Improving Hospital Glucometrics, Workflow, and Outcomes with a Computerized Intravenous Insulin Dose Calculator Built into the Electronic Health Record

Abstract

Objective: To adjust for dynamic insulin requirements in critically ill patients, intravenous (IV) insulin infusions allow for titration of the dose according to a prespecified algorithm. Despite the adaptability of IV insulin protocols, human involvement in dose calculation allows for error. We integrated a previously validated IV insulin calculator into our electronic health record (Epic) and instituted it in the cardiovascular intensive care unit (CVICU). We aim to describe the design of the calculator, the implementation process, and evaluate the calculator’s impact. Method: Employing an aggressive training program and user acceptance testing prior to significant elbow support at the time of institution, we successfully integrated the insulin calculator in our CVICU. We evaluated the glucometrics before and after implementation as well as nursing satisfaction following calculator implementation. Results: Overall, our implementation led to increased frequency of blood sugar at various glycemic targets, a trend toward less hypoglycemia or hyperglycemia. For severe hypoglycemia, our preintervention cohort had 0.02% of blood sugars less than 40 mg/dL but no blood sugars less than 40 mg/dL were identified in our patient’s postintervention. For the CVICU target blood glucose of 70-180 mg/dL, 87.97% blood sugars at baseline met goal compared to 91.39% at one month, 91.24% at three months, and 90.87% at six months postintervention. Conclusion: By utilizing an aggressive education campaign championing superusers and making adjustments to the calculator based on early problems that were encountered, we were able to improve glycemic control and limit glucose variability at our institution.

Feasibility and Performance of Continuous Glucose Monitoring to Guide Computerized Insulin Infusion Therapy in Cardiovascular Intensive Care Unit

“…After CGMs were placed (on the abdomen in all patients) and completed their warm-up period, we compared CGM and POC-BG readings every 1 to 2 hours using institutional blood glucose meters. This was done in accordance with our prior validated CII calculator, 24 instead of the Fauld et al protocol (which described readings every 1 hour). Validation was considered successful when two consecutive CGM readings were within 20% of the POC-BG when BG exceeded 100 mg/dL, or within 20 mg/dL if the POC-BG was below 100 mg/dL.…”

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024

“…Overall, the panel deemed the positive effects probably favor explicit decision support tools over conventional protocols, with low to moderate certainty of evidence. Protocols with explicit decision support have been associated with lower rates of hypoglycemia, even with INT goals (53, 102, 103). The panel does not support any commercial or published explicit decision support tool with the caveat that it should meet the criteria and apply appropriate limits on dosing (Table 5).…”

“…The conventional protocol comparators may include some important elements (Table 5) that could mask some important and critical differences in outcomes. Incorporating the tool into the EHR is feasible and likely important (103). Additional research is warranted (Table 4).…”

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary

“…We defined those elements of explicit clinical decision support tools that were critical components of acceptable protocols, preferably with computerized support and interoperability of the tool with the electronic health record. While patient outcomes were prioritized for this guideline, the panel acknowledges that insulin titration protocols add to bedside caregiver cognitive burden and workload and could be minimized with a well-designed explicit decision support tool that directs treatment (65,66). Protocols incorporating these tools were associated with reduced frequency of moderate hypoglycemia less than 3.3 mmol/L (60 mg/dL) and greater proportion of BG values within the target range (45,50,(67)(68)(69)(70)(71)(72)(73)(74)(75)(76).…”