Use and validation of a survey tool to measure the perceived effectiveness of insulin prescribing safety interventions in UK hospitals

AIMS

To describe the use and validation of a survey tool to elicit the opinion of hospital pharmacists and medicines safety officers in the UK regarding the perceived effectiveness of strategies to improve insulin prescribing safety in hospitals.

METHODS

One respondent from each participating organization completed the survey on behalf of the main acute hospital in their trust (n = 92). A five-point Likert scale was used to determine opinion on how effective 22 different interventions were at promoting insulin safety at the respondent's trust. The tool, the Perception of Effectiveness of Prescribing Safety Interventions for Insulin (PEPSII) questionnaire, underwent content validity testing. The reliability was estimated using Cronbach's alpha (α).

RESULTS

The PEPSII questionnaire demonstrated good reliability (α = 0.867). Outreach team review and mandatory insulin education were the highest-scoring interventions; the insulin passport was amongst the lowest scoring interventions. Most interventions were considered more effective by trusts using them compared to those who didn't, except for self-administration policies, electronic prescribing and the insulin passport.

CONCLUSIONS

The perceived effectiveness of a variety of insulin prescribing safety strategies in UK hospitals was described by leveraging a purposely developed survey tool. The results describe current levels of support for recommended interventions, and may facilitate the direction of both local and national insulin prescribing safety improvement efforts.

Strategies to reduce insulin prescribing errors in UK hospitals: results from a national survey

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.

Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

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.

Glutamine protects function and improves preservation of small bowel segments

BACKGROUND

Improved organ preservation is essential for the success of small bowel transplantation. Small bowel is usually preserved in UW (University of Wisconsin) solution which does not contain glutamine (Gln), the principal fuel for the enterocyte. We hypothesized that Gln-supplemented UW would improve mucosal function and structure of cold preserved small intestine.

MATERIALS AND METHODS

Jejunum (40 cm) was harvested from Lewis rats and preserved for 18 hr at 4 degrees C in saline; UW solution only; UW with 1, 2, or 4% Gln; and UW containing 1, 2, or 4% isonitrogenous balanced nonessential amino acids (NEAA). 14C glucose transport, mucosal protein, mucosal maltase and alkaline phosphatase, jejunal villous height, and histologic damage were measured.

RESULTS

UW with 2% Gln significantly increased glucose transport and mucosal protein when compared to the 2% NEAA and UW-only groups. Two percent Gln significantly decreased histologic damage of jejunum following cold preservation. Increasing Gln to 4% did not significantly increase its efficacy when compared to the UW with 2% Gln group. There were no significant differences in the activities of mucosal maltase and alkaline phosphatase among the various treatment groups.

CONCLUSIONS

The addition of Gln, optimally provided at a concentration of 2%, to UW solution may protect the preserved small bowel segments from cold ischemic injury and improve mucosal function.

Resection-induced colonic adaptation is augmented by IGF-I and associated with upregulation of colonic IGF-I mRNA

The effects of exogenous insulin-like growth factor-I (IGF-I) on colonic adaptation were examined in male Sprague-Dawley rats (n = 60, 225-275 mg) after either a 60% small bowel and cecal resection (RX) or mid-small bowel transection with reanastomosis (TX). Animals received a 7-day treatment with either IGF-I (2.4 mg.kg-1.day-1) or vehicle (V; 0.1 mol/l acetic acid). Body weight decreased significantly after resection (-25.6 +/- 4.0 g; P < 0.05 vs. TX/V). IGF-I treatment significantly reduced weight loss after resection (-12.4 +/- 3.8 g; P < 0.01 vs. RX/V) and induced significant weight gain after transection (15.6 +/- 4.0 g; P < 0.05 vs. TX/V). Plasma IGF-I decreased with resection (526 +/- 41 TX/V vs. 344 +/- 17 ng/ml RX/V; P < 0.01). IGF-I treatment significantly increased plasma IGF-I levels (805 +/- 100 ng/ml TX/IGF, 677 +/- 56 ng/ml RX/IGF). After resection, IGF-I treatment significantly increased colonic mucosal weight, DNA, protein content, and crypt depth when compared with resection alone (P < 0.05). Colonic water absorption, measured by an in vivo [3H]polyethylene glycol assay, was significantly increased by IGF-I treatment in resected animals (399 +/- 23 RX/IGF vs. 306 +/- 32 microliter.cm-1.h-1 RX/V; P < 0.05). Resection resulted in increased steady-state colonic IGF-I mRNA (182% of TX/V; P < 0.01) without significantly affecting IGF-I receptor mRNA expression. Regulation of IGF binding protein (BP)-3 and -4 was discoordinate, with IGFBP-3 mRNA tending to decrease with resection (67% of TX/V; P is not significant) and IGFBP-4 increasing significantly (191% of TX/V; P < 0.05). An important role for IGF-I in colonic adaptation after massive intestinal resection is indicated by 1) significantly enhanced colonic mucosal growth and water absorption with IGF-I treatment and 2) postresection upregulation of colonic IGF-I mRNA and alteration of IGFBP-3 and IGFBP-4 mRNA expression.

Insulin-like growth factor-I (IGF-I) and glutamine improve structure and function in the small bowel allograft

IGF-I, a mitogenic polypeptide hormone, and glutamine (GLN), the preferred enterocyte fuel, singularly improve growth and structure of the small bowel isograft; however, their combined effects on intestinal allografts are unknown. This study examined the effects of IGF-I and GLN, singularly and in combination, on the structure and function of the intestinal allograft. Fifty-nine adult rats underwent resection of the distal 60% of small bowel and received either a 40-cm isograft or an allograft. Either IGF-I (2.4 mg/kg/day) or its vehicle was infused continuously by subcutaneous minipumps. An isocaloric polymeric diet with either 2% GLN or isonitrogenously balanced 2% nonessential amino acids was given continuously by gastrostomy for 10 days. Five groups were studied: isograft (ISO) alone, allograft (ALLO) alone, ALLO and GLN, ALLO and IGF-I, and ALLO and IGF-I with GLN. All recipients received Cyclosporine A (15 mg/kg, im) daily. Mucosal villus height, surface area, crypt depth, IgA, IgG, IgM, and intercellular adhesion molecule-1 (ICAM-1) plasma cells in intestinal tissue, glucose and water absorption of intestinal graft, bacterial translocation (BT) to mesenteric lymph nodes, and body weight were determined. IGF-I increased villus height, surface area (P < 0.001), crypt depth (P < 0.01), and glucose absorption (P < 0.05) compared to the ISO and ALLO groups. GLN increased only crypt depth when compared to the ALLO group (P < 0.01). Both IGF-I and GLN independently decreased BT to MLN (P < 0.05) and, in combination, enhanced water absorption (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin-like growth factor-I improves mucosal structure and function in transplanted rat small intestine

The transplanted small intestine develops significant mucosal atrophy, impaired nutrient and water absorption, and increased bacterial translocation to mesenteric lymph nodes in rats maintained on elemental diets or total parenteral nutrition. This study determined the effects of administration of an peptide growth factor (insulin-like growth factor-I[IGF-I]) on the mucosal structure and barrier function of rat small bowel isografts. Thirty-six adult Lewis rats underwent either resection of the distal 60% of the small bowel and proximal colon followed by a 40-cm orthotopic jejunal isograft or proximal small bowel transection and distal small bowel resection to leave an analogous length of small intestine in control animals. All rats received an isocaloric, isonitrogenous, polymeric diet (200 kcal/kg/day, 2 gN/kg/day) by gastrostomy and were infused with either IGF-I (2.4 mg/kg/day) or vehicle by osmotic pumps subcutaneously. After 10 days of treatment, jejunal crypt cell production, mucosal morphometric indices, glucose and water absorption, body weight, and bacterial translocation to mesenteric lymph nodes (MLN) were measured. Jejunal mRNA content for IGF-I, IGF-I receptor, and IGF-binding proteins 3 and 4 (IGFBP-3,4) were determined by Northern blotting. Crypt cell production, villus height, crypt depth, and villus surface area were significantly increased in control and transplanted jejunum of rats infused with IGF-I when compared to animals given vehicle alone. Additionally, jejunal glucose absorption and water absorption were significantly improved in both IGF-I groups when compared with their respective vehicle controls. IGF-I infusion increased body weight in transplanted and control animals and markedly reduced bacterial translocation to MLN after small bowel transplantation. Jejunal levels of IGF-I mRNA were significantly increased in transplanted animals when compared to transected controls. IGF-I treatment significantly increased IGFBP-3 tissue mRNA levels in both transected and transplanted animals. These results demonstrate that IGF-I administration, after small bowel transplantation, improves mucosal structure and absorptive function and reduces bacterial translocation to MLN. IGF-I may have important effects in transplanted small bowel both as an endogenous and administered growth factor.

Glutamine reduces bacterial translocation after small bowel transplantation in cyclosporine-treated rats

Bacterial translocation (BT) of enteric organisms is a major cause of sepsis in patients undergoing small bowel transplantation (SBT). Cyclosporine (CsA) may be toxic to intestinal epithelium and increase the risk of BT. Glutamine (Gln) is the preferred enterocyte fuel and maintains graft epithelial integrity in experimental SBT. This study determined the effects of CsA on mucosal structure and function of transplanted intestinal isograft and examined whether Gln-enriched diet reversed CsA-induced intestinal toxicity. Thirty-three adult Lewis rats underwent resection of the distal 60% of small bowel and received an orthotopic jejunal isograft. Rats received either elemental diet with 2% Gln or the same diet with balanced nonessential amino acids (non-Gln) by gastrostomy for 10 days. CsA (15 mg/kg, im) or olive oil was injected daily. Rats were assigned to four groups: non-Gln with vehicle, non-Gln with CsA, Gln with vehicle, and Gln with CsA. Mucosal villous height, surface area, crypt depth, 14C glucose absorption, BT to mesenteric lymph nodes (MLN), and body weight change were evaluated. The non-Gln with CsA group had the highest incidence of BT (P < 0.001). Gln groups had significantly decreased BT (P < 0.01) and increased crypt depth and villous surface area (P < 0.01) when compared to non-Gln groups. Body weight significantly decreased in CsA groups when compared to non-CsA groups (P < 0.01). These results indicate at CsA significantly decreased body weight and increased BT without decreasing mucosal structure and glucose absorption of intestinal isografts.(ABSTRACT TRUNCATED AT 250 WORDS)

Fiber: effect on bacterial translocation and intestinal mucin content

Total parenteral nutrition (TPN) and elemental diet (ED) produce intestinal atrophy and increase bacterial translocation (BT) to mesenteric lymph nodes. The increased rate of BT may be due to alterations in mucosal structure, enzyme activity, or mucin content. Fiber improves intestinal structure and function in rats and may reduce the rate of BT. This study determined whether the addition of fiber to TPN or ED would maintain intestinal integrity and decrease BT to the mesenteric lymph nodes. Fifty-six adult male Sprague-Dawley rats underwent placement of jugular catheters and were assigned to one of five dietary groups: TPN, TPN+oral oat fiber (TPNF) 2 g/day, ED, ED+oral oat fiber (EDF) 2 g/day, or AIN-76 (control); they were pair-fed for 7 days. On day 8 the mesenteric lymph nodes were removed for bacterial cultures; and jejunal mucosal weight, DNA, protein, alkaline phosphatase, maltase, and jejunal mucin content were measured. Enteral nutrition significantly decreased BT when compared to parenteral feeding, and fiber significantly decreased BT when administered to rats receiving TPN or ED. Improvements in intestinal mucosal structure were not consistently associated with decreased rates of BT. Additionally, BT occurred independently of jejunal mucin concentration. Mechanisms other than maintenance of mucosal structure or mucin content are important in the mediation of fiber-induced decreased BT in rats receiving TPN or ED.

Butyrate increases colonocyte protein synthesis in ulcerative colitis

Butyrate promotes epithelial cell healing and improves symptoms when administered rectally in patients with distal ulcerative colitis (UC). It was hypothesized that butyrate may enhance healing in patients with UC by stimulating colonocyte proliferation and/or protein production. Mucosa from the descending colon was obtained from patients with UC (n = 5), Crohn's disease (n = 8), diverticulitis (n = 6), and cancer (normal tissue 10 cm from tumor; n = 10). Epithelial cells were isolated using dispase/collagenase and differential sedimentation and incubated for 4 hr at 37 degrees C with either Na butyrate (10 mM) or NaCl (10 mM). Protein synthesis was assessed by [14C]leucine incorporation and proliferation was determined with [3H]thymidine. Mean viability and purity were >88%. Spontaneous proliferation was significantly increased in UC when compared to diverticulitis and normal controls. Butyrate significantly increased protein synthesis in UC epithelial cells when compared to saline control. The therapeutic effects of butyrate in patients with UC may be due to its use by epithelial cells as a metabolic fuel to increase protein production and promote healing.

Validity of a perceived exertion scale for children: a pilot study

The purpose of this study was to examine the validity of a recently developed rating scale of perceived exertion, the Children's Effort Rating Table (CERT), for controlling exercise intensity in young children. 16 children (M age = 9.9 yr., SD = 1.2) performed three separate exercise tests on a mechanically braked cycle ergometer. Stage I (response protocol) consisted of a graded test with heart rate and perceived effort rating recorded in response to specified steady-state work outputs. Stage II (production protocol) examined subjects' ability to produce work outputs corresponding to levels 5, 7, and 9 of the CERT. This protocol was repeated on a further occasion (Stage III) to assess the reliability of the findings. Pearson correlations between ratings and heart rate (0.76) and ratings and work output (0.75) highlight the potential of the scale as a valid measure of exercise intensity. Also, the work rates produced by subjects in Stage II correlated 0.89 with those predicted from Stage I; however, analysis of variance showed that work output was significantly lower in Stage II than predicted. Finally, an intraclass correlation of 0.91 between Stages II and III suggests that the scale gave a reliable estimate of exercise intensity of children. The findings from this pilot study suggest that children's perceptions of effort might be used to guide intensity of exercise during structured activity classes.

Infectious drug resistance during an outbreak of samonellosis

The sudden acquisition of aminoglycoside resistance among Salmonella group C1 isolates causing summer diarrhoea raised the possibility oif plasmid-mediated reistance. The demonstration of circular DNA species in the resistant, but not in the sensitive salmonellae and the transfer by conjugation of antibiotic resistance to a sensitive strain of Escherichic coli, was consistent with plasmid-mediated resistance.