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Tan G, Li Y, Zhou G. The connotation between perioperative glycemic control approach and sternal wound infection in individuals with diabetes mellitus experiencing cardiac surgery: A meta-analysis. Int Wound J 2023; 20:3324-3330. [PMID: 37190865 PMCID: PMC10502249 DOI: 10.1111/iwj.14213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
A meta-analysis investigation to measure the connotation between perioperative glycemic control (GC) approach and sternal wound infection (SWI) in individuals with diabetes mellitus (DM) experiencing cardiac surgery (CS). A comprehensive literature inspection till February 2023 was applied and 2654 interrelated investigations were reviewed. The 12 chosen investigations enclosed 1564 individuals with DM and CS in the chosen investigations' starting point, 790 of them were using strict GC, and 774 were using moderate GC. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the Connotation between the perioperative GC approach and SWI in individuals with DM experiencing CS by the dichotomous and continuous approaches and a fixed or random model. Strict GC had significantly lower SWI (OR, 0.33; 95% CI, -0.22-0.50, P < .001) compared with those with moderate GC in individuals with DM and CS. Strict GC had significantly lower SWI compared with those with moderate GC in individuals with DM and CS. However, caused of the small sample sizes of several chosen investigations for this meta-analysis, care must be exercised when dealing with its values.
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Affiliation(s)
- Gang Tan
- Department of Cardiovascular MedicineSichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
| | - Yongfang Li
- Department of EndoscopySichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
| | - Guangpeng Zhou
- Department of EndocrinologySichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
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2
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Shoaib H, Hussain YK, Ahmed S. Improving Clinician Confidence in Insulin Prescriptions at Discharge for Individuals With Newly Diagnosed Type 1 Diabetes. Cureus 2023; 15:e43643. [PMID: 37719599 PMCID: PMC10504911 DOI: 10.7759/cureus.43643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Background In a questionnaire, we found that pediatric clinicians at Basildon and Thurrock University Hospital (BTUH) have low confidence levels in prescribing multiple daily injections (MDI) for newly diagnosed pediatric patients with type 1 diabetes mellitus. We designed and evaluated locally tailored prescription guidance to improve confidence in MDI discharge prescriptions for pediatric doctors of all grades. Methods We designed a prescription guidance tool by adapting existing local guidelines to improve clinician familiarity with MDI prescriptions and prevent prescription errors. The intervention was delivered in a single pediatric unit to doctors of all levels. Feedback was collected, and the clinicians' confidence in their MDI prescriptions was evaluated before and after the intervention. Questionnaires were distributed to all pediatric doctors within the unit to assess their confidence in prescribing MDIs using a five-point Likert Scale. Furthermore, the questionnaires aimed to determine whether clinicians regularly consulted the existing local guidelines. Local guidelines were adapted in consultation with the local pediatric diabetic multidisciplinary team (MDT) and with reference to the East of England Pediatric Diabetes Network to present MDI guidance in a more concise format, which includes an example MDI discharge medication checklist. Following approval by the local guidelines management group, additional changes were made to enhance the practicality and accessibility of the discharge prescription guidance for clinicians. These guidelines were distributed to the pediatric MDT via email and displayed in visible areas of the department. Results Out of the 13 doctors surveyed, 10 provided pre- and post-intervention feedback (77%). Statistical significance was calculated using unpaired t-tests. Ninety percent of pediatric doctors routinely refer to local guidelines for guidance on MDI prescriptions. However, 50% of respondents felt that existing local guidelines were not easily accessible, given the time and effort required to locate them. The mean confidence score for completing MDI prescriptions at discharge before the intervention was 1.9 (SD: 0.83). After the intervention, it increased to 4 (SD: 0.63) (95% CI: 2.79-1.41, p<0.0001). Ninety percent of pediatric doctors felt that the design and display of the MDI guidelines optimized patient care. Conclusions Following the presentation of the project at a local audit and quality improvement (QI) meeting, the adapted guidelines were included in the junior doctor induction program at BTUH and made accessible on the local intranet. The production of locally tailored prescription guidance for MDI prescriptions at discharge has led to an increase in the confidence of pediatric doctors when writing their prescriptions. We aimed to continue updating this guidance as necessary and making further developments to enhance clinician confidence.
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Affiliation(s)
- Haris Shoaib
- Medicine, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Yunus K Hussain
- Medicine, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Shahida Ahmed
- Pediatrics, Basildon and Thurrock University Hospital, Basildon, GBR
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Alqahtani N. Reducing potential errors associated with insulin administration: An integrative review. J Eval Clin Pract 2022; 28:1037-1049. [PMID: 35179287 DOI: 10.1111/jep.13668] [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: 12/01/2021] [Revised: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, OBJECTIVES Around one-third of medication errors resulting in death within 48 h involve insulin therapy. Despite a growing number of interventional strategies that have been published over the past decade, it remains unclear which of these interventions is effective in reducing insulin errors. Therefore, the study aimed to synthesize interventions to reduce the frequency of insulin errors in either home or health care settings. METHODS This integrative review was conducted based on Whittemore and Knafl's four steps, which includes problem identification, literature search, data analysis and presentation. Six databases including Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, PsychInfo and Cochrane were searched from January 2010 through July 2021. The level of evidence quality was assessed according to the Johns Hopkins Nursing Evidence-Based Practice grading scale. RESULTS Sixteen studies meeting inclusion criteria were reviewed. The results provide strong support for teaching patients how to use automated bolus calculators and educating patients to self-administer insulin to prevent insulin errors in the home setting. Computerized protocols, education and double-checking procedures were also found to be effective strategies for minimizing insulin errors in healthcare settings. CONCLUSION While the strategies might be effective in reducing insulin administration errors in the home settings, computerized protocols, continuing education and the manual validation of insulin products appear to be the most effective strategies for reducing such insulin errors in healthcare settings. Understanding these findings may help clinicians and patients to decrease the number of insulin errors administration.
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Affiliation(s)
- Naji Alqahtani
- Nursing Administration and Education Department, College of Nursing, King Saud University, Riyadh, Saudi Arabia
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Postoperative Glycemic Variability as a Predictor of Adverse Outcomes Following Lumbar Fusion. Spine (Phila Pa 1976) 2022; 47:E304-E311. [PMID: 34474452 DOI: 10.1097/brs.0000000000004214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cross-sectional study. OBJECTIVE This study aims to evaluate the effect size of postoperative glycemic variability on surgical outcomes among patients who have undergone one- to three-level lumbar fusion. SUMMARY OF BACKGROUND DATA While numerous patient characteristics have been associated with surgical outcomes after lumbar fusion, recent studies have described the measuring of postoperative glycemic variability as another promising marker. METHODS A total of 850 patients were stratified into tertiles (low, moderate, high) based on degree of postoperative glycemic variability defined by coefficient of variation (CV). Surgical site infections were determined via chart review based on the Centers for Disease Control and Prevention definition. Demographic factors, surgical characteristics, inpatient complications, readmissions, and reoperations were determined by chart review and telephone encounters. RESULTS Overall, a statistically significant difference in 90-day adverse outcomes was observed when stratified by postoperative glycemic variability. In particular, patients with high CV had a higher odds ratio (OR) of readmission (OR = 2.19 [1.17, 4.09]; P = 0.01), experiencing a surgical site infection (OR = 3.22 [1.39, 7.45]; P = 0.01), and undergoing reoperations (OR = 2.65 [1.34, 5.23]; P = 0.01) compared with patients with low CV. No significant association was seen between low and moderate CV groups. Higher CV patients were more likely to experience longer hospital stays (β: 1.03; P = 0.01). Among the three groups, high CV group experienced the highest proportion of complications. CONCLUSION Our study establishes a significant relationship between postoperative glycemic variability and inpatient complications, length of stay, and 90-day adverse outcomes. While HbA1c has classically been used as the principal marker to assess blood glucose control, our results show CV to be a strong predictor of postoperative adverse outcomes. Future high-quality, prospective studies are necessary to explore the true effect of CV, as well as its practicality in clinical practice. Nevertheless, fluctuations in blood glucose levels during the inpatient stay should be limited to improve patient results.Level of Evidence: 4.
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Abstract
Hintergrund Eine Hyperglykämie bei Menschen mit und ohne Diabetes, die ins Krankenhaus eingeliefert werden, ist mit einem erheblichen Anstieg von Morbidität, Mortalität und Gesundheitskosten verbunden. Während eines Krankenhausaufenthaltes treten Stoffwechseldekompensationen häufig als Folge unterschiedlicher Ereignisse oder Zusatztherapien auf. Aufgrund des erhöhten Risikos für eine Zunahme der Morbidität, verbunden mit längerem Krankenhausaufenthalt sowie höheren Kosten und Mortalität, erscheint eine genaue Betrachtung der Bedeutung von Glukosewerten und der Therapieformen im Krankenhaus sinnvoll und angebracht. Material und Methode Aktuelle Befunde, Übersichtsarbeiten und Grundlagendaten wurden analysiert und in einer kurzen Übersicht zusammengefasst und diskutiert. Fazit Eine persistierende Hyperglykämie im Krankenhaus ist häufig und oft mit unzureichenden Ergebnissen des Krankenhausaufenthaltes verbunden. Die kontinuierliche Insulininfusion bleibt die Therapie der Wahl während hyperglykämischer Krisen und kritischen Erkrankungen. Auch bei nicht kritisch kranken Menschen mit ausgeprägter Hyperglykämie, schon ambulant bekannten hohen Insulindosen, mit Typ-1-Diabetes oder mit steroidinduzierter Hyperglykämie bleibt Insulin das Mittel der Wahl.
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Affiliation(s)
- Michael Jecht
- Diabetesschwerpunktpraxis, Rodensteinstr. 32, 13593 Berlin, Deutschland
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Mathioudakis N, Aboabdo M, Abusamaan MS, Yuan C, Lewis Boyer L, Pilla SJ, Johnson E, Desai S, Knight A, Greene P, Golden SH. Stakeholder Perspectives on an Inpatient Hypoglycemia Informatics Alert: Mixed Methods Study. JMIR Hum Factors 2021; 8:e31214. [PMID: 34842544 PMCID: PMC8665392 DOI: 10.2196/31214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background Iatrogenic hypoglycemia is a common occurrence among hospitalized patients and is associated with poor clinical outcomes and increased mortality. Clinical decision support systems can be used to reduce the incidence of this potentially avoidable adverse event. Objective This study aims to determine the desired features and functionality of a real-time informatics alert to prevent iatrogenic hypoglycemia in a hospital setting. Methods Using the Agency for Healthcare Research and Quality Five Rights of Effective Clinical Decision Support Framework, we conducted a mixed methods study using an electronic survey and focus group sessions of hospital-based providers. The goal was to elicit stakeholder input to inform the future development of a real-time informatics alert to target iatrogenic hypoglycemia. In addition to perceptions about the importance of the problem and existing barriers, we sought input regarding the content, format, channel, timing, and recipient for the alert (ie, the Five Rights). Thematic analysis of focus group sessions was conducted using deductive and inductive approaches. Results A 21-item electronic survey was completed by 102 inpatient-based providers, followed by 2 focus group sessions (6 providers per session). Respondents universally agreed or strongly agreed that inpatient iatrogenic hypoglycemia is an important problem that can be addressed with an informatics alert. Stakeholders expressed a preference for an alert that is nonintrusive, accurate, communicated in near real time to the ordering provider, and provides actionable treatment recommendations. Several electronic medical record tools, including alert indicators in the patient header, glucose management report, and laboratory results section, were deemed acceptable formats for consideration. Concerns regarding alert fatigue were prevalent among both survey respondents and focus group participants. Conclusions The design preferences identified in this study will provide the framework needed for an informatics team to develop a prototype alert for pilot testing and evaluation. This alert will help meet the needs of hospital-based clinicians caring for patients with diabetes who are at a high risk of treatment-related hypoglycemia.
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Affiliation(s)
- Nestoras Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Moeen Aboabdo
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Christina Yuan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - LaPricia Lewis Boyer
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Scott J Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Erica Johnson
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Sanjay Desai
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Amy Knight
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Peter Greene
- Department of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Sherita H Golden
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Faulds ER, Boutsicaris A, Sumner L, Jones L, McNett M, Smetana KS, May CC, Buschur E, Exline MC, Ringel MD, Dungan K. Use of Continuous Glucose Monitor in Critically Ill COVID-19 Patients Requiring Insulin Infusion: An Observational Study. J Clin Endocrinol Metab 2021; 106:e4007-e4016. [PMID: 34100545 DOI: 10.1210/clinem/dgab409] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Indexed: 12/11/2022]
Abstract
CONTEXT The coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU). OBJECTIVE To evaluate feasibility and patient safety of a hybrid monitoring strategy of point-of-care (POC) BG plus continuous glucose monitor (CGM) in the ICU. DESIGN Retrospective analysis. SETTING ICU of an academic medical center. PATIENTS Patients with COVID-19 on IV insulin. INTERVENTION After meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed. MAIN OUTCOME MEASURES Outcomes included frequency of POC BG, workflow, safety, and accuracy measures. RESULTS The study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter (71% reduction compared with standard of 24/day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70 to 180 mg/dL was 64 ± 23% on day 1 and 72 ± 16% on days 2 through 7, whereas time <70 mg/dL was 1.5 ± 4.1% on day 1 and <1% on days 2 through 7. CONCLUSIONS This study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.
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Affiliation(s)
- Eileen R Faulds
- The Ohio State University College of Nursing, The Ohio State University Medical Center, Columbus, OH, USA
| | | | - Lyndsey Sumner
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Laureen Jones
- The Ohio State University Medical Center, Columbus, OH, USA
| | - Molly McNett
- Implementation/Translation Science Core, Helene Fuld Health Trust National Institute for EBP, Columbus, OH, USA
| | | | - Casey C May
- The Ohio State University Medical Center, Columbus, OH, USA
| | - Elizabeth Buschur
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew C Exline
- Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
| | - Kathleen Dungan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
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Ana Y, Prafulla S, Deepa R, Babu GR. Emerging and Public Health Challenges Existing in Gestational Diabetes Mellitus and Diabetes in Pregnancy. Endocrinol Metab Clin North Am 2021; 50:513-530. [PMID: 34399959 DOI: 10.1016/j.ecl.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We review the evidence available worldwide on the various challenges in the screening, management, prevention of gestational diabetes mellitus and diabetes in pregnancy. The use of multiple screening and diagnostic tests prescribed by numerous guidelines is challenging for practitioners. Also, sociocultural, demographic and economic challenges affect the prevention and care. Life-course perspectives need to be adopted, as well as an integrated approach in public health care is essential. Tackling these challenges at each phase of life-course, with development and adherence to the country-specific guidelines by practitioners can decrease the burden of gestational diabetes mellitus and diabetes in pregnancy.
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Affiliation(s)
- Yamuna Ana
- Public Health Foundation of India, IIPH-H, Bangalore Campus, SIHFW Premises, Beside Leprosy Hospital, 1st Cross, Magadi Road, Bangalore 560023, Karnataka, India
| | - Shriyan Prafulla
- Public Health Foundation of India, IIPH-H, Bangalore Campus, SIHFW Premises, Beside Leprosy Hospital, 1st Cross, Magadi Road, Bangalore 560023, Karnataka, India
| | - Ravi Deepa
- Public Health Foundation of India, IIPH-H, Bangalore Campus, SIHFW Premises, Beside Leprosy Hospital, 1st Cross, Magadi Road, Bangalore 560023, Karnataka, India
| | - Giridhara R Babu
- Lifecourse Epidemiology, Public Health Foundation of India, IIPH-H, Bangalore Campus, SIHFW Premises, Beside Leprosy Hospital, 1st Cross, Magadi Road, Bangalore 560023, Karnataka, India.
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11
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Massoomi F, Burger M, de Vries C. Advances in safe insulin infusions. Drugs Context 2021; 10:2021-1-6. [PMID: 34349818 PMCID: PMC8289406 DOI: 10.7573/dic.2021-1-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/09/2021] [Indexed: 11/21/2022] Open
Abstract
Hyperglycaemia is recognized as a marker of adverse clinical outcomes for hospitalized patients with and without diabetes, including mortality, morbidity, increased length of stay, infections and overall complications. In some cases, intravenous (IV) insulin infusions are the optimal intervention and, to date, these have been compounded in hospital pharmacy departments or, alternatively, at the point of care, when timeliness is a concern or the pharmacy is closed. However, in-house compounding of high-risk medications such as IV insulin poses risks both for patients and institutions. The critical nature of certain high-risk therapies has led to the development of ready-to-administer products to improve the safety, timeliness, efficacy and efficiency of critical infusions. Recently, IV insulin, a high-alert therapy, has been added to the ready-to-use armamentarium. This narrative review explores the expanding indications, risks and opportunities associated with insulin infusions and potential options for improved safety.
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12
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Patel PD, Canseco JA, Wilt Z, Okroj KT, Chang M, Reyes AA, Bowles DR, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion. J Am Acad Orthop Surg 2021; 29:580-588. [PMID: 34135295 DOI: 10.5435/jaaos-d-20-00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/03/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes. METHODS A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates. RESULTS Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications. DISCUSSION This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.
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Affiliation(s)
- Parthik D Patel
- From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Hitchen SA, Lan NSR, Ali US, Hort AL, Larbalestier R, Yeap BB, Fegan PG. Investigating the effect of an education program on diabetes and lipid lowering medication usage following coronary artery bypass graft surgery. Intern Med J 2021; 52:1354-1365. [PMID: 34033208 DOI: 10.1111/imj.15393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/14/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Guidelines advocate multifactorial cardiovascular risk management in patients with diabetes and atherosclerotic cardiovascular disease. In hospitalised patients with diabetes following coronary artery bypass graft (CABG) we evaluated the impacts of decision-support algorithms for optimising glycaemia and lipid-lowering. We also assessed the safety of initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors near time of hospital discharge. METHODS This was a single-site, pre- and post-intervention analysis of glucose and lipid management in consecutive hospitalised patients with diabetes undergoing CABG surgery. The intervention involved education and decision-support algorithms designed by a multidisciplinary committee to guide cardiac surgery unit clinicians. RESULTS A total of 200 patients were included in the study. The pre- and post-intervention groups had similar baseline characteristics (HbA1c 7.9 ± 1.9% versus 8.1 ± 1.8%). Of 4092 blood glucose measurements the incidence of levels between 5 to 10 mmol/L was not different post-intervention (55.5% versus 57.0%, p = 0.441). Fewer endocrinology consultations occurred (59.0% versus 45.0%, p = 0.048) and rates of hypoglycaemia remained low. High-intensity statin was prescribed in >90% pre- and post-intervention although non-statin lipid-lowering agents remained <10% despite patients not achieving LDL-C targets. No 30-day readmissions for diabetic ketoacidosis occurred in patients prescribed SGLT2 inhibitors. CONCLUSION The intervention did not improve inpatient glycaemia or increase non-statin lipid-lowering prescriptions in patients with diabetes following CABG surgery but did reduce reliance on specialty input. Initiation of SGLT2 inhibitor therapy near time of hospital discharge was not associated with safety concerns. Alternative interventions or strategies are required to optimise glycaemia and non-statin lipid-lowering therapy prescribing in this setting. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sarah A Hitchen
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Department of Pharmacy, Fiona Stanley Hospital, Western Australia, Australia
| | - Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Department of Cardiology, Fiona Stanley Hospital, Western Australia.,Medical School, The University of Western Australia, Western Australia, Australia
| | - Umar S Ali
- Medical School, The University of Western Australia, Western Australia, Australia.,Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Western Australia, Australia
| | - Adam L Hort
- Department of Pharmacy, Fiona Stanley Hospital, Western Australia, Australia
| | - R Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Western Australia, Australia
| | - Bu B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Medical School, The University of Western Australia, Western Australia, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Western Australia, Australia.,Medical School, Curtin University, Western Australia, Australia
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14
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Lloyd M, Bennett N, Wilkinson A, Furlong N, Cardwell J, Michaels S. A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting. Res Social Adm Pharm 2021; 17:2006-2014. [PMID: 33775557 DOI: 10.1016/j.sapharm.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
AIMS To explore the impact of a prescribing feedback intervention on insulin prescribing. METHODS This was a mixed-methods study in a hospital setting. An insulin prescribing feedback intervention was delivered verbally and in writing to twelve doctors. Insulin prescribing error frequency was compared to ten doctors who had not received the feedback intervention. Insulin prescribing was audited over four weeks at the start and end of the intervention period. Semi-structured interviews were conducted with participating doctors who had received feedback, and qualitative data analysed thematically to explore the impact of the intervention on their prescribing practice. RESULTS Prescribing data were collected on 370 insulin prescriptions with 241 errors identified. A significant reduction (χ2 = 22.6, p=<0.05) in insulin prescribing error frequency was observed in the intervention group, with a non-significant increase reported in the control group. Feedback was received positively and considered valuable by doctors, supporting development of their knowledge and skills and encouraging reflection on their prescribing performance. Doctors described enhanced confidence in insulin prescribing and a desire to improve as a prescriber and avoid harm, with feedback raising awareness of their development needs. Prescribers also described enhanced team work, with greater information and feedback seeking behavior to inform future prescribing decisions. CONCLUSIONS Feedback has potential to improve insulin prescribing and is a valued and acceptable process intervention for doctors. The impact on insulin prescribing practice is varied and complex influencing the capability, opportunity and motivation of prescribers to adapt and evolve their behavior in response to ongoing feedback.
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Affiliation(s)
- M Lloyd
- Clinical Education Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK.
| | - N Bennett
- Clinical Education Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - A Wilkinson
- Pharmacy Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - N Furlong
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - J Cardwell
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - S Michaels
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
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15
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A Longitudinal Assessment of the Quality of Insulin Prescribing with Different Prescribing Systems. PHARMACY 2021; 9:pharmacy9010053. [PMID: 33807829 PMCID: PMC8005941 DOI: 10.3390/pharmacy9010053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/05/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022] Open
Abstract
Accurate and complete prescriptions of insulin are crucial to prevent medication errors from occurring. Two core components for safe insulin prescriptions are the word 'units' being written in full for the dose, and clear documentation of the insulin device alongside the name. A retrospective review of annual audit data was conducted for insulin prescriptions to assess the impact of changes to the prescribing system within a secondary care setting, at five time points over a period of 7 years (2014 to 2020). The review points were based on when changes were made, from standardized paper charts with a dedicated section for insulin prescribing, to a standalone hospital wide electronic prescribing and medicines administration (ePMA) system, and finally an integrated electronic health record system (EHRS). The measured outcomes were compliance with recommended standards for documentation of 'units' in full, and inclusion of the insulin device as part of the prescription. Overall, an improvement was seen in both outcomes of interest. Device documentation improved incrementally with each system change-34% for paper charts, 23%-56% for standalone ePMA, and 100% for ePMA integrated within EHRS. Findings highlight that differences in ePMA systems may have varying impact on safe prescribing practices.
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Faulds ER, Jones L, McNett M, Smetana KS, May CC, Sumner L, Buschur E, Exline M, Ringel MD, Dungan K. Facilitators and Barriers to Nursing Implementation of Continuous Glucose Monitoring (CGM) in Critically Ill Patients With COVID-19. Endocr Pract 2021; 27:354-361. [PMID: 33515756 PMCID: PMC7839794 DOI: 10.1016/j.eprac.2021.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We describe our implementation of a continuous glucose monitoring (CGM) guideline to support intravenous insulin administration and reduce point of care (POC) glucose monitoring frequency in the coronavirus disease 2019 medical intensive care unit (MICU) and evaluate nurses' experience with implementation of CGM and hybrid POC + CGM protocol using the Promoting Action on Research in Health Services framework. METHODS A multidisciplinary team created a guideline providing criteria for establishing initial sensor-meter agreement within each individual patient followed by hybrid use of CGM and POC. POC measures were obtained hourly during initial validation, then every 6 hours. We conducted a focus group among MICU nurses to evaluate initial implementation efforts with content areas focused on initial assessment of evidence, context, and facilitation to identify barriers and facilitators. The focus group was analyzed using a qualitative descriptive approach. RESULTS The protocol was integrated through a rapid cycle review process and ultimately disseminated nationally. The Diabetes Consult Service performed device set-up and nurses received just-in-time training. The majority of barriers centered on contextual factors, including limitations of the physical environment, complex device set-up, hospital firewalls, need for training, and CGM documentation. Nurses' perceived device accuracy and utility were exceptionally high. Solutions were devised to maximize facilitation and sustainability for nurses while maintaining patient safety. CONCLUSION Outpatient CGM systems can be implemented in the MICU using a hybrid protocol implementation science approach. These efforts hold tremendous potential to reduce healthcare worker exposure while maintaining glucose control during the COVID-19 pandemic.
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Affiliation(s)
- Eileen R Faulds
- The Ohio State University College of Nursing, The Ohio State University Medical Center, Columbus, Ohio.
| | - Laureen Jones
- The Ohio State University Medical Center, Columbus, Ohio
| | - Molly McNett
- Helene Fuld Health Trust National Institute for EBP, Columbus, Ohio
| | | | - Casey C May
- The Ohio State University Medical Center, Columbus, Ohio
| | - Lyndsey Sumner
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Elizabeth Buschur
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
| | - Matthew Exline
- Division of Critical Care Medicine, The Ohio State University Medical Center, The Ohio State University Medical Center, Columbus, Ohio
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
| | - Kathleen Dungan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
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17
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Kopanz J, Sendlhofer G, Lichtenegger K, Semlitsch B, Riedl R, Pieber TR, Tax C, Brunner G, Plank J. Evaluation of an implemented new insulin chart to improve quality and safety of diabetes care in a large university hospital: a follow-up study. BMJ Open 2021; 11:e041298. [PMID: 33500281 PMCID: PMC7839871 DOI: 10.1136/bmjopen-2020-041298] [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] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate structure, documentation, treatment quality of a new implemented standardised insulin chart in adult medical inpatient wards at a university hospital. DESIGN A before-after study (3 to 5 months after implementation) was used to compare the quality of old versus new insulin charts. SETTING University Hospital Graz, Austria. PARTICIPANTS Healthcare professionals (n=237) were questioned regarding structure quality of blank insulin charts. INTERVENTIONS A new standardised insulin chart was implemented and healthcare professionals were trained regarding features of this chart. Data from insulinised inpatients were evaluated regarding documentation and treatment quality of filled-in insulin charts (n=108 old insulin charts vs n=100 new insulin charts). MAIN OUTCOMES AND MEASURES The primary endpoint was documentation error for insulin administration. RESULTS Healthcare professionals reported an improved structure quality of the new insulin chart with a Likert type response scale increase in all nine items. Documentation errors for insulin administration (primary endpoint) occurred more often on old than new insulin charts (77% vs 5%, p<0.001). Documentation errors for insulin prescription were more frequent on old insulin charts (100% vs 42%) whereas documentation errors for insulin management rarely occurred in any group (10% vs 8%). Patients of both chart evaluation groups (age: 71±11 vs 71±12 years, 47% vs 42% women, 75% vs 87% type 2 diabetes for old vs new charts, respectively) had a mean of 4±2 good diabetes days. Overall, 26 vs 18 hypoglycaemic episodes (blood glucose (BG) <4.0 mmol/L (72 mg/dL), p=0.28), including 7 vs 2 severe hypoglycaemic episodes (BG <3.0 mmol/L (54 mg/dL), p=0.17) were documented on old versus new insulin charts. CONCLUSIONS The implementation of a structured documentation form together with training measures for healthcare professionals led to less documentation errors and safe management of glycaemic control in hospitalised patients in a short time follow-up. A rollout at further medical wards is recommended, and sustainability in the long-term has to be demonstrated.
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Affiliation(s)
- Julia Kopanz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, University Hospital of Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Katharina Lichtenegger
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Semlitsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christa Tax
- Chief Nursing Director, University Hospital Graz, Graz, Styria, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Chief Medical Director, University Hospital Graz, Graz, Styria, Austria
| | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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19
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Evaluating the Impact of Inadequate Meal Consumption on Insulin-Related Hypoglycemia in Hospitalized Patients. Endocr Pract 2020; 27:443-448. [PMID: 33934753 DOI: 10.1016/j.eprac.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/09/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Meal intake is sometimes reduced in hospitalized patients. Meal-time insulin administration can cause hypoglycemia when a meal is not consumed. Inpatient providers may avoid ordering meal-time insulin due to hypoglycemia concerns, which can result in hyperglycemia. The frequency of reduced meal intake in hospitalized patients remains inadequately determined. This quality improvement project evaluates the percentage of meals consumed by hospitalized patients with insulin orders and the resulting risk of postmeal hypoglycemia (blood glucose [BG] <70 mg/dL, <3.9 mmol/L). METHODS This was a retrospective quality improvement project evaluating patients with any subcutaneous insulin orders hospitalized at a regional academic medical center between 2015 and 2017. BG, laboratory values, point of care, insulin administration, diet orders, and percentage of meal consumed documented by registered nurses were abstracted from electronic health records. RESULTS Meal consumption ≥50% was observed for 85% of meals with insulin orders, and bedside registered nurses were accurate at estimating this percentage. Age ≥65 years was a risk factor for reduced meal consumption (21% of meals 0%-49% consumed, P < .05 vs age < 65 years [12%]). Receiving meal-time insulin and then consuming only 0% to 49% of a meal (defined here as a mismatch) was not rare (6% of meals) and increased postmeal hypoglycemia risk. However, the attributable risk of postmeal hypoglycemia due to this mismatch was low (4 events per 1000) in patients with premeal BG between 70 and 180 mg/dL. CONCLUSION This project demonstrates that hospitalized patients treated with subcutaneous insulin have a low attributable risk of postmeal hypoglycemia related to inadequate meal intake.
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20
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Bain A, Hasan SS, Kavanagh S, Babar ZUD. Strategies to reduce insulin prescribing errors in UK hospitals: results from a national survey. Diabet Med 2020; 37:1176-1184. [PMID: 31845373 DOI: 10.1111/dme.14209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 02/01/2023]
Abstract
AIM To describe insulin prescribing practice in National Health Service hospitals in the UK and the current use of interventions and strategies to reduce insulin prescribing errors. METHODS We sent a cross-sectional questionnaire to chief pharmacists in all National Health Service hospital trusts in the UK in January 2019. Questions concerned the use and functionality of electronic and paper systems used to prescribe subcutaneous insulin, along with features and interventions designed to reduce insulin prescribing errors. RESULTS Ninety-five hospital trusts responded (54%). Electronic prescribing of insulin was reported in 40% of hospitals, most of which were teaching hospitals in England. We found a wide variation in the functionality of both electronic prescribing and paper-based systems to enable the safe prescribing of insulin for inpatients. The availability of specialist diabetes pharmacists to support the safe prescribing of insulin was low (29%), but was positively associated with the use of a greater number of insulin prescribing error reduction strategies (P=0.002). The use of specific interventions to improve insulin prescribing quality (e.g. self-administration policies) varied greatly between respondent hospitals. CONCLUSIONS There is potential to optimize the functionality of both electronic and paper-based prescribing systems to improve the safe prescribing of insulin in hospitals in the UK. The wide variation in the use of insulin error reduction strategies may be improved by the availability of specialist diabetes pharmacists who can support the implementation of insulin-prescribing interventions.
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Affiliation(s)
- A Bain
- School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S S Hasan
- School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
| | - S Kavanagh
- School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Z-U-D Babar
- School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
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21
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Li W, Ping F, Xu L, Zhang H, Dong Y, Yu K, Li Y. The Effect of LM25 and LM50 on Hypoglycemia in Chinese T2DM Patients: Post Hoc Analysis of a Randomized Crossover Trial. Diabetes Ther 2020; 11:643-654. [PMID: 31981211 PMCID: PMC7048899 DOI: 10.1007/s13300-020-00766-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION To investigate the safety of insulin lispro Mix 25 and 50 (LM25 and LM50) in hypoglycemia in patients with type 2 diabetes mellitus (T2DM). METHODS This was a post hoc analysis of a phase IV, randomized, crossover clinical trial in Chinese patients with T2DM switching from premixed human insulin 70/30 (PHI70/30) to LM25 or LM50. Eighty-one subjects received a two-stage crossover protocol of either LM25 or LM50 twice daily for 16 weeks. Habitual diet was taken, and self-monitoring of blood glucose (SMBG) was performed throughout the study period. High-carbohydrate diet (HCD), high-fat diet (HFD) and habitual diet patterns were taken, and 72 h continuous glucose monitoring (CGM) was performed at the last 3 days of each treatment stage. RESULTS The frequencies of nocturnal hypoglycemia in LM50 were lower than those in LM25 under a Chinese habitual diet pattern. The related factors of hypoglycemia in patients with T2DM treated with a LM25 or LM50 regimen were the weight-based daily mean insulin dose and the type of combined oral hypoglycemic agents. Under both HCD and habitual diet patterns, the optimal cut point values of bedtime glucose predicting nocturnal hypoglycemia in LM50 were lower than those in LM25. CONCLUSIONS The risk of nocturnal hypoglycemia in the LM50 regimen was lower than that in the LM25 regimen under the HCD pattern, and the safety range of bedtime glucose for the LM50 regimen was wider than that of the LM25 regimen in Chinese T2DM patients. Premixed insulin analogs combined with acarbose were more helpful to reduce the incidence of hypoglycemia. TRIAL REGISTRATION http://www.chictr.org.cn #ChiCTR-TTRCC-12002516.
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Affiliation(s)
- Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingling Xu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaxiu Dong
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kang Yu
- Department of Clinical Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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23
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Dungan K, Merrill J, Long C, Binkley P. Effect of beta blocker use and type on hypoglycemia risk among hospitalized insulin requiring patients. Cardiovasc Diabetol 2019; 18:163. [PMID: 31775749 PMCID: PMC6882013 DOI: 10.1186/s12933-019-0967-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/10/2019] [Indexed: 01/30/2023] Open
Abstract
Background Although beta blockers could increase the risk of hypoglycemia, the difference between subtypes on hypoglycemia and mortality have not been studied. This study sought to determine the relationship between type of beta blocker and incidence of hypoglycemia and mortality in hospitalized patients. Methods We retrospectively identified non-critically ill hospitalized insulin requiring patients who were undergoing bedside glucose monitoring and received either carvedilol or a selective beta blocker (metoprolol or atenolol). Patients receiving other beta blockers were excluded. Hypoglycemia was defined as any glucose < 3.9 mmol/L within 24 h of admission (Hypo1day) or throughout hospitalization (HypoT) and any glucose < 2.2 mmol/L throughout hospitalization (Hyposevere). Results There were 1020 patients on carvedilol, 886 on selective beta blockers, and 10,216 on no beta blocker at admission. After controlling for other variables, the odds of Hypo1day, HypoT and Hyposevere were higher for carvedilol and selective beta blocker recipients than non-recipients, but only in basal insulin nonusers. The odds of Hypo1day (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.28, 3.09, p = 0.0002) and HypoT (OR 1.38, 95% CI 1.02, 1.86, p = 0.03) but not Hyposevere (OR 1.90, 95% CI 0.90, 4.02, p = 0.09) were greater for selective beta blocker vs. carvedilol recipients in basal insulin nonusers. Hypo1day, HypoT, and Hyposevere were all associated with increased mortality in adjusted models among non-beta blocker and selective beta blocker recipients, but not among carvedilol recipients. Conclusions Beta blocker use is associated with increased odds of hypoglycemia among hospitalized patients not requiring basal insulin, and odds are greater for selective beta blockers than for carvedilol. The odds of hypoglycemia-associated mortality are increased with selective beta blocker use or nonusers but not in carvedilol users, warranting further study.
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Affiliation(s)
- Kathleen Dungan
- Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH, 43210-1296, USA.
| | - Jennifer Merrill
- Division of Endocrinology, Duke University, 30 Duke Medicine Circle, Durham, NC, 22710, USA
| | - Clarine Long
- The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA
| | - Philip Binkley
- Division of Cardiovascular Medicine, The Ohio State University, 452 W. 10th Ave, Columbus, OH, 43210, 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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25
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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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Gibbs HG, McLernon T, Call R, Outten K, Efird L, Doyle PA, Stuart EA, Mathioudakis N, Glasgow N, Joshi A, George P, Feroli B, Zink EK. Randomized controlled evaluation of an insulin pen storage policy. Am J Health Syst Pharm 2019; 74:2054-2059. [PMID: 29222362 DOI: 10.2146/ajhp160348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Results of a quality-improvement project to enhance safeguards against "wrong-pen-to-patient" insulin pen errors by permitting secure bedside storage of insulin pens are reported. METHODS A cluster-randomized controlled evaluation was conducted at an academic medical center to assess adherence with institutional policy on insulin pen storage before and after implementation of a revised policy allowing pen storage in locking boxes in patient rooms. In phase 1 of the study, baseline data on policy adherence were captured for 8 patient care units (4 designated as intervention units and 4 designated as control units). In phase 2, policy adherence was assessed through direct observation during weekly audits after lock boxes were installed on intervention units and education on proper insulin pen storage was provided to nurses in all 8 units. RESULTS Phase 1 rates of adherence to insulin pen storage policy were 59% in the intervention units and 49% in the control units (p = 0.56). During phase 2, there was no significant change from baseline in control unit adherence (67%, p = 0.26), but adherence in intervention units improved significantly, to 89% (p = 0.005). Common types of observed nonadherence included pens being unsecured in patient rooms or nurses' pockets or left in patient-specific medication drawers after patient discharge. CONCLUSION An institutional policy change permitting secure storage of insulin pens close to the point of care, paired with nurse education, increased adherence more than education alone.
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Affiliation(s)
- Haley G Gibbs
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Tara McLernon
- School of Nursing, University of Northern Colorado, Greeley, CO
| | - Rosemary Call
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Katie Outten
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Leigh Efird
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY
| | - Peter A Doyle
- Clinical Engineering Services, Johns Hopkins Hospital, Baltimore, MD
| | - Elizabeth A Stuart
- Department of Mental Health, Department of Biostatistics, and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nicole Glasgow
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | | | - Pravin George
- Department of Neurology, Division of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Bob Feroli
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Elizabeth K Zink
- Department of Neuroscience Nursing, Johns Hopkins Hospital, Baltimore, MD
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Altyar AE, Sadoun SA, Alradadi RS, Aljohani SS. Evaluating Pharmacy Practice in Hospital Settings in Jeddah City, Saudi Arabia: Prescribing and Transcribing-2018. Hosp Pharm 2019; 55:306-313. [PMID: 32999500 DOI: 10.1177/0018578719844707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose: The aim of this study was to evaluate the prescription and transcription processes in hospital settings in Jeddah city, Saudi Arabia. Method: A customized version of the original American Society of Health-System Pharmacists (ASHP) survey was distributed to a total of 26 hospitals in Jeddah city that fits our criteria starting from December 2017. Hospitals' names were adopted from the Ministry of Health and Jeddah Municipality websites. All questionnaires were collected in June 2018. After that, they were classified according to the type of care provided by the hospital, size, ownership, teaching affiliation, and accreditation. Data were entered electronically using Google forms, and then Microsoft Excel was used to conduct descriptive statistics. Results: The survey had a response rate of 57%. A strict formulary system was adopted in 53.3% of hospitals, and clinical practice guidelines were used to optimize medication use in 86.7% of hospitals. Pharmacists do not have the authority to write medication orders in about 86.7% of hospitals and only 40.0% of hospitals have pharmacists routinely assigned to patient care units. However, Pharmacists actively provided consultation, mostly in drug information (80.0%). Computerized prescriber order entry (CPOE) is used to receive medication orders electronically in 80.0% of hospitals, and electronic health record (EHR) is used in about 53.3% of hospitals and 50.0% of those hospitals have pharmacists who document their clinical intervention in EHR. Conclusion: Survey results suggest that pharmacists in hospital settings have not yet been positioned to improve the prescribing and transcribing components of the medication-use process.
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Abstract
It is the position of American Association of Diabetes Educators (AADE) that all inpatient interdisciplinary teams include a diabetes educator to lead or support improvement efforts that affect patients hospitalized with diabetes or hyperglycemia. This not only encompasses patient and family education but education of interdisciplinary team members and achievement of diabetes-related organizational quality metrics and performance outcomes.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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El Khoury G, Mansour H, Kabbara WK, Chamoun N, Atallah N, Salameh P. Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon. Curr Diabetes Rev 2019; 15:133-140. [PMID: 29357807 DOI: 10.2174/1573399814666180119142254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. OBJECTIVE The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. METHODS The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. RESULTS A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). CONCLUSION Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.
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Affiliation(s)
- Ghada El Khoury
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Hanine Mansour
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Wissam K Kabbara
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nibal Chamoun
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Nadim Atallah
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, P.O Box: 36-Byblos, Lebanon
| | - Pascale Salameh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Jacob BC, Peasah SK, Chan HL, Niculas D, Shogbon Nwaesei A. Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients. Hosp Pharm 2018; 54:197-202. [PMID: 31205332 DOI: 10.1177/0018578718779012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose: Hypoglycemia is a common adverse event associated with insulin during treatment of hyperkalemia in hospitalized patients; however, limited data exist regarding hypoglycemia incidence and appropriate dosing strategies for treatment of patients in the emergency department. The study objective was to determine the incidence of hypoglycemia associated with insulin use during treatment of hyperkalemia among patients seen in the emergency department. Methods: This was an Institutional Review Board (IRB)-approved retrospective, chart-review study. All adult patients who received intravenous regular insulin as a result of an order from the emergency department hyperkalemia order set were eligible for inclusion. The main clinical outcomes were incidence of hypoglycemia (blood glucose <70 mg/dL) and severe hypoglycemia (blood glucose <40 mg/dL). Blood glucose was checked within 24 hours of insulin administration. Results: A total of 172 patients were included. The incidence of hypoglycemia was 19.8% (n = 34) and the incidence of severe hypoglycemia was 5.2% (n = 9). Hypoglycemic patients had a significantly lower median blood glucose at baseline compared to those who did not develop hypoglycemia (83.5 [72.0-112.0] mg/dL vs 123.0 [96.0-167.0] mg/dL, P < .0001); however, no difference was noted between groups in the average insulin dose administered (0.11 ± 0.04 units/kg vs 0.12 ± 0.05 units/kg, P = .6175). Conclusion: There is a concerning risk of hypoglycemia associated with insulin use during treatment of hyperkalemia in the emergency department. Standard insulin doses may not be appropriate in some cases like patients with lower baseline blood glucose. Further research is warranted to develop safer hyperkalemia treatment protocols that mitigate this high risk of hypoglycemia associated with insulin use.
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Affiliation(s)
| | | | - Hannah L Chan
- University of Alabama at Birmingham Hospital, Birmingham, AL, USA
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Smego A, Lawson S, Courter JD, Warden D, Corathers S. Decreasing the Time to Insulin Administration for Hospitalized Patients With Cystic Fibrosis-Related Diabetes. Hosp Pediatr 2018; 8:288-292. [PMID: 29691278 DOI: 10.1542/hpeds.2017-0199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Children with cystic fibrosis-related diabetes (CFRD) represent a commonly hospitalized pediatric population whose members require insulin for blood glucose (BG) control. The aim of this quality improvement initiative was to increase the proportion of hospitalized patients with CFRD receiving insulin within 30 minutes of a BG check while decreasing severe hypo- and hyperglycemia episodes. METHODS Quality improvement methodology (gathering a team of stakeholders, identifying metrics, implementing iterative plan-do-study-act cycles and analysis of data over time) was applied in the setting of a cystic fibrosis unit in a tertiary care children's hospital. The percentage of patients with CFRD who received rapid-acting insulin within 30 minutes of a BG check and the rates of hypoglycemia (BG <70 mg/dL) and hyperglycemia (BG >200 mg/dL) were measured. Improvement interventions were focused on efficient communication among patients, nurses and providers; refining carbohydrate calculation; and sharing expectations with patients and caregivers. RESULTS The proportion of rapid-acting insulin doses given within 30 minutes increased from a baseline mean 40% to a sustained mean of 78%. During active improvement interventions, success rates of 100% were achieved. Hyperglycemic events (BG >200 mg/dL) decreased from 125 events to 85 events per 100 rapid-acting insulin days. Hypoglycemic events (BG <70 mg/dL) remained low at <5 events per 100 rapid-acting insulin days. CONCLUSIONS Systematic implementation of low-cost interventions successfully resulted in measurable improvement in timely rapid-acting insulin administration for hospitalized patients with CFRD and lower rates of severe hypo- and hyperglycemia on the unit. Future efforts will be directed to increase the reliability of interventions to maintain optimal performance and outcomes.
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Affiliation(s)
| | | | | | - Deborah Warden
- Patient Services, Cystic Fibrosis/Complex Pulmonary Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Braithwaite SS, Clark LP, Idrees T, Qureshi F, Soetan OT. Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion. Curr Diab Rep 2018; 18:26. [PMID: 29582176 DOI: 10.1007/s11892-018-0994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier. RECENT FINDINGS Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Lisa P Clark
- Presence Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- Presence Saint Joseph Hospital, 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
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Nishida S, Hayashi Y, Suzuki A, Kobayashi R, Inuzuka T, Itoh Y. Relationship between number of drugs and duration of hospital stay in older patients with neuromuscular diseases. Geriatr Gerontol Int 2018; 18:1018-1024. [DOI: 10.1111/ggi.13292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/07/2017] [Accepted: 01/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Shohei Nishida
- Department of Pharmacy; Gifu University Hospital; Gifu Japan
| | - Yuichi Hayashi
- Department of Neurology and Geriatrics; Gifu University Graduate School of Medicine; Gifu Japan
| | - Akio Suzuki
- Department of Pharmacy; Gifu University Hospital; Gifu Japan
| | - Ryo Kobayashi
- Department of Pharmacy; Gifu University Hospital; Gifu Japan
| | - Takashi Inuzuka
- Department of Neurology and Geriatrics; Gifu University Graduate School of Medicine; Gifu Japan
| | - Yoshinori Itoh
- Department of Pharmacy; Gifu University Hospital; Gifu Japan
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Abstract
It is the position of American Association of Diabetes Educators (AADE) that all inpatient interdisciplinary teams include a diabetes educator to lead or support improvement efforts that affect patients hospitalized with diabetes or hyperglycemia. This not only encompasses patient and family education but education of interdisciplinary team members and achievement of diabetes-related organizational quality metrics and performance outcomes.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Sinha Gregory N, Seley JJ, Ukena J, Shah S, Fred MR, Dargar SK, Mauer E, Kim RJ. Decreased Rates of Inpatient Hypoglycemia Following Implementation of an Automated Tool in the Electronic Medical Record for Identifying Root Causes. J Diabetes Sci Technol 2018; 12:63-68. [PMID: 29251063 PMCID: PMC5761991 DOI: 10.1177/1932296817744808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective was to identify root causes of hypoglycemia on medicine inpatient units using an automated tool. Data collected will guide educational interventions aimed at improving patient care and safety by decreasing rates of hypoglycemia. METHODS A survey was conducted among RNs to identify risk factors for hypoglycemia. Survey data were used to create a hypoglycemia root cause survey tool in the EMR. RNs were prompted to utilize the tool when blood glucose (BG) < 70 mg/dL. Once the most common modifiable cause of hypoglycemia was identified, an educational intervention for safe and effective use of insulin was launched. This strategy was designed to empower the care team to reduce the insulin dose when appropriate to prevent future hypoglycemic episodes. RESULTS BG data were compared from March and April in 2016 and 2017. Rates of hypoglycemia (BG < 70 mg/dL) decreased from 2.3% to 1.5%; BG values in target range (70-180 mg/dL) increased from 59.4% to 65.7%; hyperglycemia (BG > 180 mg/dL) decreased from 38.3% to 32.8% (all P values < .001). The number of patients with recurrent hypoglycemia (3 or more episodes) decreased from 5.7% to 2.2% ( P = .044). CONCLUSIONS The two most frequent modifiable causes of hypoglycemia (insulin and nutrition) were identified by an RN survey and confirmed by chart review. A targeted educational intervention addressing safe and effective insulin dosing resulted in a significant decrease in both hypoglycemia and recurrent hypoglycemia. This was associated with an improvement in overall glycemic control. Ongoing clinician education regarding insulin and nutrition accompanied by discussions between RNs and prescribers to address hypoglycemic events in real-time could continue to lower the rate of occurrence.
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Affiliation(s)
- Naina Sinha Gregory
- Department of Medicine, Division of Endocrinology, Weill Cornell Medicine, New York, NY, USA
- Naina Sinha Gregory, MD, Department of Medicine, Division of Endocrinology, Weill Cornell Medicine, 211 E 80th St, New York, NY 10021, USA.
| | - Jane Jeffrie Seley
- Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA
| | - Jenny Ukena
- Department of Medicine, Division of Endocrinology, Weill Cornell Medicine, New York, NY, USA
| | - Sona Shah
- Department of Medicine, Division of Endocrinology, Weill Cornell Medicine, New York, NY, USA
| | - Matthew R. Fred
- Information Technology Consultant, New York-Presbyterian Hospital, New York, NY, USA
| | - Savira Kochhar Dargar
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth Mauer
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | - Robert J. Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
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Abstract
It is the position of American Association of Diabetes Educators (AADE) that all inpatient interdisciplinary teams include a diabetes educator to lead or support improvement efforts that affect patients hospitalized with diabetes or hyperglycemia. This not only encompasses patient and family education but education of interdisciplinary team members and achievement of diabetes-related organizational quality metrics and performance outcomes.
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Abstract
PURPOSE OF REVIEW We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients. RECENT FINDINGS Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Dharmesh B Bavda
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- , 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
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Abstract
PURPOSE OF REVIEW The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings. RECENT FINDINGS Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.
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Alwan D, Chipps E, Yen PY, Dungan K. Evaluation of the timing and coordination of prandial insulin administration in the hospital. Diabetes Res Clin Pract 2017; 131:18-32. [PMID: 28668719 DOI: 10.1016/j.diabres.2017.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 06/08/2017] [Accepted: 06/15/2017] [Indexed: 11/29/2022]
Abstract
AIMS The objective of this study was to examine the relationship between measures of coordinated insulin delivery and capillary blood glucose (CBG) levels among hospitalized patients and to assess nurse perceptions of insulin administration. METHODS Hospitalized patients (n=451) receiving rapid acting insulin analog (RAIA) using carbohydrate counting were retrospectively analyzed. Nurses (n=35) were asked to complete an 18-item anonymous survey assessing perception of RAIA dosing. RESULTS The median time from breakfast CBG to RAIA dose was 93 (IQR 57-138) min. There was no association between timeliness measures and mean CBG at lunch or dinner. Hypoglycemia was rare (N=2). More than half (54%) of nurses were confident all of the time in determining the correct dose of RAIA, though none were confident in administering it on time. The majority of nurses perceived an electronic dosing calculator and a patient reminder to notify the nurse at the end of the meal favorably. CONCLUSIONS The data demonstrate suboptimal coordination of CBG monitoring and insulin doses using a flexible meal insulin dosing strategy, though there was minimal impact on glycemic control. Nurses reported high confidence in the ability to calculate the correct insulin dose but not in the ability to administer it on time.
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Affiliation(s)
- Dhuha Alwan
- The Ohio State University, College of Public Health, United States
| | - Esther Chipps
- The Ohio State University, College of Nursing, The Ohio State University Wexner Medical Center, 600 Ackerman Road, E2016, Columbus, OH, United States
| | - Po-Yin Yen
- The Ohio State University Department of Biomedical Informatics, 250 Lincoln Tower, 1800 Cannon Drive, Columbus, OH, United States
| | - Kathleen Dungan
- The Ohio State University, Division of Endocrinology, Diabetes & Metabolism, United States.
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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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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting. RECENT FINDINGS Strategies to reduce hypoglycemia rates should focus on the most common causes of iatrogenic hypoglycemia. Creating a standardized insulin order set with built-in clinical decision support can help reduce rates of hypoglycemia. Coordination of blood glucose monitoring, meal tray delivery, and insulin administration is an important and challenging task. Protocols and processes should be in place to deal with interruptions in nutrition to minimize risk of hypoglycemia. A glucose management page that has all the pertinent information summarized in one page allows for active surveillance and quick identification of patients who may be at risk of hypoglycemia. Finally, education of prescribers, nurses, food and nutrition services, and patients is important so that every member of the healthcare team can work together to prevent hypoglycemia. By implementing strategies to reduce hypoglycemia, we hope to lower rates of adverse events and improve quality of care while also reducing hospital costs. Future research should focus on the impact of an overall reduction in hypoglycemia to determine whether the expected benefits are achieved.
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Affiliation(s)
- Kristen Kulasa
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA.
| | - Patricia Juang
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA
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Harada S, Suzuki A, Nishida S, Kobayashi R, Tamai S, Kumada K, Murakami N, Itoh Y. Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet. J Eval Clin Pract 2017; 23:582-585. [PMID: 27928867 DOI: 10.1111/jep.12674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 11/29/2022]
Abstract
Insulin is frequently used for glycemic control. Medication errors related to insulin are a common problem for medical institutions. Here, we prepared a standardized sliding scale insulin (SSI) order sheet and assessed the effect of its introduction. Observations before and after the introduction of the standardized SSI template were conducted at Gifu University Hospital. The incidence of medication errors, hyperglycemia, and hypoglycemia related to SSI were obtained from the electronic medical records. The introduction of the standardized SSI order sheet significantly reduced the incidence of medication errors related to SSI compared with that prior to its introduction (12/165 [7.3%] vs 4/159 [2.1%], P = .048). However, the incidence of hyperglycemia (≥250 mg/dL) and hypoglycemia (≤50 mg/dL) in patients who received SSI was not significantly different between the 2 groups. The introduction of the standardized SSI order sheet reduced the incidence of medication errors related to SSI.
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Affiliation(s)
- Saki Harada
- Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Shohei Nishida
- Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Sayuri Tamai
- Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Keisuke Kumada
- Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Nobuo Murakami
- Patient Safety Division, Gifu University Hospital, Yanagido, Gifu, Japan
| | - Yoshinori Itoh
- Department of Pharmacy, Gifu University Hospital, Yanagido, Gifu, Japan
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Maynard GA, Holdych J, Kendall H, Harrison K, Montgomery PA, Kulasa K. IMPROVING GLYCEMIC CONTROL SAFELY IN CRITICAL CARE PATIENTS: A COLLABORATIVE SYSTEMS APPROACH IN NINE HOSPITALS. Endocr Pract 2017; 23:583-593. [PMID: 28225315 DOI: 10.4158/ep161569.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Safely improve glycemic control in the critical care units of nine hospitals. METHODS Critical care adult inpatients from nine hospitals with ≥4 point-of-care blood glucose (BG) readings over ≥2 days were targeted by collaborative improvement efforts to reduce hyper- and hypoglycemia. Balanced glucometric goals for each hospital were set targeting improvement from baseline or goals deemed desirable from Society of Hospital Medicine (SHM) benchmarking data. Collaborative interventions included standardized insulin infusion protocols, hypoglycemia prevention bundles, audit and feedback, education, and measure-vention (coupling measurement of patients "off protocol" with concurrent interventions to correct suboptimal care). RESULTS All sites improved glycemic control. Six reached prespecified levels of improvement of the day-weighted mean BG. The day-weighted mean BG for the cohort decreased by 7.7 mg/dL (95% confidence interval [CI], 7.0 mg/dL to 8.4 mg/dL) to 151.3 mg/dL. Six of nine sites showed improvement in the percent intensive care unit (ICU) days with severe hyperglycemia (any BG >299 mg/dL). ICU severe hyperglycemic days declined from 8.6 to 7.2% for the cohort (relative risk, 0.84; 95% CI, 0.80 to 0.88). Patient days with any BG <70 mg/dL were reduced by 0.4% (95% CI, 0.06% to 0.6%), from 4.5 to 4.1%, for a small but statistically significant reduction in hypoglycemia. Seven of nine sites showed improvement. CONCLUSION Multihospital improvements in ICU glycemic control, severe hyperglycemia, and hypoglycemia are feasible. Balanced goals for glycemic control and hypoglycemia in the ICU using SHM benchmarks and metrics enhanced successful improvement efforts with good staff acceptance and sustainability. ABBREVIATIONS BG = blood glucose CMI = case-mix index CY = calendar year DKA = diabetic ketoacidosis EMR = electronic medical record GBMF = Gordon and Betty Moore Foundation ICU = intensive care unit IIP = insulin infusion protocol SHM = Society of z Hospital Medicine.
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Improving Glycemic Control Safely in Non-Critical Care Patients: A Collaborative Systems Approach in Nine Hospitals. Jt Comm J Qual Patient Saf 2017; 43:179-188. [PMID: 28325206 DOI: 10.1016/j.jcjq.2017.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Practice variations in insulin management and glycemic adverse events led nine Dignity Health hospitals to initiate a collaborative effort to improve hypoglycemia, uncontrolled hyperglycemia, and glycemic control. METHODS Non-critical care adult inpatients with ≥4 point-of-care blood glucose (BG) readings in a ≥2-day period were included. Balanced glucometric goals for each hospital were individualized to improve performance by 10%-20% from baseline or achieve top performance derived from Society of Hospital Medicine (SHM) benchmarking studies. Baseline measures (2011) were compared to mature results (postintervention, 2014). Protocols for insulin management and hypoglycemia prevention were piloted at one facility and were then spread to the cohort. Interventions included standardized order sets, education, mentoring from physician experts, feedback of metrics, and measure-vention (coupling measurement of patients "off protocol" with concurrent intervention to correct lapses in care). RESULTS The day-weighted mean BG for the cohort improved by 11.4 mg/dL (95% confidence interval [CI]: 11.0-11.8]; all nine sites improved. Eight of the sites reduced severe hyperglycemic days, and the percentage of patient-days with any BG > 299 mg/dL for the total cohort improved from 11.6% to 8.8% (relative risk, 0.76 [95% CI: 0.74-0.78]). The percentage of patient-days with any BG < 70 mg/dL remained unchanged at 3.6%. Eight of the sites either reduced hypoglycemia by 20% or achieved SHM best-quartile rates. CONCLUSION Multihospital improvements in glycemic control and severe hyperglycemia without significant increases in hypoglycemia are feasible using portable low-cost toolkits and metrics.
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Forough AS, Esfahani PR. Impact of Pharmacist Intervention on Appropriate Insulin Pen Use in Older Patients with Type 2 Diabetes Mellitus in a Rural Area in Iran. J Res Pharm Pract 2017; 6:114-119. [PMID: 28616435 PMCID: PMC5463546 DOI: 10.4103/jrpp.jrpp_16_151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of pharmacist-conducted educational intervention on reducing errors related to inappropriate insulin pen use. METHODS This was a prospective, before-after study with an educational intervention component. The study was conducted on 122 elderly diabetic patients. Data were collected through interviews using researcher-administered questionnaires as well as patients' medical records. Patients were asked about the preparation, injection, and storage techniques, they followed when using insulin pens. Blood glucose parameters were extracted from laboratory records. After the detection of errors, patients and their caregivers were instructed about the insulin pen use by the pharmacist. Patients were reevaluated after 12 weeks. FINDINGS Patients' mean age was 67.2 ± 3.5 with male: female ratio of 71:51. Mean diabetes duration was 7.1 ± 2.8 years. Fifty-four patients (44.2%) stated that they had received instructions for insulin pen use previously. The majority of this group (24 cases, 44.4%) reported that the instructions were given by a pharmacist. The mean number of errors decreased from 3.99 ± 0.22 errors per patient to 1.49 ± 0.13 errors (odds ratio: 0.28, 95% confidence interval: 0.23-0.33,P < 0.05). Of eleven evaluated insulin pen-related medication error items, nine items experienced a significant decrease after patient education. Fasting plasma glucose (FPG) levels decreased significantly from 161.7 ± 12.5 to 147.3 ± 13.1 mg/dL (P < 0.05). However, glycated hemoglobin levels did not change significantly after 3 months (P = 0.18). Controlled FPG had a significant rise from 45% before education to 63.9% postintervention (P < 0.05). CONCLUSION Pharmacists can play an important role in safe and efficient use of insulin pen in elderly diabetic patients by minimizing the likelihood of medication errors associated with insulin pen use.
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Affiliation(s)
- Aida Sefidani Forough
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,Department of Pharmaceutical Care, Amiralmomenin Hospital, Khodabandeh, Iran
| | - Parsa Riazi Esfahani
- National Organization for Development of Exceptional Talents (NODET), Tehran, Iran
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Brown KE, Hertig JB. Determining Current Insulin Pen Use Practices and Errors in the Inpatient Setting. Jt Comm J Qual Patient Saf 2016; 42:568-AP7. [PMID: 28334561 DOI: 10.1016/s1553-7250(16)30109-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The use of insulin pens in the inpatient setting has continued to be a controversial decision. Insulin pens provide several advantages, but given significant reports of medication errors, several organizations have issued alerts to caution users about safety concerns. A survey was conducted to assess the prevalence of insulin pen use and current utilization trends in the inpatient setting. METHODS The 31-question guided-logic survey was developed based on review of primary literature regarding insulin pen utilization and evaluated by a panel of medication safety experts from a variety of health care settings. The survey was sent electronically to subscribers of medication safety organizations. RESULTS The survey was completed by 474 respondents. Approximately three fourths of respondents indicated insulin pens were on formulary at their institution (n = 332; 74%). Of those who have had insulin pens on formulary, 15% (n = 49) are no longer using them. The most common reasons for not utilizing pens were cost and safety concerns. Pens were reported to be stored in the pharmacy prior to administration (n = 230; 78%) and in a patient's bin (n = 202; 69%) afterward. More than half of respondents use two patient identifiers on the pen and label with a bar code. Approximately 30% reported that an insulin pen has been used on more than one patient at least once in their institution, while 6% were not sure. CONCLUSION Insulin pens are widely being used in the inpatient setting. Various mitigation strategies are employed to reduce the risk of harm associated with insulin pen use. Health care professionals believe insulin pens are clinically useful and can be used safely in the inpatient setting. Many organizations and expert panels disseminate best practices in an effort to help ensure their safety. Further studies are needed to assess and validate the risk mitigation strategies identified through this research.
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Affiliation(s)
- Katelyn E Brown
- Formerly Regulatory Pharmaceutical Fellow in Medication Safety, Purdue University, Indianapolis; Therapeutic Consultant for Diabetes in US Health Outcomes, Eli Lilly and Company, Indianapolis.
| | - John B Hertig
- Associate Director, Center for Medication Safety Advancement; Courtesy Clinical Assistant Professor of Pharmacy Practice, Purdue University, Indianapolis; Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety
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Paparella SF. Reducing the Risk with U-500 Insulin: What Every Ed Nurse Should Know. J Emerg Nurs 2016; 42:527-529. [PMID: 27912808 DOI: 10.1016/j.jen.2016.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 11/29/2022]
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