Glucose Management Clinical Decision Support to Improve Outcomes in Academic and Community Hospitals

项目摘要/摘要 每年约有900万糖尿病患者住院治疗，超过30%的住院患者没有 糖尿病患者因急性疾病而出现高血糖。HG增加了传染性和非传染性疾病的风险 感染并发症和死亡、住院时间(LOS)、医院资源利用和总体 医疗保健成本。虽然血糖控制降低了这些风险，但在医院控制HG是困难的，因为 多重障碍，如识别和主动治疗血糖异常，以及适当排序 在医院用胰岛素治疗高血压。临床决策支持(CDS)是一种使用计算机化的人- 电子病历(EMR)中的特定数据被证明可以改善医院护理。在众多的 模式，ALERT-CDS被证明可以改善护理服务的提供，提供者的主动性，特别是血糖控制 在学术机构的重症监护环境中。然而，ALERT-CDS尚未在外部进行研究 在重症监护病房(ICU)，或在大多数患者接受护理的社区医院。此外，它的影响 对患者结果的影响尚未在任何情况下进行测试。提议的项目使用一种创新的警报-CDS 我们开发和验证的工具，它可以自动识别血糖异常和胰岛素不足 医院里的行政部门。它通过建议提醒临床医生支持决策，而无需 取代了他们的临床判断。在我们的初步研究中，我们发现这种ALERT-CDS工具降低了经常性高 血糖水平和缩短的LOS。基于这一前景看好的初步数据，在这个项目中，我们建议研究 我们的CDS工具对非集约型患者的临床、经济和提供者绩效结果的影响 在学术医院和社区医院护理病人。我们建议将这一资源提供给 在36个月中每3个月间歇性地出现在EMR中，从而使我们能够比较18个月的 干预和18个月的标准护理。根据我们的初步研究，我们预计样本量为12,560 受试者将给我们80%的能力来检测0.34天(~8小时)的住院时间差异，主要是 这是我们研究的终点。我们提出了以下目标：目标1)确定警报-CDS结束的影响 学术医院和社区医院非ICU患者临床结局的常规护理。目标 2)确定相对于传统护理的ALERT-CDS对非ICU的经济结果的影响 一家学术医院和一家社区医院的病人。目的3)确定ALERT-CDS对住院患者的影响 血糖控制提供者的观点，能力和实践表现之间的学术和 一家社区医院。我们假设，该工具将增加提供者对血糖异常的了解 让他们对胰岛素的使用做出更好的决定。我们的研究取得了预期的成功 在领导层利益相关者的大力支持下，建立了一支成熟的多学科调查团队 两家医院都有。我们建议的研究有可能建立一种新的管理范式 住院患者的血糖异常对临床和经济结果有重大的积极影响。

Project Summary/Abstract Approximately 9 million patients with diabetes (DM) are hospitalized annually and over 30% of inpatients without DM experience high glucose (HG) due to their acute illness. HG increases the risk of infectious and non- infectious complications and death, hospital length of stay (LOS), utilization of hospital resources and overall healthcare costs. While glucose control reduces these risks, controlling HG in the hospital is difficult due to multiple barriers such as recognizing and proactively treating glucose abnormalities, and adequately ordering insulin to treat HG in the hospital. Clinical decision support (CDS) is a system that uses computerized person- specific data in the electronic medical record (EMR) proven to improve hospital care. Among the various modalities, alert-CDS is shown to improve care delivery, providers’ proactivity, and glucose control specifically in intensive care settings of academic institutions. However, alert-CDS has not yet been studied outside of intensive care units (ICU), or in community hospitals where most patients receive care. Furthermore, its impact on patients’ outcomes has not been tested in any setting. The proposed project uses an innovative alert-CDS tool we developed and validated which automatically identifies dysglycemia and inadequacies in insulin administration in the hospital. It alerts clinicians with recommendations to support decision making without superseding their clinical judgement. In our pilot study, we found that this alert-CDS tool reduced recurrent high glucose levels and shortened LOS. Based on this promising preliminary data, in this project we propose to study the impact of our CDS tool on clinical, economic and providers’ performance outcomes among non-intensive care patients both in an academic and a community hospital. We propose to make this resource available intermittently in the EMR every 3 months during 36 months, thus allowing us to compare 18 months of intervention and 18 months of standard care. Based on our pilot study, we expect that a sample size of 12,560 subjects will give us an 80% power of detecting 0.34 days (~ 8 hours) difference in length of stay, the primary endpoint of our study. We propose the following aims: Aim 1) To determine the impact of the alert-CDS over conventional care on the clinical outcomes of non-ICU patients in an academic and a community hospital. Aim 2) To determine the impact of the alert-CDS over conventional care on the economic outcomes of non-ICU patients in an academic and a community hospital. Aim 3) To determine the impact of alert-CDS for inpatient glycemic control on providers’ perspectives, competencies and practice performance between an academic and a community hospital. We hypothesize that the tool will increase providers’ knowledge about dysglycemia allowing them to make better decisions about insulin administration. The anticipated success of our study builds upon a well-established multidisciplinary team of investigators strongly supported by leadership stakeholders in both hospitals. Our proposed study has the potential of establishing a new paradigm in the management of dysglycemia in hospitalized patients with a major positive impact on clinical and economic outcomes.