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Kensara RE, Ismail S, Aseeri M, Hasan H, Al Rahimi J, Zarif H, El Khansa S. The impact of the implementation of computerized insulin order sets for the control of hyperglycemia in hospitalized cardiac patients. Cardiovasc Endocrinol Metab 2024; 13:e02961. [PMID: 38116231 PMCID: PMC10727652 DOI: 10.1097/xce.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023]
Abstract
Background Glycemic control is crucial in managing hospitalized patients with type II diabetes (T2DM), and it presents as a clinical challenge in the cardiac population. Therefore, we aimed to evaluate the impact of computerized insulin order sets in T2DM hospitalized cardiac patients. Methods A quasi-experimental, pre- and post-study design. We included T2DM patients who were hospitalized for at least 3 days. Patients undergoing cardiac surgery were excluded. The primary endpoint was the mean difference in random blood glucose level (BGL) before and after the implementation of insulin order sets. While the secondary endpoints were to compare the median differences in fasting BGLs and the number of hyperglycemic and hypoglycemic episodes during the first 7 days. The study consisted of three phases: pre-implementation, intervention and post-phase. In the intervention phase, insulin order sets were integrated into the electronic prescribing system, and education was provided to the cardiology department. The post-phase included the patient's post-implementations. Results A total of 194 patients were enrolled during the study period. The mean random BGL was 11.17 mmol/L, 95% CI, 10.6-11.7 in the pre-phase and 9.5 mmol/L, 95% CI, 9-1 -9.9 mmol/L in the post-phase (P < 0.001). The median fasting BGL was 9.2 mmol/L (7.4-11.8, IQR) in the pre-phase and 8.5 mmol/L (6.6-10.3, IQR) in the post-phase (P = 0.027). The number of hypoglycemic episodes was 24 in pre-phase and 33 in post-phase (P = 0.13). Conclusion The use of computerized insulin order sets was associated with potential improvements in random and fasting glycemic control without increasing the risk of hyperglycemia or hypoglycemia.
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Affiliation(s)
- Raed Ehsan Kensara
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
| | - Sherin Ismail
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Mohammed Aseeri
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
| | - Hani Hasan
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
| | - Jamilah Al Rahimi
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
- Department of Cardiac Sciences, Ministry of National Guard-Health Affairs
| | - Hawazen Zarif
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
- Department of Medicine, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Sara El Khansa
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
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Sly B, Russell AW, Sullivan C. Digital interventions to improve safety and quality of inpatient diabetes management: A systematic review. Int J Med Inform 2021; 157:104596. [PMID: 34785487 DOI: 10.1016/j.ijmedinf.2021.104596] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 09/01/2021] [Accepted: 09/25/2021] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Diabetes is common amongst hospitalised patients and contributes to increased length of stay and poorer outcomes. Digital transformation, particularly the implementation of electronic medical records (EMRs), is rapidly occurring across the healthcare sector and provides an opportunity to improve the safety and quality of inpatient diabetes care. Alongside this revolution has been a considerable and ongoing evolution of digital interventions to optimise care of inpatients with diabetes including optimisation of EMRs, digital clinical decision support systems (CDSS) and solutions utilising data visibility to allow targeted patient review. OBJECTIVE To systematically appraise the recent literature to determine which digitally-enabled interventions including EMR, CDSS and data visibility solutions improve the safety and quality of non-critical care inpatient diabetes management. METHODS Pubmed, Embase and Cochrane databases were searched for suitable articles. Selected articles underwent quality assessment and analysis with results grouped by intervention type. RESULTS 1202 articles were identified with 42 meeting inclusion criteria. Four key interventions were identified; computerised physician order entry (n = 4), clinician decision support systems (n = 21), EMR driven active case finding (data visibility solutions) and targeted patient review (n = 10) and multicomponent system interventions (n = 7). Studies reported on glucometric outcomes, evidence-based medication ordering including medication errors, and patient and user outcomes. An improvement in glucometric measures particularly mean blood glucose and proportion of target range blood glucose levels and rates of evidence-based insulin prescribing were consistently demonstrated. CONCLUSION Digitally-enabled interventions utilised to improve quality and safety of inpatient diabetes care were heterogenous in design. The majority of studies across all intervention types reported positive effects for evidence-based prescribing and glucometric outcomes. There was less evidence for digital interventions reducing diabetes medication administration errors or impacting patient outcomes (length of stay).
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Affiliation(s)
- Benjamin Sly
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, 4006 Brisbane, Australia; Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, 4102 Brisbane, Australia.
| | - Anthony W Russell
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, 4006 Brisbane, Australia; Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, 4102 Brisbane, Australia
| | - Clair Sullivan
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, 4006 Brisbane, Australia; Metro North Hospital and Health Service, Butterfield St, Herston, 4029 Brisbane, Australia
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Fostering Best Practices for Reducing Opioid-Induced Constipation Using Technology. Comput Inform Nurs 2019; 37:551-557. [PMID: 31724977 DOI: 10.1097/cin.0000000000000598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohamed M, Assal A, Boyle L, Kwok E, DeSousa F, Karovitch A, Malcolm J. Development and Implementation of a Diabetic Ketoacidosis Protocol for Adults With Type 1 and Type 2 Diabetes at a Tertiary Care Multicampus Hospital. Can J Diabetes 2019; 43:256-260.e3. [DOI: 10.1016/j.jcjd.2018.08.192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
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Clark A, Kraut E, Yen HH, Moore S, Hopman W, Houlden RL. Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit. Can J Diabetes 2018; 43:304-308.e3. [PMID: 30713091 DOI: 10.1016/j.jcjd.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA. METHODS We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25 years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed. RESULTS The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53 days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6 days (2.44 to 8.99) (p=0.102). CONCLUSION A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.
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Affiliation(s)
- Alexa Clark
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Eyal Kraut
- Division of Endocrinology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hope H Yen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Moore
- School of Nursing (PhD candidate), Queen's University, Kingston, Ontario, Canada
| | - Wilma Hopman
- Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Robyn L Houlden
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Helmle KE, Chacko S, Chan T, Drake A, Edwards AL, Moore GE, Philp LC, Popeski N, Roedler RL, Rogers EJR, Zimmermann GL, McKeen J. Knowledge Translation to Optimize Adult Inpatient Glycemic Management With Basal Bolus Insulin Therapy and Improve Patient Outcomes. Can J Diabetes 2017; 42:505-513.e1. [PMID: 29555341 DOI: 10.1016/j.jcjd.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/19/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To develop and evaluate a Basal Bolus Insulin Therapy (BBIT) Knowledge Translation toolkit to address barriers to adoption of established best practice with BBIT in the care of adult inpatients. METHODS This study was conducted in 2 phases and focused on the hospitalist provider group across 4 acute care facilities in Calgary. Phase 1 involved a qualitative evaluation of provider and site specific barriers and facilitators, which were mapped to validated interventions using behaviour change theory. This informed the co-development and optimization of the BBIT Knowledge Translation toolkit, with each tool targeting a specific barrier to improved diabetes care practice, including BBIT ordering. In Phase 2, the BBIT Knowledge Translation toolkit was implemented and evaluated, focusing on BBIT ordering frequency, as well as secondary outcomes of hyperglycemia (patient-days with BG >14.0 mmol/L), hypoglycemia (patient-days with BG <4.0 mmol/L), and acute length of stay. RESULTS Implementation of the BBIT Knowledge Translation toolkit resulted in a significant 13% absolute increase in BBIT ordering. Hyperglycemic patient-days were significantly reduced, with no increase in hypoglycemia. There was a significant, absolute 14% reduction in length of stay. CONCLUSIONS The implementation of an evidence-informed, multifaceted BBIT Knowledge Translation toolkit effectively reduced a deeply entrenched in-patient diabetes care gap. The resulting sustained practice change improved patient clinical and system resource utilization outcomes. This systemic approach to implementation will guide further scale and spread of glycemic optimization initiatives.
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Affiliation(s)
- Karmon E Helmle
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Sunita Chacko
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Trevor Chan
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alison Drake
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alun L Edwards
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glenda E Moore
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Leta C Philp
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Naomi Popeski
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Rhonda L Roedler
- Pharmacy Services, South Health Campus, Alberta Health Services, Calgary, Alberta, Canada
| | - Edwin J R Rogers
- Clinical Analytics, Analytics, Data Integration, Measurement and Reporting (DIMR), Alberta Health Services, Calgary, Alberta, Canada
| | - Gabrielle L Zimmermann
- Knowledge Translation Platform, Alberta SPOR SUPPORT Unit, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
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Improving Insulin Administration Through Redesigning Processes of Care: A Multidisciplinary Team Approach. J Patient Saf 2017; 13:122-128. [DOI: 10.1097/pts.0000000000000128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Steely AM, Smith L, Callas PW, Nathan MH, Lahiri JE, Stanley AC, Steinthorsson G, Bertges DJ. Prospective Study of Postoperative Glycemic Control with a Standardized Insulin Infusion Protocol after Infrainguinal Bypass and Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2017; 44:211-220. [PMID: 28502888 DOI: 10.1016/j.avsg.2017.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/30/2017] [Accepted: 04/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study is to examine the effect of moderate postoperative glycemic control in diabetic and nondiabetic patients undergoing infrainguinal bypass (INFRA) or open abdominal aortic aneurysm (OAAA) repair. METHODS In a single center prospective study, we investigated postoperative glycemic control using a standardized insulin infusion protocol after elective INFRA bypass (n = 53, 62%) and OAAA repair (n = 33, 38%) between January 2013 and March 2015. The primary end point was optimal glycemic control, defined as having ≥85% of blood glucose values within the 80-150 mg/dL target range. Suboptimal glycemic control was defined as <85% of blood glucose values within the blood glucose target range. Secondary end points included in-hospital and 30-day surgical site infection (SSI) rates, composite adverse events, length of stay (LOS), and hospital cost. RESULTS Optimal glycemic control was achieved more commonly after OAAA repair than INFRA bypass (85% vs. 64%, P = 0.04). Moderate hypoglycemia (<70 mg/dL) was observed in 32 (37%) patients, while severe hypoglycemia (<50 mg/dL) was observed in 6 (7%) patients. SSI at 30 days was more common after INFRA bypass (n = 15, 29%) than OAAA repair (n = 2, 6%) (P = 0.01). In-hospital (6% vs. 6%, P = 1.0) and 30-day (24% vs. 22%, P = 1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after INFRA bypass. In-hospital (4% vs. 0%, P = 1.0) and 30-day (4% vs. 0%, P = 1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after OAAA repair. The percentage of blood glucose > 250 mg/dL was similar for patients with and without SSI (3% vs. 2%, P = 0.36). Adverse cardiac and pulmonary events after INFRA bypass were similar between groups (9% vs. 21%, P = 0.23; 0% vs. 5%, P = 0.36, respectively). Adverse cardiac and pulmonary events after OAAA repair were similar between groups (2% vs. 0%, P = 1.0; 4% vs. 0%, P = 1.0, respectively). Mean LOS was significantly lower in patients with optimal glycemic control after INFRA bypass (4.2 vs. 7.3 days, P = 0.02). Mean LOS was similar after OAAA repair for patients with optimal and suboptimal control (5.8 vs. 6.4 days, P = 0.46). Inpatient hospital costs after INFRA bypass were lower for the group with optimal (median $25,012, interquartile range [IQ] range $21,726-28,331) versus suboptimal glycemic control (median $28,944, IQ range 24,773-41,270, P = 0.02). CONCLUSIONS Postoperative hyperglycemia is common after INFRA bypass and OAAA repair and can be effectively ameliorated with an insulin infusion protocol. The protocol was low risk with reduced LOS and cost after INFRA bypass. Complications including SSI were not reduced in patients with optimal perioperative glycemic control.
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Affiliation(s)
- Andrea M Steely
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Lisa Smith
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Peter W Callas
- University of Vermont College of Medicine, University of Vermont, Burlington, VT
| | - Muriel H Nathan
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Julie E Lahiri
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Andrew C Stanley
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Georg Steinthorsson
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT.
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Wong B, Mamdani MM, Yu CH. Computerized Insulin Order Sets and Glycemic Control in Hospitalized Patients. Am J Med 2017; 130:366.e1-366.e6. [PMID: 27818228 DOI: 10.1016/j.amjmed.2016.09.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/22/2016] [Accepted: 09/24/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the impact of computerized provider order entry subcutaneous insulin order sets on inpatient glycemic control and ordering behavior. METHODS This was an interrupted time series study of non-intensive care patients at an urban teaching hospital. The primary outcome was proportion of capillary blood glucose in optimal range (4.0-10.0 mmol/L [72-180 mg/dL]) during the 6 months before and after a change to a computerized provider order entry-integrated insulin order set. Secondary outcomes included other measures of glycemia (hyperglycemia [>13.9mmol/L (250 mg/dL)], hypoglycemia [<4.0 mmol/L (72 mg/dL)], severe hypoglycemia [<2.2 mmol/L (40 mg/dL)]) and ordering behavior (use of basal-bolus-correctional insulin regimens). Comparisons of sensitivity-based versus generic correctional scale were also conducted. RESULTS A total of 63,393 measurements were obtained from June 2011 to June 2012. Order set usage was limited (51.5%). The weekly proportion of capillary blood glucose within the optimal range was not significantly different after the switch to computerized provider order entry order sets (pre-period: 64.9% vs post-period: 65.3%, P = .996). There were no differences in the proportions of moderate or severe hyperglycemia (pre-period: 10.9% vs post-period: 12.0%, P = .061) and hypoglycemia (pre-period: 1.9% vs post-period: 1.6%, P = .144). However, an increased proportion within the optimal range was seen in those with an order set featuring a sensitivity-based correctional scale versus orders without (65.3% vs 55.0%, P <.001). Increased basal-bolus-correctional ordering was observed after protocol implementation (20.3% vs 23.6%, P <.0001). CONCLUSIONS With low institutional uptake, computerized insulin order sets did not improve inpatient glycemic control.
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Affiliation(s)
- Bertha Wong
- Department of Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- St. Michaels' Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Catherine H Yu
- Department of Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada; St. Michaels' Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Ontario, Canada.
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Hommel I, Wollersheim H, Tack CJ, Mulder J, van Gurp PJ, Hulscher MEJL. Impact of a multifaceted strategy to improve perioperative diabetes care. Diabet Med 2017; 34:278-285. [PMID: 27087429 DOI: 10.1111/dme.13130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/29/2022]
Abstract
AIMS To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway. METHODS We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely. RESULTS Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period. CONCLUSIONS The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.
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Affiliation(s)
- I Hommel
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - H Wollersheim
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - C J Tack
- Department of Internal Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - J Mulder
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - P J van Gurp
- Department of Internal Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - M E J L Hulscher
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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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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Ballard DW, Kim AS, Huang J, Park DK, Kene MV, Chettipally UK, Iskin HR, Hsu J, Vinson DR, Mark DG, Reed ME. Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke. Ann Emerg Med 2015; 66:601-10. [PMID: 26362574 PMCID: PMC5111545 DOI: 10.1016/j.annemergmed.2015.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/16/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke. METHODS We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center. RESULTS Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality. CONCLUSION For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.
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Affiliation(s)
- Dustin W Ballard
- Kaiser Permanente San Rafael Medical Center, San Rafael, CA; Kaiser Permanente Division of Research, Oakland, CA.
| | - Anthony S Kim
- Department of Neurology, University of California at San Francisco, San Francisco, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - David K Park
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Mamata V Kene
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Uli K Chettipally
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA
| | | | - John Hsu
- Mongan Institute for Health Policy, Massachusetts General Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dustin G Mark
- Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
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Mulla CM, Lieb DC, McFarland R, Aloi JA. Tides of change: improving glucometrics in a large multihospital health care system. J Diabetes Sci Technol 2015; 9:602-8. [PMID: 25519292 PMCID: PMC4604527 DOI: 10.1177/1932296814563953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study explores the relationship between education for inpatient diabetes providers and the utilization of insulin order sets, inpatient glucometrics, and length of stay in a large health care system. METHODS The study included patients with and without the diagnosis of diabetes. An education campaign included provider-directed diabetes education administered via online learning modules and in-person presentations by trained individuals. Relationships among provider-attended diabetes education, order set usage, and inpatient glucometrics (hypo- and hyperglycemia) were analyzed, as well as length of stay. RESULTS Insulin use knowledge scores for all providers averaged 52%, and improved significantly to 93% (P < .001) by the end of the education intervention period. Likewise utilization of electronic basal-bolus order sets increased from a baseline of 20% for patients receiving insulin to 86% within 6 weeks (P < .01) of introduction of order sets. During the study, the incidence of hypoglycemia and hyperglycemia declined from 1.47% to 1.27% and from 23.21% to 17.80%, respectively. However, these improvements were not sustained beyond the completion of the education campaign. CONCLUSIONS Education of diabetes health care providers was provided in a large, multihospital system through the use of online learning modules. Adoption of standardized insulin order sets was associated with an improvement in glucometrics. This educational and quality initiative resulted in overall improvements in insulin knowledge, adherence to recommended order sets, inpatient glucometrics, and patient length of stay. These improvements were not sustained, reinforcing the need for repeated educational interventions for those involved in providing inpatient diabetes care.
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Affiliation(s)
| | - David C Lieb
- Eastern Virginia Medical School, Department of Medicine, Strelitz Diabetes Center for Endocrine and Metabolic Disorders, Norfolk, VA, USA
| | | | - Joseph A Aloi
- Eastern Virginia Medical School, Department of Medicine, Strelitz Diabetes Center for Endocrine and Metabolic Disorders, Norfolk, VA, USA
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Abstract
The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.
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Affiliation(s)
- Joseph A Aloi
- Eastern Virginia Medical School, Division of Endocrinology and Metabolism, 855 W. Brambleton Avenue, Norfolk, VA, 23510, USA,
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15
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Role of Subcutaneous Insulin Management Protocols and Order Sets in Inpatient Diabetes Management. Can J Diabetes 2014; 38:101-17. [DOI: 10.1016/j.jcjd.2014.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 11/23/2022]
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Miller DB. Glycemic Targets in Hospital and Barriers to Attaining Them. Can J Diabetes 2014; 38:74-8. [DOI: 10.1016/j.jcjd.2014.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/01/2014] [Indexed: 11/16/2022]
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Heeke S, Wood F, Schuck J. Improving care transitions from hospital to home: standardized orders for home health nursing with remote telemonitoring. J Nurs Care Qual 2013; 29:E21-8. [PMID: 23938358 DOI: 10.1097/ncq.0b013e3182a520b6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A task force at a multihospital health care system partnered with home health agencies to improve gaps during the discharge transition process. A standardized order template for home health nursing and remote telemonitoring was developed to decrease discrepancies in communication between hospital health care providers and home health nurses caring for patients with heart failure. Pilot results showed significantly improved communication with no readmissions, using the order template.
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Affiliation(s)
- Sheila Heeke
- Cardiology (Dr Heeke) and Care Coordination (Ms Schuck), Emory Healthcare, Inc, Atlanta, Georgia; Capstone College of Nursing, University of Alabama, Tuscaloosa (Dr Wood); and Wesley Woods Geriatric Hospital, Atlanta, Georgia (Ms Schuck). Dr Heeke is now with Neurological Surgery, Emory Healthcare, Inc, Atlanta, Georgia
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