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Thabit H, Schofield J. Technology in the management of diabetes in hospitalised adults. Diabetologia 2024:10.1007/s00125-024-06206-4. [PMID: 38953925 DOI: 10.1007/s00125-024-06206-4] [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: 03/04/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.
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Affiliation(s)
- Hood Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Jonathan Schofield
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Clubbs Coldron B, Coates V, Khamis A, MacRury S. Use of Continuous Glucose Monitoring in Non-ICU Hospital Settings for People With Diabetes: A Scoping Review of Emerging Benefits and Issues. J Diabetes Sci Technol 2023; 17:467-473. [PMID: 34696622 PMCID: PMC10012381 DOI: 10.1177/19322968211053652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Evidence indicates that poor glycemic control is associated with increased morbidity and length of stay in hospital. There are a wide range of guidelines published, which seek to ensure safe and effective inpatient glycemic control in the hospital setting. However, the implementation of these protocols is limited in practice. In particular, the feasibility of "flash" and continuous glucose monitoring (CGM) remains untested on general wards. METHOD Scoping Review. RESULTS If used in the general ward hospital settings, CGM and flash glucose monitoring (FGM) systems could lead to improved glycemic control, decreased length of stay, and reduced risk of severe hypoglycemia or hyperglycemia. Potential problems include lack of experience with this technology and costs of sensors. Rapid analysis of glucose measurements can facilitate clinical decision making and therapy adjustment in the hospital setting. In addition, people with diabetes may be empowered to better self-manage their condition in hospital as they have direct access to their glucose data. CONCLUSIONS More studies are required in which the feasibility, benefits and limitations of FGM and CGM in non-intensive care unit hospital settings are elucidated. We need evidence on which types of hospital wards might benefit from the introduction of this technology and the contexts in which they are less useful. We also need to identify the types of people who are most likely to find FGM and CGM useful for self-management and for which populations they have the most benefit in terms of clinical outcomes and length of stay.
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Affiliation(s)
- Benjamin Clubbs Coldron
- Division of Rural Health and
Wellbeing, Centre for Health Science, University of Highlands and Islands,
Inverness, UK
| | - Vivien Coates
- School of Nursing, Ulster
University, Derry, UK
- Western Health and Social Care
Trust, Altnagelvin Area Hospital, Londonderry, UK
| | - Amjed Khamis
- Letterkenny University Hospital,
Letterkenny, Ireland
| | - Sandra MacRury
- Division of Rural Health and
Wellbeing, Centre for Health Science, University of Highlands and Islands,
Inverness, UK
- Raigmore Hospital, Inverness,
UK
- Sandra MacRury, MBChB, FRCP, MD,
Division of Rural Health and Wellbeing, Centre for Health Science,
University of Highlands and Islands, Old Perth Road, Inverness IV2
3JH, UK.
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Phelan H, Hanas R, Hofer SE, James S, Landry A, Lee W, Wood JR, Codner E. Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:912-925. [PMID: 36093857 DOI: 10.1111/pedi.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Helen Phelan
- Pediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla Hospital, Uddevalla, and Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Alanna Landry
- Department of Paediatrics, Oak Valley Health, Markham, Ontario, Canada
| | - Warren Lee
- Dr. Warren Lee's Paediatrics, Growth & Diabetes Centre, and KK Hospital, Singapore, Singapore
| | - Jamie R Wood
- University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile
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Gerwer JE, Bacani G, Juang PS, Kulasa K. Electronic Health Record-Based Decision-Making Support in Inpatient Diabetes Management. Curr Diab Rep 2022; 22:433-440. [PMID: 35917098 PMCID: PMC9355925 DOI: 10.1007/s11892-022-01481-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review discusses ways in which the electronic health record (EHR) can offer clinical decision support (CDS) tools for management of inpatient diabetes and hyperglycemia. RECENT FINDINGS The use of electronic order sets can help providers order comprehensive basal bolus insulin regimens that are consistent with current guidelines. Order sets have been shown to reduce insulin errors and hypoglycemia rates. They can also help set glycemic targets, give hemoglobin A1C reminders, guide weight-based dosing, and match insulin regimen to nutritional profile. Glycemic management dashboards allow multiple variables affecting blood glucose to be shown in a single view, which allows for efficient evaluation of glucose trends and adjustment of insulin regimen. With the use glycemic management dashboards, active surveillance and remote management also become feasible. Hypoglycemia prevention and management are another part of inpatient diabetes management that is enhanced by EHR CDS tools. Furthermore, diagnosis and management of diabetic ketoacidosis and hyperglycemia hyperosmolar state are improved with the aid of EHR CDS tools. The use of EHR CDS tools helps improve the care of patients with diabetes and hyperglycemia in the inpatient hospital setting.
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Affiliation(s)
- Johanna E. Gerwer
- grid.266100.30000 0001 2107 4242Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA USA
| | - Grace Bacani
- grid.266100.30000 0001 2107 4242Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA USA
| | - Patricia S. Juang
- grid.266100.30000 0001 2107 4242Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA USA
| | - Kristen Kulasa
- grid.266100.30000 0001 2107 4242Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA USA
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Pichardo-Lowden AR. Clinical Decision Support for Diabetes Care in the Hospital: A Time for Change Toward Improvement of Management and Outcomes. J Diabetes Sci Technol 2022; 16:771-774. [PMID: 33412952 PMCID: PMC9294585 DOI: 10.1177/1932296820982661] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The increasing prevalence of diabetes permeates hospitals and dysglycemia is associated with poor clinical and economic outcomes. Despite endorsed guidelines, barriers to optimal management and gaps in care prevail. Providers' limitations on knowledge, attitudes, and decision-making about hospital diabetes management are common. This adds to the complexity of dispersed glucose and insulin dosing data within medical records. This creates a dichotomy as safe and effective care are key objectives of healthcare organizations. This perspective highlights evidence of the benefits of clinical decision support (CDS) in hospital glycemic management. It elaborates on barriers CDS can help resolve, and factors driving its success. CDS represents a resource to individualize care and improve outcomes. It can help overcome a multifactorial problem impacting patients' lives on a daily basis.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Division
of Endocrinology, Diabetes and Metabolism, Milton S. Hershey Medical Center.
Penn State Health, Penn State College of Medicine, Hershey, PA, USA
- Ariana R Pichardo-Lowden, MD, MEd,
MSc, Associate Professor of Medicine, Department of Medicine, Division
of Endocrinology, Diabetes and Metabolism, Milton S. Hershey Medical
Center, Penn State Health, Penn State College of Medicine, 500
University Drive, Hershey, PA 17033 USA.
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Zhu Y, Zheng X. Application of a Computerized Decision Support System to Develop Care Strategies for Elderly Hemodialysis Patients. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:5060484. [PMID: 34249296 PMCID: PMC8238583 DOI: 10.1155/2021/5060484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/09/2021] [Indexed: 12/25/2022]
Abstract
In this paper, the strategy of elderly haemodialysis patients' care is analysed by the computer's decision system to conduct an in-depth research machine. Maintenance haemodialysis patients have a high demand for continuation care, and healthcare workers should provide personalized and specialized seamless continuation care services for patients according to patients' needs, by reasonably using the hospital, community, and other health resources and with the help of emerging network technologies, such as information platforms and wearable devices to prolong the survival period of patients and improve their self-management ability and quality of life. The service provision and compensation strategy of the combined healthcare model should be optimized to improve the health protection of the elderly and promote health equity. On the one hand, it should target strengthening the service provision of healthcare integration, guide the elderly to reasonably choose the healthcare integration model, and pay attention to the spiritual and cultural needs and end-of-life care services for the elderly. On the other hand, we should expand the financing channels of medical insurance, optimize the design of compensation mechanisms, explore the role of health risk sharing, and accelerate the development of long-term care insurance, independent of basic medical insurance. The reliability of the scale was found to be 0.916 for the total Cronbach alpha coefficient, 0.798-0.919 for each dimension, and 0.813 for the fold-half reliability of the scale; the validity indicated that the correlation coefficient range of each article day with the total scale score was 0.27-0.72, and the correlation coefficient range of each dimension with the total scale was 0.56-0.72. The validation factor analysis was used to verify the structure of the scale. The validation factor analysis indexes met the fitting criteria after correction. The model fitted better with the actual model after correction, indicating that the scale has good reliability.
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Affiliation(s)
- Yiqiu Zhu
- The First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu, China
| | - Xiyi Zheng
- The First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu, China
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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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Galindo RJ, Umpierrez GE, Rushakoff RJ, Basu A, Lohnes S, Nichols JH, Spanakis EK, Espinoza J, Palermo NE, Awadjie DG, Bak L, Buckingham B, Cook CB, Freckmann G, Heinemann L, Hovorka R, Mathioudakis N, Newman T, O’Neal DN, Rickert M, Sacks DB, Seley JJ, Wallia A, Shang T, Zhang JY, Han J, Klonoff DC. Continuous Glucose Monitors and Automated Insulin Dosing Systems in the Hospital Consensus Guideline. J Diabetes Sci Technol 2020; 14:1035-1064. [PMID: 32985262 PMCID: PMC7645140 DOI: 10.1177/1932296820954163] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article is the work product of the Continuous Glucose Monitor and Automated Insulin Dosing Systems in the Hospital Consensus Guideline Panel, which was organized by Diabetes Technology Society and met virtually on April 23, 2020. The guideline panel consisted of 24 international experts in the use of continuous glucose monitors (CGMs) and automated insulin dosing (AID) systems representing adult endocrinology, pediatric endocrinology, obstetrics and gynecology, advanced practice nursing, diabetes care and education, clinical chemistry, bioengineering, and product liability law. The panelists reviewed the medical literature pertaining to five topics: (1) continuation of home CGMs after hospitalization, (2) initiation of CGMs in the hospital, (3) continuation of AID systems in the hospital, (4) logistics and hands-on care of hospitalized patients using CGMs and AID systems, and (5) data management of CGMs and AID systems in the hospital. The panelists then developed three types of recommendations for each topic, including clinical practice (to use the technology optimally), research (to improve the safety and effectiveness of the technology), and hospital policies (to build an environment for facilitating use of these devices) for each of the five topics. The panelists voted on 78 proposed recommendations. Based on the panel vote, 77 recommendations were classified as either strong or mild. One recommendation failed to reach consensus. Additional research is needed on CGMs and AID systems in the hospital setting regarding device accuracy, practices for deployment, data management, and achievable outcomes. This guideline is intended to support these technologies for the management of hospitalized patients with diabetes.
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Affiliation(s)
| | | | | | - Ananda Basu
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suzanne Lohnes
- University of California San Diego Medical Center, La Jolla, CA, USA
| | | | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
| | | | - Nadine E. Palermo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Tonya Newman
- Neal, Gerber and Eisenberg LLP, Chicago, IL, USA
| | - David N. O’Neal
- University of Melbourne Department of Medicine, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive Room 5147, San Mateo, CA 94401, USA.
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Abstract
PURPOSE OF REVIEW Coordination of glucose monitoring, mealtimes, and insulin delivery in the hospital is complex, involving interactions between multiple key agents and overlapping workflows. The purpose of this review is to evaluate the scope of the problem as well as to assess evidence for interventions. RECENT FINDINGS In recent years, there has been an emphasis on systems-based approaches which address multiple contributing components of the problem at once in an effort to more seamlessly integrate workflows. Technological advances, such as decision support systems and advances in automated insulin delivery, and strategies that minimize the need for complex insulin regimens hold promise for future study. Evaluation of the coordination of insulin delivery is limited by a lack of standardized metrics and systematically collected mealtimes. Nevertheless, successful efforts include system-wide multicomponent interventions, though advances in therapeutic approaches may be of value.
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Affiliation(s)
- Kathleen Dungan
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, OH, 43210, USA.
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Abstract
Improvements in glycemic control using continuous glucose monitoring (CGM) systems have been demonstrated in the outpatient setting. Among hospitalized patients the use of CGM is largely investigational, particularly in the non-ICU setting. Although there is no commercially available closed-loop system, it has recently been evaluated in the non-critical care setting. Both CGMs and closed-loop systems may lead to improved glycemic control, decreased length of stay, reduced risk of adverse events related to severe hypoglycemia or hyperglycemia. Limitations of inpatient use of CGM and closed-loop systems include lack of FDA approvals, inexperience with this technology, and costs related to supplies. Significant investment may be necessary for hospital staff training and for development of infrastructure to support inpatient use. Additional limitations for CGM systems includes potential inaccuracy of interstitial glucose measurements due to medication interferences, sensor lag, or sensor drift. Limitations for closed-loop systems also includes need for routine monitoring to detect infusion site issues as well as monitoring to ensure adequate insulin supply in reservoir to avoid abrupt cessation of insulin infusion leading to severe hyperglycemia. Hospital staff must be familiar with trouble-shooting and conversion to alternative mode of insulin delivery in the event of insulin pump malfunction. Given these complexities, implementation of closed-loop systems may require involvement of an endocrinology team, limiting widespread adoption. This article reviews current state of CGM and closed-loop system use in the non-ICU setting, available literature, advantages and limitations, as well as suggestions for future CGM design, specifically for the inpatient setting.
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Affiliation(s)
- Meng Wang
- Division of Hospital Medicine, Baltimore
Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Lakshmi G. Singh
- Division of Diabetes and Endocrinology,
Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Elias K. Spanakis
- Division of Diabetes and Endocrinology,
Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
- Division of Endocrinology, Diabetes and
Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
- Elias K. Spanakis, MD, Division of Diabetes
and Endocrinology, Baltimore Veterans Affairs Medical Center and Division of
Endocrinology, Diabetes and Nutrition, University of Maryland School of
Medicine, 10 N Greene St, 5D134, Baltimore, MD 21201, 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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Affiliation(s)
- Lia Bally
- University Hospital Bern, Bern, Switzerland
| | - Hood Thabit
- Manchester University Hospitals NHS Foundation, Manchester, United Kingdom
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Umpierrez GE, Klonoff DC. Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital. Diabetes Care 2018; 41:1579-1589. [PMID: 29936424 PMCID: PMC6054505 DOI: 10.2337/dci18-0002] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/20/2018] [Indexed: 02/03/2023]
Abstract
The use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems has gained wide acceptance in diabetes care. These devices have been demonstrated to be clinically valuable, improving glycemic control and reducing risks of hypoglycemia in ambulatory patients with type 1 diabetes and type 2 diabetes. Approximately 30-40% of patients with type 1 diabetes and an increasing number of insulin-requiring patients with type 2 diabetes are using pump and sensor technology. As the popularity of these devices increases, it becomes very likely that hospital health care providers will face the need to manage the inpatient care of patients under insulin pump therapy and CGM. The American Diabetes Association advocates allowing patients who are physically and mentally able to continue to use their pumps when hospitalized. Health care institutions must have clear policies and procedures to allow the patient to continue to receive CSII treatment to maximize safety and to comply with existing regulations related to self-management of medication. Randomized controlled trials are needed to determine whether CSII therapy and CGM systems in the hospital are associated with improved clinical outcomes compared with intermittent monitoring and conventional insulin treatment or with a favorable cost-benefit ratio.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
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Affiliation(s)
- H R Murphy
- UK and Republic of Ireland Regional Editor, Diabetic Medicine, London, UK
- Department of Women's and Children's Health, Kings College, London, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - R I G Holt
- Editor-in-Chief, Diabetic Medicine, Southampton, UK
- University of Southampton, Southampton, UK
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