Multicenter Validation of a Computer-Based Clinical Decision Support Tool for Glucose Control in Adult and Pediatric Intensive Care Units
Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized...
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| Published in | Journal of diabetes science and technology Vol. 2; no. 3; pp. 357 - 368 |
|---|---|
| Main Authors | , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
Diabetes Technology Society
01.05.2008
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| Series | Computerized Algorithms |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1932-2968 1932-3107 |
| DOI | 10.1177/193229680800200304 |
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| Abstract | Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers.
We required attending physicians of eligible patients to independently intend to use intravenous insulin to normalize blood glucose. We used eProtocol-insulin for glucose control for a duration determined by the clinical caregivers. Adults had an anticipated length of stay of 3 or more days. In pediatric ICUs, we also required support or intended support with mechanical ventilation for greater than 24 hours or with a vasoactive infusion. We recorded all instances in which eProtocol-insulin instructions were not accepted and all blood glucose values. An independent data safety and monitoring board monitored study results and subject safety. Bedside nurses were selected randomly to complete a paper survey describing their perceptions of quality of care and workload related to eProtocol-insulin use.
Clinicians accepted 93% of eProtocol-insulin instructions (11,773/12,645) in 100 adult and 48 pediatric subjects. Forty-eight percent of glucose values were in the target range. Both of these results met a priori-defined efficacy thresholds. Only 0.18% of glucose values were < or =40 mg/dl. This is lower than values reported in prior IIT studies. Although nurses reported eProtocol-insulin required as much work as managing a mechanical ventilator, most nurses felt eProtocol-insulin had a low impact on their ability to complete non-IIT nursing activities.
A multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children. |
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| AbstractList | Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers.
We required attending physicians of eligible patients to independently intend to use intravenous insulin to normalize blood glucose. We used eProtocol-insulin for glucose control for a duration determined by the clinical caregivers. Adults had an anticipated length of stay of 3 or more days. In pediatric ICUs, we also required support or intended support with mechanical ventilation for greater than 24 hours or with a vasoactive infusion. We recorded all instances in which eProtocol-insulin instructions were not accepted and all blood glucose values. An independent data safety and monitoring board monitored study results and subject safety. Bedside nurses were selected randomly to complete a paper survey describing their perceptions of quality of care and workload related to eProtocol-insulin use.
Clinicians accepted 93% of eProtocol-insulin instructions (11,773/12,645) in 100 adult and 48 pediatric subjects. Forty-eight percent of glucose values were in the target range. Both of these results met a priori-defined efficacy thresholds. Only 0.18% of glucose values were < or =40 mg/dl. This is lower than values reported in prior IIT studies. Although nurses reported eProtocol-insulin required as much work as managing a mechanical ventilator, most nurses felt eProtocol-insulin had a low impact on their ability to complete non-IIT nursing activities.
A multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children. Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers.INTRODUCTIONHyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers.We required attending physicians of eligible patients to independently intend to use intravenous insulin to normalize blood glucose. We used eProtocol-insulin for glucose control for a duration determined by the clinical caregivers. Adults had an anticipated length of stay of 3 or more days. In pediatric ICUs, we also required support or intended support with mechanical ventilation for greater than 24 hours or with a vasoactive infusion. We recorded all instances in which eProtocol-insulin instructions were not accepted and all blood glucose values. An independent data safety and monitoring board monitored study results and subject safety. Bedside nurses were selected randomly to complete a paper survey describing their perceptions of quality of care and workload related to eProtocol-insulin use.METHODSWe required attending physicians of eligible patients to independently intend to use intravenous insulin to normalize blood glucose. We used eProtocol-insulin for glucose control for a duration determined by the clinical caregivers. Adults had an anticipated length of stay of 3 or more days. In pediatric ICUs, we also required support or intended support with mechanical ventilation for greater than 24 hours or with a vasoactive infusion. We recorded all instances in which eProtocol-insulin instructions were not accepted and all blood glucose values. An independent data safety and monitoring board monitored study results and subject safety. Bedside nurses were selected randomly to complete a paper survey describing their perceptions of quality of care and workload related to eProtocol-insulin use.Clinicians accepted 93% of eProtocol-insulin instructions (11,773/12,645) in 100 adult and 48 pediatric subjects. Forty-eight percent of glucose values were in the target range. Both of these results met a priori-defined efficacy thresholds. Only 0.18% of glucose values were < or =40 mg/dl. This is lower than values reported in prior IIT studies. Although nurses reported eProtocol-insulin required as much work as managing a mechanical ventilator, most nurses felt eProtocol-insulin had a low impact on their ability to complete non-IIT nursing activities.RESULTSClinicians accepted 93% of eProtocol-insulin instructions (11,773/12,645) in 100 adult and 48 pediatric subjects. Forty-eight percent of glucose values were in the target range. Both of these results met a priori-defined efficacy thresholds. Only 0.18% of glucose values were < or =40 mg/dl. This is lower than values reported in prior IIT studies. Although nurses reported eProtocol-insulin required as much work as managing a mechanical ventilator, most nurses felt eProtocol-insulin had a low impact on their ability to complete non-IIT nursing activities.A multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children.CONCLUSIONSA multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children. |
| Author | Bernard, Gordon R. Sorenson, Dean K. Hite, R. Duncan Sward, Kathy Steingrub, Jay S. Truwit, Jonathon D. Brower, Roy G. Luckett, Peter M. Curley, Martha A. Q. Morris, Alan H. Thompson, B. Taylor Zheng, Hui Hirshberg, Ellie Willson, Douglas F. Orme, James F. |
| AuthorAffiliation | 3 Biostatistics Center, Massachusetts General Hospital , Boston, Massachusetts 9 Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University , Nashville, Tennessee 10 University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania 13 Department of Nursing Informatics, University of Utah School of Nursing , Salt Lake City, Utah 5 University of Virginia , Charlottesville, Virginia 6 Children's Hospital of the University of Virginia , Charlottesville, Virginia 8 Pulmonary and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland 11 Division of Critical Care Medicine, Baystate Medical Center , Springfield, Massachusetts 4 Department of Pediatrics, University of Texas Southwestern Medical Center , Dallas, Texas 7 Section on Pulmonary and Critical Care, Wake Forest University Health Sciences , Winston-Salem, North Carolina 12 Department of BioMedical Informatics, University of Utah School of Medicine , Salt Lake City, Utah 1 Pulmonary and Critical Care Unit, Mass |
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| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/19885199$$D View this record in MEDLINE/PubMed |
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| ContentType | Journal Article |
| Contributor | Nadkarni, V Graciano, A L Sward, Kathy Truwit, J Wiedemann, H Jarvis, D Oldmixon, C Marshall, M Steingrub, J Larsen, G Curley, Martha Srinivasan, V Bayer Roth, C Bogue, C Levin, D Brower, R Howard, A Hite, R D Rubenfeld, G Guerguerian, A Sorenson, Dean Bernard, G B Steingrub, Jay Kozikowski, L Fajardo, F Hite, D Willson, D Lacroix, J Hutchins, L Jefferson, L Zheng, H Clemmer, T Heidemann, S Lazar, I Newth, C Bozeman, S Boucher, K Blumberg, L Orme, J Faustino, V Cox, P Randolph, A Thompson, B T Baumann, L Hess, J Ball, M Morris, A Cannizzaro, G Haug, Peter Tidswell, M Anand, S Meade, M Hirshberg, E Bliss, C Warner, Homer Grissom, C Thomas, N Shalaby, T Luckett, P Schoenfeld, D Patel, N |
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| Copyright | 2008 Diabetes Technology Society |
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| References | bibr11-193229680800200304 bibr6-193229680800200304 Ingle S (bibr14-193229680800200304) 2005; 2 bibr5-193229680800200304 bibr7-193229680800200304 bibr10-193229680800200304 bibr8-193229680800200304 Morris A (bibr12-193229680800200304) 2006 bibr3-193229680800200304 bibr4-193229680800200304 bibr2-193229680800200304 bibr1-193229680800200304 bibr16-193229680800200304 bibr17-193229680800200304 bibr15-193229680800200304 bibr9-193229680800200304 Saberi AA (bibr13-193229680800200304) 2004; 169 bibr23-193229680800200304 bibr24-193229680800200304 bibr25-193229680800200304 bibr19-193229680800200304 bibr18-193229680800200304 bibr21-193229680800200304 bibr22-193229680800200304 bibr20-193229680800200304 15251633 - Endocr Pract. 2004 Mar-Apr;10 Suppl 2:4-9 18184958 - N Engl J Med. 2008 Jan 10;358(2):125-39 18520641 - Crit Care Med. 2008 Jun;36(6):1787-95 16452557 - N Engl J Med. 2006 Feb 2;354(5):449-61 10691588 - Ann Intern Med. 2000 Mar 7;132(5):373-83 16385293 - J Trauma. 2005 Nov;59(5):1148-54 16871057 - Anesthesiology. 2006 Aug;105(2):244-52 15153239 - Crit Care. 2004 Jun;8(3):R122-7 18339779 - Chest. 2008 Jun;133(6):1328-35 12576937 - Crit Care Med. 2003 Feb;31(2):359-66 15215001 - Pediatr Crit Care Med. 2004 Jul;5(4):329-36 16734548 - Diabetes Technol Ther. 2006 Apr;8(2):174-90 15301325 - Mayo Clin Proc. 2004 Aug;79(8):992-1000 12576939 - Crit Care Med. 2003 Feb;31(2):374-82 11794168 - N Engl J Med. 2001 Nov 8;345(19):1359-67 14734944 - Med Care. 2004 Feb;42(2 Suppl):II67-73 17213376 - Diabetes Care. 2007 Apr;30(4):1005-11 16818563 - Pediatrics. 2006 Jul;118(1):173-9 16823014 - Am J Crit Care. 2006 Jul;15(4):370-7 17561793 - Diabetes Technol Ther. 2007 Jun;9(3):232-40 9290990 - Intensive Care Med. 1997 Jul;23(7):760-5 |
| References_xml | – ident: bibr20-193229680800200304 doi: 10.1378/chest.07-2702 – ident: bibr18-193229680800200304 doi: 10.1097/01.PCC.0000128607.68261.7C – ident: bibr17-193229680800200304 doi: 10.1097/01.ta.0000188933.16637.68 – ident: bibr22-193229680800200304 doi: 10.1089/dia.2006.0015 – ident: bibr15-193229680800200304 doi: 10.1097/01.CCM.0000045567.78801.CC – ident: bibr8-193229680800200304 doi: 10.4065/79.8.992 – ident: bibr19-193229680800200304 doi: 10.1542/peds.2005-1819 – volume: 2 start-page: A38 year: 2005 ident: bibr14-193229680800200304 publication-title: Proceedings of the American Thoracic Society – ident: bibr3-193229680800200304 doi: 10.1097/01.CCM.0000045568.12881.10 – ident: bibr6-193229680800200304 – ident: bibr2-193229680800200304 doi: 10.1056/NEJMoa052521 – ident: bibr5-193229680800200304 doi: 10.1056/NEJMoa070716 – ident: bibr23-193229680800200304 doi: 10.1186/cc2840 – ident: bibr16-193229680800200304 doi: 10.1007/s001340050406 – ident: bibr7-193229680800200304 doi: 10.2337/dc06-1964 – ident: bibr4-193229680800200304 doi: 10.4158/EP.10.S2.4 – ident: bibr25-193229680800200304 doi: 10.1097/01.mlr.0000109127.76128.aa – ident: bibr24-193229680800200304 doi: 10.1097/00000542-200608000-00006 – ident: bibr1-193229680800200304 doi: 10.1056/NEJMoa011300 – ident: bibr21-193229680800200304 doi: 10.1089/dia.2006.8.174 – start-page: 537 volume-title: Ventilator-induced lung injury year: 2006 ident: bibr12-193229680800200304 – volume: 169 start-page: A38 issue: 7 year: 2004 ident: bibr13-193229680800200304 publication-title: Am J Respir Crit Care Med. – ident: bibr10-193229680800200304 doi: 10.1097/CCM.0b013e3181743a5a – ident: bibr9-193229680800200304 doi: 10.4037/ajcc2006.15.4.370 – ident: bibr11-193229680800200304 doi: 10.7326/0003-4819-132-5-200003070-00007 – reference: 15251633 - Endocr Pract. 2004 Mar-Apr;10 Suppl 2:4-9 – reference: 11794168 - N Engl J Med. 2001 Nov 8;345(19):1359-67 – reference: 15215001 - Pediatr Crit Care Med. 2004 Jul;5(4):329-36 – reference: 16385293 - J Trauma. 2005 Nov;59(5):1148-54 – reference: 17213376 - Diabetes Care. 2007 Apr;30(4):1005-11 – reference: 18520641 - Crit Care Med. 2008 Jun;36(6):1787-95 – reference: 15301325 - Mayo Clin Proc. 2004 Aug;79(8):992-1000 – reference: 12576937 - Crit Care Med. 2003 Feb;31(2):359-66 – reference: 16452557 - N Engl J Med. 2006 Feb 2;354(5):449-61 – reference: 16818563 - Pediatrics. 2006 Jul;118(1):173-9 – reference: 16823014 - Am J Crit Care. 2006 Jul;15(4):370-7 – reference: 18184958 - N Engl J Med. 2008 Jan 10;358(2):125-39 – reference: 17561793 - Diabetes Technol Ther. 2007 Jun;9(3):232-40 – reference: 18339779 - Chest. 2008 Jun;133(6):1328-35 – reference: 9290990 - Intensive Care Med. 1997 Jul;23(7):760-5 – reference: 12576939 - Crit Care Med. 2003 Feb;31(2):374-82 – reference: 10691588 - Ann Intern Med. 2000 Mar 7;132(5):373-83 – reference: 15153239 - Crit Care. 2004 Jun;8(3):R122-7 – reference: 16734548 - Diabetes Technol Ther. 2006 Apr;8(2):174-90 – reference: 14734944 - Med Care. 2004 Feb;42(2 Suppl):II67-73 – reference: 16871057 - Anesthesiology. 2006 Aug;105(2):244-52 |
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| Title | Multicenter Validation of a Computer-Based Clinical Decision Support Tool for Glucose Control in Adult and Pediatric Intensive Care Units |
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