Ling Cui, Pamela R. Schroeder and Paul A. Sack
Inpatient and Outpatient Technologies to Assist in the Management of Insulin Dosing
Simplified systems were initially developed using this construct to help adjust insulin infusions, but more complex software has since been developed to account for a variety of clinical inpatient scenarios. FDA-approved inpatient electronic glycemic management systems include Glucommander (Glytec), EndoTool System (Monarch Medical Technologies), and GlucoStabilizer (Medical Decision Network). Another system is the Cores Diabetes App, which gives practitioners tools to calculate insulin doses but does not adjust insulin automatically and therefore has not required FDA approval.
Glytec’s Glucommander system uses evidence-based multivariate algorithms to provide care teams with insulin dosing recommendations that continuously recalculate and dynamically adjust to individual patients’ changing conditions, accounting for oral intake, weight, insulin sensitivities, and other clinical variables. It can be used with certain EMR systems, which allows the sharing of patients’ data, including blood glucose and laboratory test values. It is cleared by the FDA for use with continuous IV insulin infusion, transition from IV to SQ insulin, SQ insulin, and hospital-to-home transitions. It has also been cleared for outpatient use in pediatric and adult patients with diabetes (20).
To initiate a continuous IV insulin infusion, a bedside fingerstick blood glucose value is entered, and the system calculates an initial insulin infusion rate. Based on the rate of change in glucose level, a system alert notifies a nurse when the next blood glucose value is needed, which may be anywhere from 20 to 120 minutes later. The system continues recommending insulin infusion rates until IV insulin is discontinued (19). When a patient is stable and ready to transition to SQ insulin, the system can calculate basal and prandial insulin doses based on recent infusion rates.
To initiate SQ insulin, a total daily dose (TDD) of insulin can be calculated from the patients’ weight or based on previous experience from the outpatient setting (20). The TDD is then divided between basal and prandial insulin doses. Prandial insulin can be a fixed dose or can be based on a patient’s insulin-to-carbohydrate (I:C) ratio. The program automatically adjusts prandial doses based on the amount of carbohydrates entered by the nurse and previous responses. The Glucommander’s algorithm provides real-time dose changes from meal to meal (prandial insulin dosing) and day to day (basal insulin dosing) without requiring a new order from the provider.
Several safety features are built into the software, including nurse verification of doses, missed dose reminders with alarms, entry of mealtime carbohydrates, and hypoglycemia correction algorithms (20). Theoretically, if the initial dose of insulin initiated by a provider is reasonably close to the dose that a patient actually needs, blood glucose should be well controlled during the entire hospital course without any further provider intervention.
Glytec’s software package includes Glucommander to help adjust insulin doses and also offers surveillance, alerting, analytics, and reporting capabilities (20). Studies have shown that Glucommander implementation decreased hyperglycemia, hypoglycemia, time to target blood glucose, average length of stay, 30-day readmissions, and postoperative complications (21–24). In addition, there was an increase in nurses’ satisfaction and significant cost saving (25,26).
– This article originally appeared on Clinical Diabetes.