A Detailed Description of the Implementation of Inpatient Insulin Orders With a Commercial Electronic Health Record System

Neinstein, Aaron B.; MacMaster, Heidemarie Windham; Sullivan, Mary M.; Rushakoff, Robert J

doi:10.1177/1932296814536290

Cited by 17 publications

(8 citation statements)

References 12 publications

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“…The use of electronic health records and computerized order sets in the general ward has been adopted in several countries to support inpatient workflow and management. Computerized order sets are usually integrated into electronic patient records and can provide healthcare professionals with instructions on glucose management ; however, these are bound by pre‐existing inpatient hyperglycaemia guidelines or protocols, and are not designed to recommend complex insulin dose or therapy suggestions.…”

Section: Technology and Innovation In Inpatient Diabetes Managementmentioning

confidence: 99%

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non‐critical care settings

Thabit

Hovorka

2018

Diabet. Med.

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Emerging evidence shows that suboptimal glycaemic control is associated with increased morbidity and length of stay in hospital. Various guidelines for safe and effective inpatient glycaemic control in the non-critical care setting have been published. In spite of this, implementation in practice remains limited because of the increasing number of people with diabetes admitted to hospital and staff work burden. The use of technology in the outpatient setting has led to improved glycaemic outcomes and quality of life for people with diabetes. There remains an unmet need for technology utilisation in inpatient hyperglycaemia management in the non-critical care setting. Novel technologies have the potential to provide benefits in diabetes care in hospital by improving efficacy, safety and efficiency. Rapid analysis of glucose measurements by point-of-care devices help facilitate clinical decision-making and therapy adjustment in the hospital setting. Glucose treatment data integration with computerized glucose management systems underpins the effective use of decision support systems and may streamline clinical staff workflow. Continuous glucose monitoring and automation of insulin delivery through closed-loop systems may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia whilst reducing staff workload. This review summarizes the evidence with regard to technological methods to manage inpatient glycaemic control, their limitations and the future outlook, as well as potential strategies by healthcare organizations such as the National Health Service to mediate the adoption, procurement and use of diabetes technologies in the hospital setting.

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Section: Technology and Innovation In Inpatient Diabetes Managementmentioning

confidence: 99%

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non‐critical care settings

Thabit

Hovorka

2018

Diabet. Med.

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“…Finally, development and implementation of these hyperkalemia treatment ordersets required an experienced multidisciplinary team, including pharmacists, nurses, hospitalists, endocrinologists, and EHR system programmers. 12,13 We, therefore, encourage interprofessional collaboration for any institutions seeking to establish innovative clinical protocols.…”

Section: Discussionmentioning

confidence: 99%

Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia

Black

Lupa

Lemley

et al. 2020

Journal of Hospital Medicine

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H yperkalemia (serum potassium ≥5.1 mEq/L), if left untreated, may result in cardiac arrhythmias, severe muscle weakness, or paralysis. 1,2 Insulin administration can rapidly correct hyperkalemia by shifting serum potassium intracellularly. 3 Treatment of hyperkalemia with insulin may lead to hypoglycemia, which, when severe, can cause confusion, seizures, loss of consciousness, and death. The use of regular and short-acting insulins to correct hyperkalemia quickly in hospitalized patients results in the greatest risk of hypoglycemia within three hours of treatment. 4 Nonetheless, monitoring blood glucose levels within six hours of postinsulin administration is not a standard part of hyperkalemia treatment guidelines, 3 leaving the rates of hypoglycemia in this setting poorly characterized.Without standardized blood glucose measurement protocols, retrospective studies have reported posttreatment hypoglycemia rates of 8.7%-17.5% among all patients with hyperkalemia, 5,6 and 13% among patients with end-stage renal disease. 4 These estimates likely underestimate the true hypoglycemia rates as they measure blood glucose sporadically and are often outside the three-hour window of highest risk after insulin administration.At the University of California, San Francisco Medical Center (UCSFMC), we faced similar issues in measuring the true hypoglycemia rates associated with hyperkalemia treatment. In December 2015, a 12-month retrospective review revealed a 12% hypoglycemia rate among patients treated with insulin for hyperkalemia. This review was limited by the inclusion of only patients treated for hyperkalemia using the standard orderset supplied with the electronic health record system (EHR;

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“…Neinstein and colleagues described a 2 year process of coordinated work between physicians, nurses, pharmacists and programmers to transition to computerized provider entry for glycemic control. (21) Successful implementation of EHR system changes requires broad stakeholder input and buy-in, as well as a commitment to ongoing modifications in response to user feedback. Support from hospital administration for this substantial time and man-power investment may be more readily obtained by utilizing robust national data registries, such as the Vascular Quality Initiative (VQI), to collect and assess data.…”

Section: Discussionmentioning

confidence: 99%

Utilization of the Electronic Health Record to Improve Provision of Smoking Cessation Resources for Vascular Surgery Inpatients

Smith

Adsit²,

Jorenby³

et al. 2015

Int J Cardiovasc Res

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Background and Objectives Identification of hospitalized patients who smoke has shown significant improvement in recent years, but provision of evidence-based tobacco cessation treatment remains a challenge. This study evaluated the utilization of an electronic health record (EHR) to facilitate implementation of evidence-based clinical practice guidelines for smoking cessation on a vascular surgery inpatient unit. Methods A pre-and post-intervention cohort study was conducted over 6 months at a single academic medical center with a comprehensive EHR. All patients admitted to the vascular surgery service and documented as current smokers were included. A vascular surgery discharge order set with an evidence-based smoking cessation module was developed and implemented. The primary outcome was prescription of nicotine replacement therapy (NRT) at the time of discharge. The secondary outcome was referral for smoking cessation counseling at the time of discharge. Results There were 52 and 42 smokers in the pre-and post-intervention cohorts, respectively. Over the 3 months following implementation of the EHR order set, prescription of NRT at the time of discharge did not change significantly (27% vs 19%, p=0.30). Referral for outpatient smoking cessation counseling increased in the post-intervention group, but did not reach significance (64% vs 72%, p=0.20). Conclusions Implementation of a brief tobacco dependence treatment order set in an existing EHR increased cessation counseling referrals on a vascular surgery inpatient unit. One potential limitation of the study was the modest sample size. Not being able to make smoking cessation treatment a mandatory component in discharge orders may also have contributed to the modest effect. Assessing the differential effect of EHR-based order implementation will be important in future research on this topic.

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A Detailed Description of the Implementation of Inpatient Insulin Orders With a Commercial Electronic Health Record System

Cited by 17 publications

References 12 publications

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non‐critical care settings

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non‐critical care settings

Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia

Utilization of the Electronic Health Record to Improve Provision of Smoking Cessation Resources for Vascular Surgery Inpatients

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