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McCall AL, Lieb DC, Gianchandani R, MacMaster H, Maynard GA, Murad MH, Seaquist E, Wolfsdorf JI, Wright RF, Wiercioch W. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2023; 108:529-562. [PMID: 36477488 DOI: 10.1210/clinem/dgac596] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality. OBJECTIVE To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia. CONCLUSION The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.
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Affiliation(s)
- Anthony L McCall
- University of Virginia Medical School, Department of Medicine, Division of Endocrinology and Metabolism, Charlottesville, VA 22901, USA
| | - David C Lieb
- Eastern Virginia Medical School, Division of Endocrine and Metabolic Disorders, Department of Medicine, Norfolk, VA 23510, USA
| | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55905, USA
| | - Elizabeth Seaquist
- Diabetes Center and the Division of Endocrinology & Metabolism, Minneapolis, MN 55455, USA
| | - Joseph I Wolfsdorf
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Wojtek Wiercioch
- McMaster University GRADE Centre and Michael G. DeGroote Cochrane Canada Centre Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, L8S 4L8, Canada
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Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2022; 69:500-508. [PMID: 36038498 DOI: 10.1016/j.endien.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/28/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Hyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes. AIMS We implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA1c > 8%, to improve their metabolic control after hospital admission. METHODS Non-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge. RESULTS During the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ± 1,5 vs. 7,3 ± 1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program. CONCLUSIONS The program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.
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Control de la glucemia durante la hospitalización: Enfermera de práctica avanzada y herramientas semiautomáticas de prescripción de insulina. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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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: 8] [Impact Index Per Article: 2.7] [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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5
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Emamdjomeh AS, Warren JN, Harper CL, Olin JL. Impact of Initial eGlycemic Management System Dosing Strategy on Time to Target Blood Glucose Range. J Diabetes Sci Technol 2021; 15:242-250. [PMID: 33588608 PMCID: PMC8256082 DOI: 10.1177/1932296821992352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Glucommander™ (GM), an electronic glycemic management system, was implemented across a multi-hospital health system as the standard of care for glycemic control. GM provides insulin dosing recommendations based on patient-specific blood glucose (BG) trends after providers select either a custom dose or weight-based multiplier as the initial dosing strategy for the first 24 hours. This study evaluated the impact of initial subcutaneous (SC) GM insulin dosing strategies on glycemic management. METHODS Non-intensive care unit patients treated with SC GM using either initial custom (based on provider discretion) or weight-based multiplier settings (0.3, 0.5, or 0.7 units/kg/day) were evaluated in this retrospective chart review. The primary endpoint was time to target BG range defined as time to first two consecutive in range point of care BG. Secondary endpoints included percentage of BG values in target range, percentage of orders following institutional recommendations, length of stay (LOS), average BG, and incidence of hypoglycemia and hyperglycemia. RESULTS A review of 348 patients showed time to target BG was not significantly different between custom and multiplier groups (55 vs 64 hours, P = .07). Target BG was achieved in less than half of patients in both groups (47% vs 44%, respectively). There were no differences in hospital LOS, proportion of BG in target range, rates of hypo/hyperglycemia, and average BG. CONCLUSIONS Custom initial SC GM insulin dosing settings showed a nonsignificant decrease in time to target BG range compared to pre-defined multiplier settings. Future studies evaluating the impact of compliance with institutional recommendations on BG control are warranted.
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Affiliation(s)
| | | | | | - Jacqueline L. Olin
- Novant Health System, Charlotte, NC,
USA
- Wingate University School of Pharmacy,
Wingate, NC, USA
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Cui L, Schroeder PR, Sack PA. Inpatient and Outpatient Technologies to Assist in the Management of Insulin Dosing. Clin Diabetes 2020; 38:462-473. [PMID: 33384471 PMCID: PMC7755045 DOI: 10.2337/cd20-0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Several new technologies use computer algorithms to analyze a person's blood glucose response to insulin treatment, calculate the person's next recommended insulin dose, advise the person regarding when to check blood glucose next, and provide alerts regarding glucose control for the individual patient or across a hospital system. This article reviews U.S. Food and Drug Administration (FDA)-approved products designed to help manage insulin dosing for inpatients, as well as those available to provide people with insulin-requiring diabetes support in making adjustments to their basal and/or mealtime insulin doses. Many of these products have a provider interface that allows for remote monitoring of patients' glucose readings and insulin doses. By alleviating some of the burdens of insulin initiation and dose adjustment, these products may facilitate improved glycemic management and patient outcomes.
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Affiliation(s)
- Ling Cui
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
| | | | - Paul A Sack
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD
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Ekanayake PS, Juang PS, Kulasa K. Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control. Curr Diab Rep 2020; 20:68. [PMID: 33165676 DOI: 10.1007/s11892-020-01364-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting. RECENT FINDINGS We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoToolR (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.
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Affiliation(s)
- Preethika S Ekanayake
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA.
| | - Patricia S Juang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| | - Kristen Kulasa
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
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Kao SL, Chen Y, Ning Y, Tan M, Salloway M, Khoo EYH, Tai ES, Tan CS. Evaluating the effectiveness of a multi-faceted inpatient diabetes management program among hospitalised patients with diabetes mellitus. Clin Diabetes Endocrinol 2020; 6:21. [PMID: 33292816 PMCID: PMC7643419 DOI: 10.1186/s40842-020-00107-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/15/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is one of the most common chronic diseases. Individuals with DM are more likely to be hospitalised and stay longer than those without DM. Inpatient hypoglycemia and hyperglycemia, which are associated with adverse outcomes, are common, but can be prevented through hospital quality improvement programs. METHODS We designed a multi-faceted intervention program with the aim of reducing inpatient hypoglycemia and hyperglycemia. This was implemented over seven phases between September 2013 to January 2016, and covered all the non-critical care wards in a tertiary hospital. The program represented a pragmatic approach that leveraged on existing resources and infrastructure within the hospital. We calculated glucometric outcomes in June to August 2016 and compared them with those in June to August 2013 to assess the overall effectiveness of the program. We used regression models with generalised estimating equations to adjust for potential confounders and account for correlations of repeated outcomes within patients and admissions. RESULTS We observed significant reductions in patient-days affected by hypoglycemia (any glucose reading < 4 mmol/L: OR = 0.71, 95% CI: 0.61 to 0.83, p < 0.001), and hyperglycemia (any glucose reading > 14 mmol/L: OR = 0.84, 95% CI: 0.71 to 0.99, p = 0.041). Similar findings were observed for admission-level hypoglycemia and hyperglycemia. Further analyses suggested that these reductions started to occur four to 6 months post-implementation. CONCLUSIONS Our program was associated with sustained improvements in clinically relevant outcomes. Our described intervention could be feasibly implemented by other secondary and tertiary care hospitals by leveraging on existing infrastructure and work force.
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Affiliation(s)
- Shih Ling Kao
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Ying Chen
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Yilin Ning
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Maudrene Tan
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
| | - Mark Salloway
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Eric Yin Hao Khoo
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.
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Abstract
Hypoglycemia in inpatients with diabetes remains the most common complication of diabetes therapies. Hypoglycemia is independently associated with increased morbidity and mortality, increased length of stay, increased readmission rate, and increased cost. This review describes the importance of reporting and addressing inpatient hypoglycemia; it further summarizes eight strategies that aid clinicians in the prevention of inpatient hypoglycemia: auditing the electronic medical record, formulary restrictions and dose-limiting strategies, hyperkalemia order sets, electronic glucose management systems, prediction tools, diabetes self-management, remote surveillance, and noninsulin medications.
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Affiliation(s)
- Paulina Cruz
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, MO, USA
- Paulina Cruz, MD, Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
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10
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Abstract
PURPOSE OF REVIEW The goal of this review is to summarize information about insulin dosing software and calculators used as computerized decision support systems or electronic glucose management systems (eGMS). These are used for hospitalized, insulin-treated patients with diabetes. We describe the advantages and disadvantages and the rationale for their use. RECENT FINDINGS We compared commercially available insulin dosing software, namely, Glucommander™, EndoTool®, GlucoStabilizer®, and GlucoTab®, in addition to computerized order entry systems that are available in electronic health records. The common feature among these eGMS is their ability to limit occurrences of hypoglycemia while achieving and maintaining patients at target blood glucose level. More research needs to be done examining the efficacy of eGMS in disease-specific states and their benefits and utility in preventing adverse outcomes. Their long-term benefits to health care systems are beginning to emerge in cost-saving benefits and prevention of readmissions.
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Affiliation(s)
- Jagdeesh Ullal
- Center for Diabetes and Endocrinology, Division of Endocrinology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Joseph A Aloi
- Department of Internal Medicine, Section on Endocrinology and Metabolism, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Montero AR, Dubin JS, Sack P, Magee MF. Future technology-enabled care for diabetes and hyperglycemia in the hospital setting. World J Diabetes 2019; 10:473-480. [PMID: 31558981 PMCID: PMC6748879 DOI: 10.4239/wjd.v10.i9.473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 02/05/2023] Open
Abstract
Patients with diabetes are increasingly common in hospital settings where optimal glycemic control remains challenging. Inpatient technology-enabled support systems are being designed, adapted and evaluated to meet this challenge. Insulin pump use, increasingly common in outpatients, has been shown to be safe among select inpatients. Dedicated pump protocols and provider training are needed to optimize pump use in the hospital. Continuous glucose monitoring (CGM) has been shown to be comparable to usual care for blood glucose surveillance in intensive care unit (ICU) settings but data on cost effectiveness is lacking. CGM use in non-ICU settings remains investigational and patient use of home CGM in inpatient settings is not recommended due to safety concerns. Compared to unstructured insulin prescription, a continuum of effective electronic medical record-based support for insulin prescription exists from passive order sets to clinical decision support to fully automated electronic Glycemic Management Systems. Relative efficacy and cost among these systems remains unanswered. An array of novel platforms are being evaluated to engage patients in technology-enabled diabetes education in the hospital. These hold tremendous promise in affording universal access to hospitalized patients with diabetes to effective self-management education and its attendant short/long term clinical benefits.
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Affiliation(s)
- Alex Renato Montero
- MedStar Diabetes Institute, Washington, DC 20010, United States
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Jeffrey S Dubin
- MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Paul Sack
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Union Memorial Hospital, Baltimore, MD 21218, United States
| | - Michelle F Magee
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Health Research Institute, Washington, DC 20010, United States
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Bain A, Hasan SS, Babar ZUD. Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review. Diabet Med 2019; 36:948-960. [PMID: 31050037 DOI: 10.1111/dme.13982] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/12/2022]
Abstract
AIM To conduct a systematic review of literature to identify interventions that are effective in improving insulin prescribing for people with diabetes in the hospital setting. METHODS Computerized bibliographic databases were searched for studies published in English that described the effectiveness of interventions to improve insulin prescribing within the hospital setting. Studies were eligible for inclusion if they reported data that compared insulin prescribing practice after an intervention or compared with a control group. Studies were not excluded on the basis of publication date, geographical location or risk of bias assessment. RESULTS We identified 35 studies for inclusion in the review, including two cluster randomized controlled trials, two cohort studies, and 31 uncontrolled before-after studies. Studies reported a variety of interventions that aimed to increase insulin prescribing accuracy or completeness or decrease the use of discouraged subcutaneous sliding scale insulin regimens. Differences in definition of insulin prescribing error, terminology and common practice based on geographical location was evident, and quality issues with respect to study design and reporting somewhat limited the interpretation of conclusions. CONCLUSIONS Implementing strategies that are sensitive to local context and designed to increase adherence to insulin prescribing guidelines are associated with a reduction in prescribing errors. Future implementation should build on effective approaches including multifaceted interventions involving multiple stakeholders at various institutional levels. Future studies in insulin prescribing errors would benefit from the use of standardized approaches, terminology and outcome measures to enable greater comparison.
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Affiliation(s)
- A Bain
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S S Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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13
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Abstract
Computerized insulin dosing software provides decision support in the form of pattern management identification, standardized dosing, and ease of use in both the inpatient and outpatient settings. The purpose of this analysis article is to review the features of all three electronic glycemic management systems available in the United States and to discuss the potential benefits of an automated insulin dosing system compared to a paper protocol or electronic order set. Four articles will be presented in this inpatient focused issue that examine the safety and efficacy of the Glytec® eGlycemic Management system in a variety of patient populations.
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Affiliation(s)
| | - Jane Jeffrie Seley
- NewYork-Presbyterian Hospital/ Weill Cornell Medicine, New York, NY, USA
- Jane Jeffrie Seley, DNP, MPH, BC-ADM, CDE, Division of Endocrinology, Diabetes & Metabolism, NewYork-Presbyterian Hospital/Weill Cornell Medicine, 1300 York Ave, Box 55, New York, NY 10065, USA.
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Bode B, Clarke JG, Johnson J. Use of Decision Support Software to Titrate Multiple Daily Injections Yielded Sustained A1c Reductions After 1 Year. J Diabetes Sci Technol 2018; 12:124-128. [PMID: 29251061 PMCID: PMC5761995 DOI: 10.1177/1932296817747886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose was to improve the quality of care of at-risk patients through the addition of connected BG meters and CDSS to improve workflow and thus provide more efficient titration of patient's insulin regimens remotely between office visits in an attempt to treat them to their glucose targets faster and efficiently, and maintain that improvement over time. METHODS Hardware and software included a real-time cellular-enabled blood glucose (BG) meter and Glytec's Glucommander™ clinical decision support software (CDSS). A quality improvement (QI) project with retrospective before-and-after comparison was conducted. The training period was 90 days and then the project ran for another 11 months. A protocol comprised Glytec CDSS software, which recommends titration intervals from 3 to 28 days as a function of glycemic control, specifically, longer intervals for better control. There were 46 clinic patients. RESULTS A1C decreased from a baseline average of 10.2% to 7.8% at 3 months, 7.8% at 6 months, 7.8% at 9 months, and 7.2% at 12 months. The baseline-to-final A1C decrease shows a P < .00001 by paired t-test. Out of 36 315 BGs, the average number of BG tests per day was 3.03 during the first 3 months and 2.47 during the final 3 months. The percentage of BGs < 54 mg/dL was 0.33% and the percentage of BGs < 40 mg/dL was 0.05%. CONCLUSIONS This QI project demonstrated the use of CDSS including its built-in feature of titration interval recommendation can safely and effectively lower A1C for at-risk patients, treat patients to target safely, and maintain those improvements over 12 months of follow-up.
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Affiliation(s)
- Bruce Bode
- Atlanta Diabetes Associates, Atlanta, GA, USA
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