glycemic control questionnaire (IGCQ): a survey tool assessing perceptions and knowledge of resident physicians. BMC MEDICAL EDUCATION 2019; 19:228. [PMID: 31234836 PMCID: PMC6591905 DOI: 10.1186/s12909-019-1657-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 06/06/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Uncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool. METHODS We developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items. RESULTS Two hundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development. CONCLUSIONS We constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.
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Affiliation(s)
- William B. Horton
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - Sidney Law
- Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Monika Darji
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Mark R. Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA USA
| | - Nancy T. Kubiak
- Division of General Internal Medicine, Palliative Medicine, and Medical Education, Department of Medicine, University of Louisville, Louisville, KY USA
| | - Jennifer L. Kirby
- Divsion of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - S. Calvin Thigpen
- Division of General Internal Medicine and Hypertension, Department of Medicine, University of Mississippi Medical Center, Jackson, MS USA
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Pichardo-Lowden A, Farbaniec M, Haidet P. Overcoming barriers to diabetes care in the hospital: The power of qualitative observations to promote positive change. J Eval Clin Pract 2019; 25:448-455. [PMID: 30378222 PMCID: PMC6563155 DOI: 10.1111/jep.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/21/2018] [Accepted: 10/04/2018] [Indexed: 01/08/2023]
Abstract
AIMS Despite advocacy by diabetes societies and evidence about how to prevent the deleterious consequences of dysglycemia among hospitalized patients, deficits in clinical practice continue to present barriers to care. The purpose of this study was to examine inpatient rounding practices using a qualitative research lens to assess challenges on the care of hospitalized patients with diabetes and to develop ideas for positive changes in hospital management of diabetes and hyperglycemia. METHODS We conducted an interpretive analysis of qualitative observations during medical and surgical inpatient rounds at an academic institution. We coded, analysed, and reported data as thematic findings. RESULTS Emerging themes include omissions in discussions during rounds; unpreparedness to address diabetes or dysglycemia during rounds; identifying practice improvement opportunities to address diabetes issues: and recognizing accountability within the routine of practice. CONCLUSIONS This work guides clinicians and informs systems of practice about improvement strategies that can emerge from within hospital teams. These recommendations emphasize the interconnectedness of practice elements including thoughtful review of glucose status during rounds among patients with and without diabetes; fostering doctors and nurses to work in unison; promoting awareness and integration within and across disciplines; and advocating for better use of existing resources.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Department of Medicine, Division of Endocrinology, Penn State University, Hershey, PA, USA.,College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Michelle Farbaniec
- College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Paul Haidet
- College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA.,Departments of Medicine, Humanities, and Public Health Sciences, and the Woodward Center for Excellence in Health Sciences Education Penn State University, Hershey, PA, USA
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Fernández-Méndez R, Harvey DJR, Windle R, Adams GG. The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals. J Clin Nurs 2019; 28:2088-2100. [PMID: 30653767 DOI: 10.1111/jocn.14774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/07/2018] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols. BACKGROUND Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice. DESIGN Cross-sectional, multicentre, survey-based study. METHODS An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed. RESULTS Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia. CONCLUSIONS When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role. RELEVANCE TO CLINICAL PRACTICE Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.
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Affiliation(s)
| | | | - Richard Windle
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Gary George Adams
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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Mathioudakis N, Bashura H, Boyér L, Langan S, Padmanaban BS, Fayzullin S, Sokolinsky S, Hill Golden S. Development, Implementation, and Evaluation of a Physician-Targeted Inpatient Glycemic Management Curriculum. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2019; 6:2382120519861342. [PMID: 31321305 PMCID: PMC6630074 DOI: 10.1177/2382120519861342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Diabetes is prevalent among hospitalized patients and there are multiple challenges to attaining glycemic control in the hospital setting. We sought to develop an inpatient glycemic management curriculum with stakeholder input and to evaluate the effectiveness of this educational program on glycemic control in hospitalized patients. METHODS Using the Six-Step Approach of Kern to Curriculum Development for Medical Education, we developed and implemented an educational curriculum for inpatient glycemic management targeted to internal medicine residents and hospitalists. We surveyed physicians (n = 73) and conducted focus group sessions (n = 18 physicians) to solicit input regarding educational deficits and desired format of the educational intervention. Based on feedback from the surveys and focus groups, we developed educational goals and objectives and a case-based curriculum, which was delivered over a 1-year period via in-person teaching sessions by 2 experienced diabetes physicians at 3 hospitals. Rates of hypoglycemia and hyperglycemia were evaluated among at-risk patient days using an interrupted time-series design. RESULTS We developed a mnemonic-based (SIGNAL) curriculum consisting of 10 modules, which covers key concepts of inpatient glycemic management and provides an approach to daily glycemic management: S = steroids, I = insulin, G = glucose, N = nutritional status, A = added dextrose, and L = labs. Following implementation of the curriculum, there was no difference in the rates of hyperglycemia in insulin-treated patients following the intervention; however, there was an increase in the rates of hypoglycemia defined as blood glucose (BG) ⩽ 70 mg/dL (5.6% vs 3.0%, P < .001) and clinically significant hypoglycemia defined as BG < 54 mg/dL (1.9% vs 0.8%, P = .01). There was poor penetration of the curriculum, with 60%, 20%, and 90% of the learning modules being delivered at the three participating hospitals, respectively. CONCLUSIONS In this pilot study, a physician-targeted educational curriculum was not associated with improved glycemic control. Adapting the intervention to increase penetration and integrating the curriculum into existing clinical decision support tools may improve the effectiveness of the educational program on glycemic outcomes.
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Affiliation(s)
- Nestoras Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Holly Bashura
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - LaPricia Boyér
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Langan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bama S Padmanaban
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shamil Fayzullin
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, MD, USA
| | - Sam Sokolinsky
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, MD, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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El Khoury G, Mansour H, Kabbara WK, Chamoun N, Atallah N, Salameh P. Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon. Curr Diabetes Rev 2019; 15:133-140. [PMID: 29357807 DOI: 10.2174/1573399814666180119142254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. OBJECTIVE The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. METHODS The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. RESULTS A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). CONCLUSION Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.
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Affiliation(s)
- Ghada El Khoury
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Hanine Mansour
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Wissam K Kabbara
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nibal Chamoun
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nadim Atallah
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Pascale Salameh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Abstract
PURPOSE OF REVIEW Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients. RECENT FINDINGS To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators. In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization's structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.
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Affiliation(s)
- Andjela T Drincic
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA.
| | - Padmaja Akkireddy
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
| | - Jon T Knezevich
- Department of Pharmaceutical and Nutrition Care, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
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Abstract
PURPOSE OF REVIEW Glucometrics is the systematic analysis of inpatient glucose data and is of key interest as hospitals strive to improve inpatient glycemic control. Insulinometrics is the systematic analysis and reporting of inpatient insulin therapy. This paper reviews some of the questions to be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines. RECENT FINDINGS There remains a lack of standardization on how glucometircs should be measured and reported. Before hospitals can commit resources to compiling and extracting data, consensus must be reached on such questions as which measures to report, definitions of glycemic targets, and how data should be obtained. Examples are provided on how insulin administration can be measured and reported. Hospitals should begin assessment of glucometrics and insulinometrics. However, consensus and standardization must first occur to allow for a national benchmarking process.
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Affiliation(s)
- Bithika M Thompson
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
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Bansal S, Marwa A, Kasturi K, Perez-Colon S. Improving paediatric residents' knowledge and perspectives regarding the insulin pump using a novel educational workshop. Postgrad Med J 2017; 94:87-91. [PMID: 29054932 DOI: 10.1136/postgradmedj-2017-135002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/15/2017] [Accepted: 09/09/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES As a pilot study, we aimed to investigate the knowledge and perceptions of categorical paediatric residents (RES) at our institution regarding insulin pumps (IPs) and the impact following a targeted workshop. METHODS All RES at our institution in attendance at a routine noon conference participated in a workshop, completing an anonymous survey before and right after the intervention to evaluate knowledge, attitudes and self-reported comfort regarding IPs. The workshop consisted of a didactic lecture followed by an insulin pump (IP) device demonstration of three commonly available brands. Knowledge score (KS) was calculated for each RES based on the total correct responses. Attitudes were assessed via 5-point Likert scale. Frequencies, t-test and McNemar tests were used to analyse data. RESULTS Thirty four completed surveys were analysed out of 49 RES (69.3%) who attended the workshop. Among them, there were 19 first-year, 8 second-year and 7 third-year residents. Following the intervention, KS increased significantly (p<0.001) with progression in residents' attitudes. Overall, more RES reported being comfortable with handling the IP, including looking up and changing the settings (p<0.001). CONCLUSION There is scope for improvement in the knowledge and perceptions of RES regarding IPs. Educational interventions like ours are needed to familiarise our future physicians with IPs to allow hospitals to provide their systematic and safe inpatient use.
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Affiliation(s)
- Shipra Bansal
- Division of Pediatric Endocrinology, Department of Pediatrics, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, USA
| | - Albara Marwa
- Department of Pediatrics, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, USA
| | - Kannan Kasturi
- Department of Pediatrics, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, USA
| | - Sheila Perez-Colon
- Division of Pediatric Endocrinology, Department of Pediatrics, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, USA
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Bodnar TW, Iyengar JJ, Patil PV, Gianchandani RY. Can a single interactive seminar durably improve knowledge and confidence of hospital diabetes management? Clin Diabetes Endocrinol 2017; 2:20. [PMID: 28702254 PMCID: PMC5471697 DOI: 10.1186/s40842-016-0038-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 11/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Safe and effective diabetes management in the hospital is challenging. Inadequate knowledge has been identified by trainees as a key barrier. In this study we assess both the short-term and long-term impact of an interactive seminar on medical student knowledge and comfort with hospital diabetes management. METHODS An interactive seminar covering hospital diabetes management and utilizing an audience response system was added to the third-year medical student curriculum. Students were given a multiple choice assessment immediately before and after the seminar to assess their comprehension of the material. Students were also asked to rate their confidence on this topic. Approximately 6 months later, students were given the same assessment to determine if the improvements in hospital diabetes knowledge and confidence were durable over time. Students from the preceding medical school class, who did not have a hospital diabetes seminar as a part of their curriculum, were used as a control. RESULTS Fifty-three students participated in the short-term assessment immediately before and after the seminar. The mean score (maximum 15) was 7.7 +/- 2.7 (51%) on the pre-test and 11.4 +/- 1.8 (76%) on the post-test (p < 0.01). 75 students who attended the seminar completed the same set of questions 6 months later with mean score of 9.2 ± 2.3 (61%). The control group of 100 students who did not attend seminar had a mean score of 8.8 ± 2.5 (58%). The difference in scores between the students 6-months after the seminar and the control group was not significantly different (p = 0.30). CONCLUSIONS Despite initial short-term gains, a single seminar on hospital diabetes management did not durably improve trainee knowledge or confidence. Addition of repeated and focused interactions during clinical rotations or other sustained methods of exposure need to be evaluated.
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Affiliation(s)
- Timothy W Bodnar
- Ann Arbor Endocrinology & Diabetes Associates P.C., Ypsilanti, MI USA
| | | | | | - Roma Y Gianchandani
- 24 Frank Lloyd Wright Drive, P.O. Box 482, Ann Arbor, MI 48106 USA.,University of Michigan Health System, Ann Arbor, MI USA
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Pichardo-Lowden A, Haidet P, Umpierrez GE. PERSPECTIVES ON LEARNING AND CLINICAL PRACTICE IMPROVEMENT FOR DIABETES IN THE HOSPITAL: A REVIEW OF EDUCATIONAL INTERVENTIONS FOR PROVIDERS. Endocr Pract 2017; 23:614-626. [PMID: 28225312 DOI: 10.4158/ep161634.ra] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The management of inpatient hyperglycemia and diabetes requires expertise among many health-care providers. There is limited evidence about how education for healthcare providers can result in optimization of clinical outcomes. The purpose of this critical review of the literature is to examine methods and outcomes related to educational interventions regarding the management of diabetes and dysglycemia in the hospital setting. This report provides recommendations to advance learning, curricular planning, and clinical practice. METHODS We conducted a literature search through PubMed Medical for terms related to concepts of glycemic management in the hospital and medical education and training. This search yielded 1,493 articles published between 2003 and 2016. RESULTS The selection process resulted in 16 original articles encompassing 1,123 learners from various disciplines. We categorized findings corresponding to learning outcomes and patient care outcomes. CONCLUSION Based on the analysis, we propose the following perspectives, leveraging learning and clinical practice that can advance the care of patients with diabetes and/or dysglycemia in the hospital. These include: (1) application of knowledge related to inpatient glycemic management can be improved with active, situated, and participatory interactions of learners in the workplace; (2) instruction about inpatient glycemic management needs to reach a larger population of learners; (3) management of dysglycemia in the hospital may benefit from the integration of clinical decision support strategies; and (4) education should be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and to optimize diabetes care in hospitals.
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Amori RE, Simon B. A Primer on Diabetes Mellitus: Foundations for the Incoming First-Year Resident. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10469. [PMID: 31008247 PMCID: PMC6464467 DOI: 10.15766/mep_2374-8265.10469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 08/22/2016] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Given the increasing prevalence of diabetes mellitus, trainees should have a strong foundation in the management of diabetes. Published literature on the knowledge base and comfort level of medical trainees in diabetes care describes varying levels of exposure to diabetes management in both inpatient and outpatient settings. METHODS This eight-module curriculum provides a foundation in the diagnosis, evaluation, and management of diabetes mellitus in the adult patient, as well as pharmacological treatment, patient education, and complications. Specifically, the modules consist of an introduction to diabetes, diagnosis and glycemic goals, patient education, basic nutrition, noninsulin therapies, insulin therapies, complications of diabetes, and financial considerations and cost. Each is a stand-alone presentation that may be viewed nonsequentially. We estimate each module taking 15 to 30 minutes to read. Students received a postsurvey. RESULTS We received responses from 23 (18%) of the total eligible residents over the course of 3 years. Approximately 50% of respondents completed an endocrinology elective as either a medical student or first-year resident. Overall, the majority of respondents felt that the modules had the correct amount of content, the online format was adequate, their understanding of diabetes was enhanced, and the curriculum led to altering their care. DISCUSSION This resource is unique to MedEdPORTAL as it includes basic information on diabetes education and medical-nutritional therapy. We have required completion of these modules by our internal medicine residents since the class that enrolled in 2013. The curriculum is directed towards incoming first-year internal medicine residents but may also be used by trainees in other primary care fields.
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Affiliation(s)
- Renee E. Amori
- Assistant Professor of Medicine, Division of Endocrinology, Drexel University College of Medicine
| | - Barbara Simon
- Associate Professor of Medicine, Drexel University College of Medicine
- Division Chief of Endocrinology, Drexel University College of Medicine
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Allende-Vigo MZ, González-Rosario RA, González L, Sánchez V, Vega MA, Alvarado M, Ramón RO. Inpatient Management of Diabetes Mellitus among Noncritically Ill Patients at University Hospital of Puerto Rico. Endocr Pract 2016; 20:452-60. [PMID: 24325996 DOI: 10.4158/ep13199.or] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes. METHODS This was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed. RESULTS A total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ≥180 mg/dL) and hypoglycemia (blood glucose <70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose. CONCLUSION The management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients.
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Affiliation(s)
| | | | - Loida González
- Endocrine Section, Department of Medicine, University of Puerto Rico Medical Sciences Campus
| | - Viviana Sánchez
- Endocrine Section, Department of Medicine, University of Puerto Rico Medical Sciences Campus
| | - Mónica A Vega
- Endocrine Section, Department of Medicine, University of Puerto Rico Medical Sciences Campus
| | - Milliette Alvarado
- Endocrine Section, Department of Medicine, University of Puerto Rico Medical Sciences Campus
| | - Raul O Ramón
- Puerto Rico Clinical and Translational Research Consortium, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Beliard R, Muzykovsky K, Vincent W, Shah B, Davanos E. Perceptions, Barriers, and Knowledge of Inpatient Glycemic Control. J Pharm Pract 2016; 29:348-54. [DOI: 10.1177/0897190014566309] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To assess knowledge and perceptions of health care workers regarding optimal care for patients with hyperglycemia and identify commonly perceived barriers for the development of a hospital-wide education program. Research Design and Methods: A cross-sectional design was utilized to survey health care workers involved in managing hyperglycemia in an urban, community teaching hospital. Each health care worker received a survey specific to their health care role. Results: Approximately 50% of questions about best clinical practices were answered correctly. Correct responses varied across disciplines (n, mean ± standard deviation [SD]), that is, physicians (n = 112, 53% ± 26%), nurses (n = 43, 52% ± 35%), pharmacists (n = 20, 64% ± 23%), dietitians (n = 5, 48% ± 30%), and patient care assistants (n = 12, 38% ± 34%). Most health care workers perceived hyperglycemia treatment to be very important and that sliding scale insulin was commonly used because of convenience but not efficacy. Conclusion: Knowledge regarding hyperglycemia management was suboptimal across a sample of health care workers when compared to clinical best practices. Hyperglycemia management was perceived to be important but convenience seemed to influence the management approach more than efficacy. Knowledge, perceptions, and barriers seem to play an important role in patient care and should be considered when developing education programs prior to implementation of optimized glycemic protocols.
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Affiliation(s)
- Regine Beliard
- Department of Clinical and Administrative Sciences, Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Greater Dundalk, Baltimore, MD, USA
| | - Karina Muzykovsky
- Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA
| | - William Vincent
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
| | - Bupendra Shah
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA
| | - Evangelia Davanos
- Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA
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Poppy A, Retamal-Munoz C, Cree-Green M, Wood C, Davis S, Clements SA, Majidi S, Steck AK, Alonso GT, Chambers C, Rewers A. Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children. Pediatrics 2016; 138:peds.2015-1404. [PMID: 27317577 PMCID: PMC5901907 DOI: 10.1542/peds.2015-1404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Amy Poppy
- Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado;
| | | | - Melanie Cree-Green
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Colleen Wood
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Shanlee Davis
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Scott A. Clements
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and,Division of Endocrinology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Shideh Majidi
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Andrea K. Steck
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - G. Todd Alonso
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Christina Chambers
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Arleta Rewers
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz, Aurora, Colorado; and
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Manders IG, Stoecklein K, Lubach CHC, Bijl-Oeldrich J, Nanayakkara PWB, Rauwerda JA, Kramer MHH, Eekhoff EMW. Shift in responsibilities in diabetes care: the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT). Diabet Med 2016; 33:761-7. [PMID: 26333117 DOI: 10.1111/dme.12899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 01/05/2023]
Abstract
AIMS To investigate the feasibility, safety and efficacy of the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT), which consists of nurse-driven correctional therapy, in addition to physician-guided basal therapy, and is carried out by trained ward nurses. METHODS Data on 210 patients with diabetes consecutively admitted in the 5-month period after the introduction of N-DIABIT (intervention group) were compared with the retrospectively collected data on 200 consecutive patients with diabetes admitted in the 5-month period before N-DIABIT was introduced (control group). Additional per-protocol analyses were performed in patients in whom mean patient-based protocol adherence was ≥ 70% (intervention subgroup, n = 173 vs. control subgroup, n = 196). RESULTS There was no difference between the intervention and the control group in mean blood glucose levels (8.9 ± 0.1 and 9.1 ± 0.2 mmol/l, respectively; P = 0.38), consecutive hyperglycaemic (blood glucose ≥ 10.0 mmol/l) episodes; P = 0.15), admission duration (P = 0.79), mean number of blood glucose measurements (P = 0.21) and incidence of severe hypoglycaemia (P = 0.29). Per-protocol analyses showed significant reductions in mean blood glucose levels and consecutive hypoglycaemia and hyperglycaemia in the intervention compared with the control group. CONCLUSIONS Implementation of N-DIABIT by trained ward nurses in non-intensive care unit diabetes care is feasible, safe and non-inferior to physician-driven care alone. High protocol adherence was associated with improved glycaemic control.
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Affiliation(s)
- I G Manders
- Section of Endocrinology, VU University Medical Centre, Amsterdam, The Netherlands
| | - K Stoecklein
- Department of Anesthesiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - C H C Lubach
- Diabetes Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - J Bijl-Oeldrich
- Diabetes Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - J A Rauwerda
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - M H H Kramer
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - E M W Eekhoff
- Section of Endocrinology, VU University Medical Centre, Amsterdam, The Netherlands
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Fukuda M, Doi K, Sugawara M, Naka Y, Mochizuki K. Survey of Hypoglycemia in Elderly People With Type 2 Diabetes Mellitus in Japan. J Clin Med Res 2015; 7:967-78. [PMID: 26566411 PMCID: PMC4625818 DOI: 10.14740/jocmr2340w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 12/30/2022] Open
Abstract
Background The number of elderly type 2 diabetes mellitus (T2DM) patients in Japan is increasing continuously. Hypoglycemia is a significant issue in their treatment. However, the actual situation and related details of their hypoglycemia remain unclear. In order to elucidate them, the Japan Physicians Association conducted a large-scale questionnaire survey for physicians and their outpatients all over Japan. Methods Targeted elderly T2DM outpatients were 65 years old or older in 2011. Specialized questionnaire survey forms were distributed to both of physicians and patients. The forms for physicians included questions whether patient had hypoglycemia in the last 1 month or 1 year; those for patients included whether they experienced it in the same durations and any of the 28 symptoms that are suggestive of hypoglycemia or pertaining to geriatric syndrome in the last 1 month, as well as questions about knowledge regarding hypoglycemia. We analyzed associations between hypoglycemia and the symptoms, and between hypoglycemia and medications. Results Of 15,892 T2DM patients (age, 74.2 ± 6.3 years; diabetes duration, 12.8 ± 8.9 years; HbA1c, 7.0±1.0%), dipeptidyl peptidase-4 inhibitor (DPP-4i) was the most prescribed medication among all oral hypoglycemic agents (OHAs). The frequencies of hypoglycemia in the last 1 month recognized by physicians and experienced by patients were 7.8% and 10.4% (P < 0.0001), and in the last 1 year were 15.5% and 21.1% respectively (P < 0.0001). The most common symptom was “weakness, fatigue/feeling languid” and the majority of all patients reported neuroglycopenic or autonomic symptoms. Regarding monotherapy, hypoglycemia was observed in 32.7% of the patients with insulin, 4% in sulfonylurea (SU), 3.8% in glinide, and 3.5% in pioglitazone. The questions asking knowledge about hypoglycemia revealed that SU or insulin users had significantly more knowledge of hypoglycemia than others (P < 0.001); however, 63% of patients using insulin, and 31% of patients using SU always carried glucose or a similar medication with them. Conclusions The present study suggested two types of “hidden hypoglycemia”, one is that physicians did not detect and the other one is that patients were not aware. It is vital that physicians strive to prevent hypoglycemia by paying closer attention to symptoms of “hidden hypoglycemia” in their elderly patients.
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Affiliation(s)
- Masahiro Fukuda
- Fukuda Clinic, 2F Shin Osaka Brick Building, 1-6-1 Miyahara, Yodogawa-ku, Osaka-shi, Osaka 532-0003, Japan ; Member of the Japan Physicians Association
| | - Kunihiro Doi
- Doi Clinic, 1-54 Todou Aramaki, Uji-shi, Kyoto 611-0013, Japan ; Member of the Japan Physicians Association
| | - Masahiro Sugawara
- Sugawara Clinic, 3-9-16 Shakujiimachi, Nerima-ku, Tokyo 177-0041, Japan ; Member of the Japan Physicians Association
| | - Yoshikazu Naka
- Tomei-Atsugi Hospital, 232 Funako, Atsugi-shi, Kanagawa 243-8571, Japan ; Member of the Japan Physicians Association
| | - Kouichi Mochizuki
- Mochizuki Naika Clinic, 1F Katsura Heights, 4-5 Aioicho, Itabashi-ku, Tokyo 174-0044, Japan ; Member of the Japan Physicians Association
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Mathioudakis N, Pronovost PJ, Cosgrove SE, Hager D, Golden SH. Modeling Inpatient Glucose Management Programs on Hospital Infection Control Programs: An Infrastructural Model of Excellence. Jt Comm J Qual Patient Saf 2015; 41:325-36. [PMID: 26108126 DOI: 10.1016/s1553-7250(15)41043-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nestoras Mathioudakis
- Inpatient Diabetes Management Service, Johns Hopkins Hospital and Johns Hopkins University School of Medicine, Baltimore, USA
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Dungan KM, Sagrilla C, Abdel-Rasoul M, Osei K. Prandial insulin dosing using the carbohydrate counting technique in hospitalized patients with type 2 diabetes. Diabetes Care 2013; 36:3476-82. [PMID: 24062326 PMCID: PMC3816892 DOI: 10.2337/dc13-0121] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare a modified fixed meal dosing strategy to flexible meal dosing in hospitalized patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Patients (N = 126) with refractory hyperglycemia or requiring at least 20 units of insulin per day were randomly assigned to fixed meal dosing (including withholding the dose if less than half of the meal tray was consumed) or flexible meal dosing based upon carbohydrate intake. The inpatient diabetes management team made all treatment adjustments. Outcomes included day 3 mean glucose, 72-h glucose trend analysis, hypoglycemia (<3.9 mmol/L), and inpatient diabetes treatment satisfaction. RESULTS The mean glucose on day 3 was 9.5 and 8.8 mmol/L in the fixed and flexible meal groups, respectively (P = 0.26). The frequency of hypoglycemia was 23 and 39% overall in the fixed and flexible meal groups (P = 0.08), with half of events occurring in the morning. There was a wide range of carbohydrate intake (median 51 g/meal, 10-90% range 26-72 g on day 3). The fixed dose group required significantly more prandial insulin overall and more correction insulin over time. There was no difference in composite treatment satisfaction or dosing miscalculations between groups. CONCLUSIONS A fixed meal dosing strategy provided similar glucose control as flexible meal dosing, when managed by an inpatient diabetes treatment team. However, a larger sample size would be needed to definitively evaluate a treatment effect of flexible meal dosing in the hospital. Further study is needed to improve the delivery of bolus insulin in hospitalized patients.
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Wilson RD, Bailey M, Boyle ME, Seifert KM, Cortez KY, Baker LJ, Hovan MJ, Stepanek J, Cook CB. Description and preliminary evaluation of a diabetes technology simulation course. J Diabetes Sci Technol 2013; 7:1561-6. [PMID: 24351182 PMCID: PMC3876334 DOI: 10.1177/193229681300700616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We aim to provide data on a diabetes technology simulation course (DTSC) that instructs internal medicine residents in the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring system (CGMS) devices. METHODS The DTSC was implemented during calendar year 2012 and conducted in the institution's simulation center. It consisted of a set of prerequisites, a practicum, and completion of a web-based inpatient CSII-ordering simulation. DTSC participants included only those residents in the outpatient endocrinology rotation. Questionnaires were used to determine whether course objectives were met and to assess the satisfaction of residents with the course. Questionnaires were also administered before and after the endocrine rotation to gauge improvement in familiarity with CSII and CGMS technologies. RESULTS During the first year, 12 of 12 residents in the outpatient endocrinology rotation completed the DTSC. Residents reported that the course objectives were fully met. The mean satisfaction score with the course ranged from 4.0 to 4.9 (maximum, 5), with most variables rated above 4.5. Self-reported familiarity with the operation of CSII and CGMS devices increased significantly in the postrotation survey compared with that on the prerotation survey (both p < .01). CONCLUSIONS In this pilot program, simulation-based education increased the perceived familiarity of residents with CSII and CGMS technologies. In light of these preliminary findings, the course will continue to be offered, with further data accrual. Future work will involve piloting the DTSC approach among other types of providers, such as residents in other specialties or inpatient nursing staff.
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Affiliation(s)
- Rebecca D. Wilson
- Division of Education Administration, Mayo Clinic Hospital, Phoenix, Arizona
| | - Marilyn Bailey
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona
| | - Mary E. Boyle
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona
| | | | - Karla Y. Cortez
- Office of Leadership and Organization Development, Mayo Clinic Hospital, Phoenix, Arizona
| | | | | | - Jan Stepanek
- Division of Preventative, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Curtiss B. Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona
- Division of Preventative, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona
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[Insulin therapy among inpatients]. Presse Med 2013; 42:871-9. [PMID: 23588189 DOI: 10.1016/j.lpm.2013.02.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 02/18/2013] [Indexed: 01/08/2023] Open
Abstract
To identify patients with known diabetes or hospital-related hyperglycemia. To establish blood glucose targets according to patient's clinical state. To draw up protocols by using basal, bolus (nutritional/prandial), and supplemental insulin and not "sliding scale insulin". To avoid hypoglycaemia particularly during intravenous insulin protocols in intensive care unit. To set up glucose monitoring with a regular training of medical staff. To perform HbA1c during hospital stay to plan the treatment after discharge. To organize follow-up of the patients with hospital-related hyperglycemia.
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Ahmed A, Jabbar A, Zuberi L, Islam M, Shamim K. Diabetes related knowledge among residents and nurses: a multicenter study in Karachi, Pakistan. BMC Endocr Disord 2012; 12:18. [PMID: 22967029 PMCID: PMC3515418 DOI: 10.1186/1472-6823-12-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 08/27/2012] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Assessment of knowledge among resident trainees and nurses is very important since majority of patients admitted in hospital have underlying diabetes which could lead to adverse clinical outcomes if not managed efficiently. Therefore, the purpose of this study was to evaluate and compare the knowledge related to the management of diabetes among registered nurses (RN) and trainee residents of internal medicine (IMR), family medicine (FMR) and surgery (SR) at tertiary care hospitals of Karachi, Pakistan. METHODS A validated questionnaire consisting of 21 open ended questions related to diabetes awareness was acquired through a study done at Thomas Jefferson University Hospital, Philadelphia with the permission of primary author. RESULTS 169 IMR, 27 FMR, 86 SR and 99 RN completed a questionnaire that assessed the knowledge related to different aspects of management of diabetes. The results were further stratified by participant's specialty and level of training. The percentage of knowledge based questions answered correctly was found to be low. The overall mean correct percentage among all the participants was 50% +/- 21. There was no statistical difference in terms of knowledge between IMR & FMR residents (64% +/- 14 vs. 60% +/- 16, p = 0.47) respectively. The total scores of SR and RN were quite low (40% +/- 16 & 31% +/- 15 respectively).SR and RN were found to have profound deficit in both inpatient and outpatient knowledge of diabetes. We did not observe any improvement in level of knowledge of FMR & SR with increase in duration of their training (p = 0.47 & 0.80 respectively). In contrast, improvement in the level of knowledge of IMR was observed from first to second year of their training (p = 0.03) with no further improvement thereafter. RN's didn't respond correctly on most of the items related to in-patient management of diabetes (Mean score 40% +/- 20). CONCLUSION As there are no prior studies in our setting evaluating knowledge related to diabetes management among residents and nurses, this study is of paramount importance. Based on these results, considerable knowledge gaps were found among trainee residents and nurses pointing towards need of providing additional education to improve the delivery of diabetes care.
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Affiliation(s)
- Asma Ahmed
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Abdul Jabbar
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Lubna Zuberi
- Crozer-Chester Medical Center, 1 Medical Center Blvd Ste 101, Chester, Pennsylvania, 19013, USA
| | - Muhammad Islam
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Khusro Shamim
- Department of Emergency Medicine, The Aga Khan University Hospital, Karachi, Pakistan
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Tamler R, Green DE, Skamagas M, Breen TL, Lu K, Looker HC, Babyatsky M, Leroith D. Durability of the effect of online diabetes training for medical residents on knowledge, confidence, and inpatient glycemia. J Diabetes 2012; 4:281-90. [PMID: 22268536 DOI: 10.1111/j.1753-0407.2012.00189.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Inpatient dysglycemia is associated with increased morbidity, mortality and cost. Medical education must not only address knowledge gaps, but also improve clinical care. METHODS All 129 medicine residents at a large academic medical center were offered a case-based online curriculum on the management of inpatient dysglycemia in the fall of 2009. First-year residents took a 3-h course with 10 modules. Second and third-year residents, who had been educated the prior year, underwent abbreviated training. All residents were offered a 20-min refresher course in the spring of 2009. We assessed resident knowledge, resident confidence, and patient glycemia on two teaching wards before and after the initial intervention, as well as after the refresher course. RESULTS A total of 117 residents (91%) completed the initial training; 299 analyzed admissions generated 11, 089 blood glucose values and 4799 event blood glucose values. Admissions with target glycemia increased from 19.4% to 33.0% (P = 0.035) by the end of the curriculum. There was a strong downward trend in hyperglycemia from 22.4% to 11.3% (P = 0.055) without increased hypoglycemia. Confidence and knowledge increased significantly among first-time and repeat participants. Residents rated the intervention as highly relevant to their practice and technologically well implemented. CONCLUSION Optimization of an online curriculum covering the management of inpatient glycemia over the course of 2 years led to significantly more admissions in the target glycemia range. Given its scalability, modularity and applicability, this web-based educational intervention may become the standard curriculum for the management of inpatient glycemia.
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Affiliation(s)
- Ronald Tamler
- Division of Endocrinology, Mount Sinai School of Medicine, New York, NY, USA.
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Yu CHY, Sun XH, Nisenbaum R, Halapy H. Insulin order sets improve glycemic control and processes of care. Am J Med 2012; 125:922-8.e4. [PMID: 22800878 DOI: 10.1016/j.amjmed.2012.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 02/23/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The study objective was to evaluate the impact of a standardized preprinted subcutaneous correctional insulin order set on glycemic control, processes of care, and nursing satisfaction. METHODS This was a controlled before/after, qualitative study using focus group interviews. The intervention group consisted of patients with diabetes who were admitted to the cardiovascular surgery ward. The control group consisted of patients with diabetes who were admitted to the vascular surgery ward. Registered nurses on the cardiovascular surgery floor participated in focus groups and completed surveys. We used a multifaceted intervention including standardized insulin order sheet, educational workshops, verbal and printed reminders, printed enabler, reference sheet, and overnight helpline. Glycemic control and hypoglycemia were assessed through chart review, and nursing satisfaction with the insulin order sets was assessed through surveys and nursing focus groups, performed before and 6 months after implementation of the insulin order set. RESULTS There was a 39% reduction in proportion of blood glucose>11.0 mmol/L (198 mg/dL) in the intervention group compared with the control group (0.17 vs 0.28, P=.03). The proportion of hypoglycemia (blood glucose<4.0 mmol/L [72 mg/dL]) was no different between the 2 groups. Nurse satisfaction increased significantly (P<.02); order sets were easy to use and improved glycemic control, processes, and efficiency of care, and reduced the number of pages between nursing and medical staff. CONCLUSIONS Standardized insulin order sets reduced hyperglycemia and improved nursing satisfaction and processes of care. Successful implementation required stakeholder engagement, identification of barriers and facilitators in local practice, and tailoring the intervention to target these factors.
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Affiliation(s)
- Catherine H Y Yu
- Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
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Improving care of patients with insulin pumps during hospitalization: translating the evidence. J Nurs Care Qual 2012; 27:333-40. [PMID: 22573207 DOI: 10.1097/ncq.0b013e3182595881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The purpose of this quality improvement project was to determine whether implementation of an evidence-based standardized protocol would enhance documentation and management of blood glucose levels for patients using continuous subcutaneous insulin infusion during hospitalization. Using a comparative design, documentation and blood glucose control measures were assessed before and after implementation of the protocol. Although some improvements have been recognized, we continue to refine the process and anticipate stronger outcomes in the future.
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Abstract
Despite the emergence of glucometrics (i.e., systematic analysis of data on blood glucose levels of inpatients) as a subject of high interest, there remains a lack of standardization on how glucose parameters are measured and reported. This dilemma must be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines and that can also be supported by quality care organizations. In this article, we review some of the questions that need to be resolved through consensus and review of the evidence, and discuss some of the limitations in analyzing and reporting inpatient glucose data that must be addressed (or at least accepted as limitations) before hospitals can commit resources to gathering, compiling, and presenting inpatient glucose statistics as a health care quality measure. Standards must include consensus on which measures to report, the unit of analysis, definitions of targets for hyperglycemia treatment, a definition of hypoglycemia, determination of how data should be gathered (from chart review or from laboratory information systems), and which type of sample (blood or point of care) should be used for analysis of glycemic control. Hospitals and/or their representatives should be included in the discussion. For inpatient glucose control to remain a focus of interest, further dialogue and consensus on the topic are needed.
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Affiliation(s)
- Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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Moreno-Fernández J, Gutiérrez-Alcántara C, Palomares-Ortega R, García-Manzanares Á, Benito-López P. Valoración del programa de formación de médicos residentes en Endocrinología y Nutrición por facultativos: resultados de una encuesta. ACTA ACUST UNITED AC 2011; 58:510-5. [DOI: 10.1016/j.endonu.2011.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/01/2011] [Accepted: 07/12/2011] [Indexed: 11/17/2022]
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Wexler DJ, Shrader P, Burns SM, Cagliero E. Effectiveness of a computerized insulin order template in general medical inpatients with type 2 diabetes: a cluster randomized trial. Diabetes Care 2010; 33:2181-3. [PMID: 20664017 PMCID: PMC2945157 DOI: 10.2337/dc10-0964] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether an electronic order template for basal-bolus insulin ordering improves mean blood glucose in hospitalized general medical patients with hyperglycemia and type 2 diabetes. RESEARCH DESIGN AND METHODS We randomly assigned internal medicine resident teams on acute general medical floors to the use of an electronic insulin order template or usual insulin ordering. We measured diabetes care parameters for 1 month on all patients with type 2 diabetes and blood glucose <60 mg/dl or >180 mg/dl treated by these physicians. RESULTS Intervention group patients (n = 65) had mean glucose of 195 ± 66 mg/dl. Control group patients (n = 63) had mean glucose of 224 ± 57 mg/dl (P = 0.004). In the intervention group, there was no increase in hypoglycemia. CONCLUSIONS Access to a computer insulin order template was associated with improved mean glucose levels without increasing hypoglycemia in patients with type 2 diabetes.
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Affiliation(s)
- Deborah J Wexler
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA.
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Abstract
OBJECTIVE To determine the effect of a year-long, multifaceted diabetes curriculum on the knowledge of internal medicine residents. METHODS In this controlled, prospective study, diabetes knowledge assessment was performed with a published questionnaire to measure baseline knowledge, determine change in knowledge at 1 year, and compare resident knowledge with attending knowledge. The questionnaire was administered to residents at the beginning and end of the 2007-2008 academic year. As controls, internal medicine attendings and diabetes care providers were also given the questionnaire. The educational curriculum over the course of the year included order sets, pocket cards, lectures, and rounds. Although all residents were exposed to the education intervention, teaching targeted the postgraduate year (PGY)-1 residents. RESULTS Of 91 participating residents, 85 (93%) completed at least 1 questionnaire for a total of 103 questionnaires. Baseline and year-end assessments were completed by 18 residents. Among 25 attendings, 22 (88%) completed questionnaires. Eleven diabetes care providers participated. PGY-3 residents scored 72 +/- 10% and PGY-2 residents scored 72 +/- 8%, which was significantly greater than the PGY-1 residents' score of 62 +/- 12% (P = .004 and P = .006, respectively). Lectures were associated with knowledge improvement over time (P = .04). The mean attending score of 67 +/- 13% was not significantly different from the residents' scores. Diabetes care providers had the highest score (92 +/- 7%). CONCLUSIONS Inpatient diabetes education targeted to PGY-1 residents modestly improves resident knowledge, especially in the targeted population. Traditional educational methods may not be adequate, and improved education is needed for trainees and attendings to provide optimal diabetes care. Strategies to improve resident education may include developing more comprehensive lectures that address fundamental concepts, focusing on all PGY levels, frequent consultation with diabetologists, and case-based discussions.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, Massachusetts 02118, USA.
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Nassar AA, Partlow BJ, Boyle ME, Castro JC, Bourgeois PB, Cook CB. Outpatient-to-inpatient transition of insulin pump therapy: successes and continuing challenges. J Diabetes Sci Technol 2010; 4:863-72. [PMID: 20663450 PMCID: PMC2909518 DOI: 10.1177/193229681000400415] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Insulin pump therapy is a complex technology prone to errors when employed in the hospital setting. When patients on insulin pump therapy require hospitalization, practitioners caring for them must decide whether to allow continued pump use. We provide the largest review regarding transitioning insulin pump therapy from the outpatient to inpatient setting. METHOD Records of inpatient insulin pump users were retrospectively analyzed at a metropolitan Phoenix hospital between January 2006 and December 2009. Adherence to institutional procedures on insulin pump use was assessed, glycemic control was determined, and adverse events were examined. RESULTS We examined records on 65 patients with insulin pumps, totaling 125 hospitalizations. Mean (standard deviation) patient age was 55 (17) years, diabetes duration was 27 (14) years, pump duration was 6 (5) years, length of hospital stay was 4.7 (6.3) days, hemoglobin A1c was 7.3 (1.3)%, 85% had type 1 diabetes mellitus, 57% were women, and 97% were white. Admissions involving insulin pumps increased (23 in 2006, 17 in 2007, 40 in 2008, and 45 in 2009). Insulin pump therapy was continued in 83 (66%) hospitalizations. Among these hospitalizations, endocrinology consultations were obtained in 89%, consent agreements were found in 83%, insulin pump order sets were completed in 89%, admission glucose was checked in 100%, and nursing assessments of pump insertion sites were documented in 89%, but bedside insulin pump flow sheets were found in only 55%. Mean glucose of 175 (57) mg/dl was not significantly different than that in hospitalizations where insulin pumps were discontinued [175 (42) mg/dl] or used intermittently [177 (7) mg/dl]. There was one instance of a pump catheter kinking; however, no other adverse events (pump site infections, mechanical pump failure, diabetic ketoacidosis) were observed, and there were no use-related fatalities. CONCLUSIONS Most patients using insulin pumps can safely have their therapy transitioned when hospitalized. A policy on inpatient continuous subcutaneous insulin infusion use can be successfully implemented. Compliance with required procedures can be achieved, although there was room to improve adherence with some process measures. Further study is needed to determine how to optimize glycemic control when pumps are allowed during hospitalization.
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Affiliation(s)
- Adrienne A Nassar
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona 85259, USA
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Noschese ML, DiNardo MM, Donihi AC, Gibson JM, Koerbel GL, Saul M, Stefanovic-Racic M, Korytkowski MT. Patient outcomes after implementation of a protocol for inpatient insulin pump therapy. Endocr Pract 2009; 15:415-24. [PMID: 19491071 DOI: 10.4158/ep09063.orr] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the safety and the results of use of an inpatient insulin pump protocol (IIPP). METHODS In this quality improvement initiative, review of medical records of bedside capillary blood glucose (CBG) levels and pump-related adverse events was performed on 50 consecutive inpatients admitted to the hospital with continuous subcutaneous insulin infusion (CSII) after implementation of our IIPP. Patients were categorized in 3 groups on the basis of evidence in the medical records for IIPP in combination with inpatient diabetes service consultation (group 1; n = 34), for IIPP alone (group 2; n = 12), or for usual care (group 3; n = 4). Patients identified during hospital admission as using CSII therapy were invited to complete a satisfaction questionnaire for inpatient CSII use. RESULTS Mean CBG levels were similar among the 3 groups (groups 1, 2, and 3: 173 +/- 43 mg/dL versus 187 +/- 62 mg/dL versus 218 +/- 46 mg/dL, respectively). Although there were more patient-days with blood glucose >300 mg/dL in group 3 (P = .02), there were no significant group differences in the frequency of hypoglycemia (CBG <70 mg/dL). Only 1 pump malfunction and 1 infusion site problem were reported among all study patients. No serious adverse events related to CSII therapy occurred. The majority of patients (86%) reported satisfaction with their ability to continue CSII use in the hospital. CONCLUSION Patients using CSII as outpatients are candidates for inpatient diabetes self-management. Inexperience with these devices on the part of hospital personnel together with the limited studies of patient experience with CSII in the hospital contributes to inconsistencies in management of these patients. An IIPP provides a standardized and safe approach to the use of CSII in the hospital.
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Affiliation(s)
- Michelle L Noschese
- Division of Endocrinology, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Cook CB, Wilson RD, Hovan MJ, Hull BP, Gray RJ, Apsey HA. Development of computer-based training to enhance resident physician management of inpatient diabetes. J Diabetes Sci Technol 2009; 3:1377-87. [PMID: 20144392 PMCID: PMC2787038 DOI: 10.1177/193229680900300618] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treating hyperglycemia promotes better outcomes among inpatients. Knowledge deficits about management of inpatient diabetes are prevalent among resident physicians, which may affect the care of a substantial number of these patients. METHODS A computer-based training (CBT) curriculum on inpatient diabetes and hyperglycemia was developed and implemented for use by resident physicians and focuses on several aspects of the management of inpatient diabetes and hyperglycemia: (1) review of importance of inpatient glucose control, (2) overview of institution-specific data, (3) triaging and initial admission actions for diabetes or hyperglycemia, (4) overview of pharmacologic management, (5) insulin-dosing calculations and ordering simulations, (6) review of existing policies and procedures, and (7) discharge planning. The curriculum was first provided as a series of lectures, then formatted and placed on the institutional intranet as a CBT program. RESULTS Residents began using the inpatient CBT in September 2008. By August 2009, a total of 29 residents had participated in CBT: 8 in family medicine, 12 in internal medicine, and 9 in general surgery. Most of the 29 residents confirmed that module content met stated objectives, considered the information valuable to their inpatient practices, and believed that the quality of the online modules met expectations. The majority reported that the modules took just the right amount of time to complete (typically 30 min each). CONCLUSIONS Improvement in inpatient diabetes care requires continuous educational efforts. The CBT format and curriculum content were well accepted by the resident physicians. Ongoing assessment must determine whether resident practice patterns are influenced by such training.
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Affiliation(s)
- Curtiss B Cook
- Division of Endocrinology and the Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Scottsdale, Arizona 85259, USA.
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Cook CB, Kongable GL, Potter DJ, Abad VJ, Leija DE, Anderson M. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med 2009; 4:E7-E14. [PMID: 20013863 DOI: 10.1002/jhm.533] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite increased awareness of the value of treating inpatient hyperglycemia, little is known about glucose control in U.S. hospitals. METHODS The Remote Automated Laboratory System-Plus (RALS-Plus Medical Automation Systems, Charlottesville, VA) was used to extract inpatient point-of-care bedside glucose (POC-BG) tests from 126 hospitals for the period January to December 2007. Patient-day-weighted mean POC-BG and hypoglycemia/hyperglycemia rates were calculated for intensive care unit (ICU) and non-ICU areas. The relationship of POC-BG levels with hospital characteristics was determined. RESULTS A total of 12,559,305 POC-BG measurements were analyzed: 2,935,167 from the ICU and 9,624,138 from the non-ICU. Patient-day-weighted mean POC-BG was 165 mg/dL for ICU and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% for ICU and 31.7% for non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was low at 10.1% for ICU and 3.5% for non-ICU. For ICU and non-ICU there was a significant relationship between number of beds and patient-day-weighted mean POC-BG levels, with larger hospitals (> or = 400 beds) having lower patient-day weighted mean POC-BG per patient day than smaller hospitals (<200 beds, P < 0.001). Rural hospitals had higher POC-BG levels compared to urban and academic hospitals (P < 0.05), and hospitals in the West had the lowest values. CONCLUSIONS POC-BG data captured through automated data management software can support hospital efforts to monitor the status of inpatient glycemic control. From these data, hospital hyperglycemia is common, hypoglycemia prevalence is low, and POC-BG levels vary by hospital characteristics. Increased hospital participation in data collection and reporting may facilitate the creation of a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.
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Affiliation(s)
- Curtiss B Cook
- Mayo Clinic College of Medicine, Scottsdale, Arizona, USA
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Ena J, Casañ R, Lozano T, Leach A, Algado JT, Navarro-Diaz FJ. Long-term improvements in insulin prescribing habits and glycaemic control in medical inpatients associated with the introduction of a standardized educational approach. Diabetes Res Clin Pract 2009; 85:159-65. [PMID: 19520451 DOI: 10.1016/j.diabres.2009.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 05/12/2009] [Accepted: 05/14/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND We carried out an educational strategy to increase physician adherence to 8 recommendations for inpatient evaluation and management of diabetes endorsed by the American Diabetes Association. METHODS We evaluated physician attitude, barriers and facilitators to incorporate the proposed recommendations into clinical practice. We analyzed the impact of the educational strategy on process-of-care and outcome variables in 138 patients with type 2 diabetes discharged from the internal medicine department before the intervention, at 3-month and at 9-month after the intervention. RESULTS After the educational intervention there was a high motivation of physicians to adhere to the proposed recommendations. The intervention caused a significant reduction of insulin administered by sliding scale (50% vs. 7% vs. 3%, P=0.000), and in the median pre-discharge glycaemic values (185 mg/dL vs. 153 mg/dL vs. 161 mg/dL, P=0.005), in the three periods, respectively. The use basal-bolus-correction insulin dosage increased in postintervention periods (17% vs. 85% vs. 99%, P=0.004). Hypoglycaemia (glycaemia <60 mg/dL) episodes were similar among the three periods (0.30% vs. 0.70% vs. 1.07%, P=0.10). The intervention required improvements to promote haemoglobin(A1c) ordering on admission and diabetes intensification therapy at discharge when needed. CONCLUSION Our educational strategy improved physician adoption of practice guidelines.
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Affiliation(s)
- Javier Ena
- Hospital Marina Baixa, Department of Internal Medicine, Villajoyosa, Alicante, Spain.
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Bailon RM, Cook CB, Hovan MJ, Hull BP, Seifert KM, Miller-Cage V, Beer KA, Boyle ME, Littman SD, Magallanez JM, Fischenich JM, Harris JK, Scoggins SS, Uy J. Temporal and geographic patterns of hypoglycemia among hospitalized patients with diabetes mellitus. J Diabetes Sci Technol 2009; 3:261-8. [PMID: 20144357 PMCID: PMC2771522 DOI: 10.1177/193229680900300206] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hypoglycemia is often cited as a barrier to achieving inpatient glycemic targets. We sought to characterize hypoglycemic events in our institution by work-shift cycle and by specific treatment area. METHODS Capillary (bedside) and blood (laboratory) glucose values of <70 mg/dl for patients with either a known diagnosis of diabetes or with evidence of hyperglycemia were abstracted from our laboratory database for hospitalizations between October 1, 2007, and February 3, 2008. Hypoglycemic events were analyzed by 12 h nursing work-shift cycles (day shift, 07:00 to 18:59; night shift, 19:00 to 06:59) and by the six medical, surgical, and intensive care areas in the hospital (designated areas 1 to 6). RESULTS We identified 206 individual patients with either diabetes or hyperglycemia (mean age, 67 years; 56% men; 83% white) who had 423 hypoglycemic events. There were 78% more hypoglycemic events during the night shift (n = 271 events in 128 individual patients) than during the day shift (n = 152 events in 96 individual patients). Most of the night-shift hypoglycemic measurements were detected between 04:00 and 04:59 or 06:00 and 06:59. The mean hypoglycemic level was comparable between shifts (p = .79) and across the six inpatient areas. The number of hypoglycemic events per person increased with lengths of hospital stay >5 days. The prevalence of hypoglycemia varied across patient care areas within the hospital, with most (28%) detected in one area of the hospital. CONCLUSION There are temporal and geographic patterns in the occurrence of hypoglycemia among patients with diabetes or hyperglycemia in our hospital. Further study should focus on the reasons underlying these variations so that specific interventions can address the risk of hypoglycemia during peak times and places.
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Affiliation(s)
- Rachel M. Bailon
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Bryan P. Hull
- Division of Hospital Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Karen A. Beer
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona
| | - Mary E. Boyle
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona
| | | | | | | | | | | | - Josephine Uy
- Division of Laboratory Medicine, Mayo Clinic, Scottsdale, Arizona
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