Background: Perioperative diabetes patients are often treated with sliding-scale insulin, despite a lack of evidence to support therapeutic effectiveness. We introduced an automated subcutaneous insulin algorithm (SQIA) to improve glycemic control in these patients while maintaining the simplicity of a q4 hour adjustable sliding-scale insulin order set. Methods: In this pilot study, we implemented a fully programmed, self-adjusting SQIA as part of a structured order set in the electronic medical record for adult patients who are nil per os, or on continuous enteral tube feedings or total parenteral nutrition. The nurse only enters the current glucose in the Medication Administration Record, and then the calculated dose is shown. The new dose is based on previous dose, and current and previous glucoses. The SQIA titrates the glucose to 120-180 mg/dL. For this pilot, this order set was utilized for complex perioperative oncologic patients. Results: The median duration on the SQIA was 58 hours. Glucoses at titration initiation were highest at 206 ± 63 mg/dL, and came down to 156 ± 29 mg/dL by 72 hours. The majority of measured glucoses (66.8%, n = 647) were maintained between 80 and 180 mg/dL. There were no glucoses lower than 60 mg/dL, and only 0.3% (n = 3) were below 70 mg/dL. There was a low rate of errors (1%). Conclusions: A simple automated SQIA can be used to titrate insulin to meet the changing metabolic requirements of individuals perioperatively and maintain glucose within the target range for these hospitalized patients.
Background - We programmed a self-adjusting subcutaneous insulin algorithm (SQIA) in the electronic medical record for patients who are NPO, on total parenteral nutrition (TPN), or on continuous tube feedings (CTF). The SQIA only requires a nurse to enter a patient's current glucose value and then calculates the next insulin dose based on previous dose, and current and previous glucoses. The SQIA titrates for a goal glucose of 120 -180 mg/dL. The advantage of this automated algorithm is that no new orders are required, even if insulin is added to TPN or tube feeding rate is changed. We previously reported results of a pilot study with 67% of blood glucoses in the 80-180 mg/dL range without any hypoglycemia (glucose < 60 mg/dL). Hypothesis - Following the successful pilot, the SQIA was instituted in September 2020 at our institution's three adult hospitals. We hypothesized that glucose control with the SQIA will be non-inferior to previous inpatient glycemic management and successfully maintain blood glucoses in the goal range. Methods - The SQIA was implemented on September 3, 2020 for patients who were NPO, on TPN, or on CTF. Any clinician placing insulin orders could select the SQIA as an alternate to ordering standard fixed aspart dosing or a sliding scale at four-hour intervals. We performed a prospective analysis on all patients managed with the SQIA during the first year of implementation (9/3/2020–9/2/2021) to evaluate use of the SQIA and resulting glycemic control. Results were compared to patients during the preceding one-year period (9/3/2019-9/2/2020) who were ordered for standard subcutaneous insulin aspart dosing while being NPO, on TPN, or on CTF. Results During the study period, the SQIA was utilized during 2691 time intervals within 1774 hospitalizations. The average duration for each interval was 56.4 hours and glucoses were checked every 3.9 hours while on the SQIA. Average point-of-care blood glucose while on SQIA was 157.5 ± 52.6 mg/dL. In a similar set of 1987 hospitalized patients in the preceding year who were on standard subcutaneous insulin orders, the average blood glucose was 159.4 ± 55.1 mg/dL. Conclusions - A self-adjusting SQIA effectively maintained glucose within the goal inpatient range during our first year of implementation and was non-inferior to prior glycemic control using standard dosing protocols. The SQIA provided an avenue for effective glycemic control while eliminating the need for insulin dosage titration by clinicians. Hospitals and health systems should consider pursuing similar innovations to improve the ease of inpatient glycemic control while continuing to meet glycemic targets. Presentation: No date and time listed
We programmed a SQIA in the EMR. It requires the nurse to enter current glucose in the MAR, and then the calculated dose is shown. New dose is based on previous dose, and current and previous glucoses. The SQIA titrates the glucose to 120 -180 mg/dl for patients who are NPO, on TPN or Enteral Feedings (TF). No new orders are required even if insulin is added to TPN, or changes made in TF rates. Glucose and insulin data are shown in the table. The higher glucoses were at titration initiation. Two examples of how the titration worked are shown. Individual data demonstrate ability of the SQIA to titrate insulin and maintain glucoses in range despite significant changes to the rate of TF or addition of basal insulin as shown in Patient B. An automated SQIA allows insulin doses to be adjusted to the individual patient’s needs and maintain glucoses in range. Disclosure R.J. Rushakoff: None. E. Rov-Ikpah: None. C. San Luis: None. C. Johnson: None. S. Patzek: None. V. Juttukonda: None. H.W. Macmaster: None.
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