Standardized Glycemic Management with a Computerized Workflow and Decision Support System for Hospitalized Patients with Type 2 Diabetes on Different Wards

Abstract

Background: This study investigated the efficacy, safety, and usability of standardized glycemic management by a computerized decision support system for non-critically ill hospitalized patients with type 2 diabetes on four different wards.Materials and Methods: In this open, noncontrolled intervention study, glycemic management of 99 patients with type 2 diabetes (62% acute admissions; 41 females; age, 67±11 years; hemoglobin A1c, 65±21 mmol/mol; body mass index, 30.4±6.5 kg/m2) on clinical wards (Cardiology, Endocrinology, Nephrology, Plastic Surgery) of a tertiary-care hospital was guided by GlucoTab® (Joanneum Research GmbH [Graz, Austria] and Medical University of Graz [Graz, Austria]), a mobile decision support system providing automated workflow support and suggestions for insulin dosing to nurses and physicians.Results: Adherence to insulin dosing suggestions was high (96.5% bolus, 96.7% basal). The primary outcome measure, percentage of blood glucose (BG) measurements in the range of 70–140 mg/dL, occurred in 50.2±22.2% of all measurements. The overall mean BG level was 154±35 mg/dL. BG measurements in the ranges of 60–70 mg/dL, 40–60 mg/dL, and <40 mg/dL occurred in 1.4%, 0.5%, and 0.0% of all measurements, respectively. A regression analysis showed that acute admission to the Cardiology Ward (+30 mg/dL) and preexisting home insulin therapy (+26 mg/dL) had the strongest impact on mean BG. Acute admission to other wards had minor effects (+4 mg/dL). Ninety-one percent of the healthcare professionals felt confident with GlucoTab, and 89% believed in its practicality and 80% in its ability to prevent medication errors.Conclusions: An efficacious, safe, and user-accepted implementation of GlucoTab was demonstrated. However, for optimized personalized patient care, further algorithm modifications are required.

GlucoTab‐guided insulin therapy using insulin glargine U300 enables glycaemic control with low risk of hypoglycaemia in hospitalized patients with type 2 diabetes

“…Umpierrez et al reported 2.0% of values in the hypoglycaemic range (<3.9 mmol/L) during basal‐bolus therapy using insulin glargine U100 in surgical patients . In a previous study using GlucoTab‐guided basal‐bolus therapy in combination with insulin glargine U100 in 99 inpatients, only 1.5% of all BG measurements were less than 3.9 mmol/L . In the present study using insulin glargine U300 with an otherwise unchanged basal‐bolus algorithm, we showed even lower rates of hypoglycaemia (0.9% of all capillary BG measurements).…”

“…As GlucoTab facilitates insulin titration without requiring expert user input in the course of the treatment, it can be speculated that such a device could contribute to safely establishing glycaemic control in other fields of medicine such as surgery or neurology where other diseases are the main focus and diabetes is considered an inconvenient comorbidity. In a previous study in which GlucoTab was used on different general wards including surgery, the high acceptance rate on the part of staff, accompanied by good glycaemic control, was demonstrated . Acceptance rates and the mean glucose values achieved exceeded those seen in internal medicine wards where physicians interfered more with therapy.…”

“…One component of GlucoTab incorporates a basal‐bolus insulin dosing algorithm that aims to achieve the recommended glycaemic target range of fasting and pre‐meal BG values of 5.6 to 7.8 mmol/L . Details of the algorithm, which was not specifically modified for this study, are described elsewhere . In brief, an initial total daily insulin dose is calculated upon enrolment depending on patient age, renal function and body weight.…”

“…In studies investigating glycaemic control in the hospital setting, NPH insulin, insulin glargine U100 or insulin detemir were used as basal insulin . To the best of our knowledge, novel basal insulin analogues, insulin glargine U300 or insulin degludec, have not yet been combined with automated basal‐bolus insulin algorithms for the hospital setting.…”

The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes

“…[113] With respect to CPOE-based interventions, most studies found improvements in rates of hyperglycemia with an overall average reduction in patient day-weighted mean blood glucose ranging from 10.8 to 15.6 mg/dl, with only one of the studies showing a significant increase in hypoglycemic events. [113] Since the publication of this meta-analysis, there have been several additional studies evaluating the impact of CPOEs on glycemic outcomes [112, 114, 115]. Most, but not all, of these studies showed similar reductions in hyperglycemia rates without worsening hypoglycemia.…”