Analysis and Optimization of Titratable Insulin Infusions to Improve Nurse Workflow and Patient Outcomes

EHR instance consolidation provided a unique post-merger opportunity to align titratable insulin infusion practice across over 50 hospitals and freestanding emergency departments. While significant literature has been published comparing paper-protocol and homegrown external calculator transitions to an EHR-imbedded titratable insulin infusion calculator within a single department or hospital, literature comparing an EHR-imbedded algorithm against proprietary FDA-approved software and across a sizable health system with varied pre-intervention states is lacking. Bon Secours Mercy Health’s (BSMH) varied “prior state” (multiple paper protocols and two different vendor programs) provided a unique opportunity to aggregate pre-/post-intervention data comparing a standardized imbedded algorithm against a wide variety of evidence-based tools (as opposed to a single pre-intervention workflow).

Across this endeavour, nursing informatics worked to design and optimize analytic tools to evaluate effectiveness of the aligned approach during a controlled pilot, then ensure safe expansion across the remainder of the health system. Clinician feedback via weekly touchbases and associate survey allowed for consideration of qualitative findings. Both sets of data proved useful in calculator optimization. Examples of optimization from quantitative data analysis include elimination of an ISC (insulin sensitivity coefficient)/multiplier reset as well as elimination of infusion pause for blood glucose values below target range, but not hypoglycemic. These features were standard in the original algorithm BSMH selected for use; however, they did not align with prior paper protocol or proprietary system behavior – and appeared to decrease time in target range while also increasing anion gap in diabetic ketoacidosis (DKA). Examples of optimization from clinician feedback include development of condition-specific, evidence-based target ranges (to enable use of the calculator across departments for all titratable insulin infusions) and development of blood glucose alerts for ED and IP nurses, with the potential to build out as push notifications. Reminders to switch to dextrose-containing IVF when blood glucose has reached 250mg/dL or below for DKA and hyperosmolar hyperglycemic syndrome (HHS) is another example. This quantitative/qualitative interdisciplinary approach has allowed BSMH to transition to the imbedded calculator with confidence, maximize clinician buy-in, improve patient outcomes, and reduce vendor cost/reliance.