Clinical decision support to improve management of diabetes and dysglycemia in the hospital: a path to optimizing practice and outcomes

Abstract

IntroductionInnovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations.Research design and methodsThe tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9–4.4 mmol/L (70–80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods.ResultsWhen active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized.ConclusionEMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.

Use of a Continuous Glucose Monitoring System in High-Risk Hospitalized Noncritically Ill Patients With Diabetes After Cardiac Surgery and During Their Transition of Care From the Intensive Care Unit During COVID-19: A Pilot Study

“…Studies have demonstrated the need for improved transitions of care in hospitalized patients. [ 39 ] Glycemic management on the medical and surgical wards following an ICU transfer is an important transition of care that is high risk and could potentially be associated with gaps in care that could negatively impact patients’ safety and length of stay. In comparison to the ICU, patients receive less monitoring on the wards and the nurse-to-patient ratios are higher.…”

Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

“…The 3.1% incidence of stress hyperglycemia in our study cohort denotes unequivocally elevated glucose values at which providers should consider treatment. Our detection criteria sustained a hospital-wide clinical decision support program employing real-time notifications and provision of practice recommendations 40 . Studies have reported a greater incidence in adult patients admitted to various hospital settings 1 , 3 , due to more inclusive criteria of hyperglycemia compared to our inclusion criteria.…”

“… An algorithmic workflow codified to match common data elements corresponding to glycemic data and patient characteristics was used to recognize stress hyperglycemia events among hospitalized patients in real time. The algorithm was instituted as part of a hospital-wide program evaluating clinical decision support in the EHR with the purpose of addressing gaps in glycemic care by providing practice recommendations 40 . For the purpose of this study, we defined stress hyperglycemia among hospitalized patients as two point-of-care BG levels ≥ 10 mmol/L (180 mg/dL) at least 3 h apart within a 36-h-period during an inpatient encounter without documentation or biochemical evidence of diabetes.…”

“…Our definition of stress hyperglycemia was more strict than the recommended threshold for monitoring and treatment in guidelines of 7.8 mmol/L (140 mg/dL) 6 , 32 , 33 . We used this threshold to avoid equivocal attribution of stress hyperglycemia as its recognition was followed by real-time notifications to clinicians through an alert-based clinical decision support program 40 . A case detection tool and registry identified patients meeting biochemical criteria for stress hyperglycemia and who were lacking documentation of it upon hospital discharge in the diagnosis or problem list based on ICD-10 code (“hyperglycemia, unspecified” -R73.9), SnoMed, or IMO codes.…”

“…Our definition of stress hyperglycemia was more strict than the recommended threshold for monitoring and treatment in guidelines of 7.8 mmol/L (140 mg/dL) 6 , 32 , 33 . We used this threshold to avoid equivocal attribution of stress hyperglycemia as its recognition was followed by real-time notifications to clinicians through an alert-based clinical decision support program 40 .…”