Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes.
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ABSTRACT:
SUBMITTER: Helmle KE
PROVIDER: S-EPMC6336121 | biostudies-literature | 2019 Jan
REPOSITORIES: biostudies-literature
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Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes.
Helmle Karmon E KE Dechant Anthony L AL Edwards Alun L AL
Clinical diabetes : a publication of the American Diabetes Association 20190101 1
<b>IN BRIEF</b> "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc. (ACP), and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the e ...[more]
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Project description:BackgroundMental comorbidities of physically ill patients lead to higher morbidity, mortality, health-care utilization and costs.ObjectiveThe aim of the study was to investigate the impact of mental comorbidity and physical multimorbidity on the length-of-stay in medical inpatients at a maximum-care university hospital.DesignThe study follows a retrospective, quantitative cross-sectional analysis approach to investigate mental comorbidity and physical multimorbidity in internal medicine patients.PatientsThe study comprised a total of n = 28.553 inpatients treated in 2017, 2018 and 2019 at a German Medical University Hospital.Main measuresInpatients with a mental comorbidity showed a median length-of-stay of eight days that was two days longer compared to inpatients without a mental comorbidity. Neurotic and somatoform disorders (ICD-10 F4), behavioral syndromes (F5) and organic disorders (F0) were leading with respect to length-of-stay, followed by affective disorders (F3), schizophrenia and delusional disorders (F2), and substance use (F1), all above the sample mean length-of-stay. The impact of mental comorbidity on length-of-stay was greatest for middle-aged patients. Mental comorbidity and Elixhauser score as a measure for physical multimorbidity showed a significant interaction effect indicating that the impact of mental comorbidity on length-of-stay was greater in patients with higher Elixhauser scores.ConclusionsThe findings provide new insights in medical inpatients how mental comorbidity and physical multimorbidity interact with respect to length-of-stay. Mental comorbidity had a large effect on length-of-stay, especially in patients with high levels of physical multimorbidity. Thus, there is an urgent need for new service models to especially care for multimorbid inpatients with mental comorbidity.
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Project description:ObjectiveNeonatal abstinence syndrome (NAS) occurs due to abrupt discontinuation of chronic fetal exposure to substances used by the mother during pregnancy. As the incidence of NAS continues to increase, medical teams are evaluating strategies to reduce length of stay (LOS). Increased LOS contributes to poorer mother-infant bonding and neurodevelopmental outcomes as well as increased health care cost. As part of an ongoing quality improvement project, the objective of this study was to determine if formal interprofessional rounds affected LOS for infants with NAS.MethodsThis was a retrospective analysis at a single hospital system to determine if interprofessional rounds had an impact on NAS LOS. On February 5, 2016, introduction of formal weekly interprofessional NAS-specific rounds occurred in addition to daily patient care rounds. Every patient with opioid exposure undergoing Finnegan scoring, treated with weight-based morphine, and >35 weeks gestation was included. Data were collected on LOS and length of therapy for eligible patients. This study evaluated the impact of interprofessional rounds on LOS 17 months after its implementation compared with 13 months immediately preceding.ResultsAmong the 119 infants (51 pre and 68 post) meeting inclusion criteria, the median LOS for the post-rounds group was significantly shorter than the pre-rounds group (13 vs 16 days, p = 0.001). The median length of therapy (morphine with or without clonidine) was also significantly shorter in the post-rounds versus the pre-rounds group (8 vs 12 days, p = 0.001).ConclusionsFormal weekly interprofessional NAS rounds decreased LOS and length of therapy.
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Project description:ObjectivesAnemia, either chronic or newly developed in the hospital as a result of underlying disease and/or phlebotomy, is seen commonly among general medical inpatients, and its impact on the quality and efficiency of care is unknown.MethodsThis study investigated the relation among hemoglobin level, length of stay, and 30-day unplanned readmission rates in a cohort of 314 general medical inpatients 18 years old and older admitted to a teaching hospital during a period of 4 months in a large urban academic medical center, using retrospective chart review of the electronic health record.ResultsAnemia was common among this cohort of general medical inpatients (44.6%), and there was a statistically significant decrease in hemoglobin levels during their hospitalization. Anemic patients, as compared with nonanemic patients, had significantly longer mean and median length of stay. More important, the admission hemoglobin level and its change during hospitalization were significant predictors of increased length of stay. For every 1-U increase in admission hemoglobin level, the median length of stay was reduced by 0.5 days. For every 1-U increase in the level of hemoglobin change, the median length of stay was extended by 1.5 days. Likewise, the discharge hemoglobin level predicted the rate of 30-day unplanned readmission. For every 1-U decrease in discharge hemoglobin level, the readmission rate increased by nearly 4%. These relations remained after adjusting for common demographic and clinical variables, including age, sex, nutritional status, and number of comorbidities.ConclusionsAnemia is common among general medical inpatients and adversely affects their length of stay and 30-day unplanned readmission rate.
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Project description:IntroductionPostoperative atrial fibrillation (POAF) is a common complication following cardiac surgery associated with increased morbidity and mortality. Although sustained hyperglycemia is a known risk factor of AF and poor ICU outcomes, emerging in-vitro studies reveal acute glycemic fluctuations to be an additional independent predictor of AF. The effect of acute glycemic fluctuations on the incidence of POAF in the clinical setting remains unclear. We aim to investigate the effect of the magnitude of acute perioperative glycemic fluctuations on the incidence of POAF in a multi-ethnic Southeast-Asian population.MethodsWe obtained data from1743 patients who underwent elective CABG in a tertiary heart centre from 2009-2011. Patients were kept to a tight baseline glycemic control in accordance with hospital protocol. The magnitude of the difference between the highest and lowest perioperative glucose levels up till the first 48 postoperative hours was employed as a measure of glycemic fluctuation. Patients were divided into 4 groups for analysis based on the magnitude of glycemic fluctuation:A)0-2mmol/L(N = 147); B)>2-4mmol/L(N = 426); C)>4-6mmol/L(N = 513); D)>6mmol/L(N = 657).Our primary outcome was the incidence of POAF. Secondary outcomes included ICU and 30-day mortality and length of stay.ResultsThe overall incidence of POAF was 14.7%. This increased as the magnitude of glycemic fluctuation increased, and was statistically highest in Group D(16.4%) as compared with the other 3 sub-groups. Multivariate logistic regression revealed the magnitude of perioperative glycemic fluctuation to be an independent risk factor of POAF(O.R.1.06, 95% C.I.1.01-1.11, p = 0.014).ICU length of stay was statistically highest in Group D(63.1 hours, p = < .001). However, ICU and 30 day mortality rates were similar among the 4 groups.ConclusionIncreased magnitudes of acute perioperative glycemic fluctuations are associated with a significantly increased risk of POAF and length of ICU stay; and should therefore be minimised but balanced against the risks of hypoglycemia so as to avoid POAF and optimise patient outcomes.
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Project description:BackgroundLength of stay (LOS) for inpatient psychiatric services is an important factor with serious drawbacks when it is extended more than needed. Impacts on economy, social functioning, and stigma can hamper improvement and affect the patients' experiences on future mental healthcare. Predictions of which patients have a higher chance for prolonged LOS have been extensively researched. Previous systematic reviews found consistent predictors of both longer and shorter LOS. However, they do not provide an estimate from the pooled effect sizes. Furthermore, to our knowledge, there is no meta-analysis on the influence of these factors. The primary objective of this study will be to provide point estimates on the effect sizes of all studied predictors of the LOS of psychiatric inpatients.MethodsWe will conduct a systematic search in PubMed, MEDLINE, EMBASE, and PsycINFO for observational studies evaluating the effect size of independent factors on the length of stay of psychiatric inpatients. Prospective and retrospective cohorts that assess the influence of predictors through the reporting of standardized regression coefficients will be included. We will provide a qualitative synthesis of the findings from each study and perform a meta-analysis from pooled regression coefficients that were adjusted for other variables or confounders in order to obtain a point estimate and confidence interval for all factors extracted from the included studies.DiscussionThe results from this study may provide more accurate predictions for mental health institutions, psychiatrists, mental health service providers, patients, and families on the prognosis regarding the length of stay for needed inpatient care. This information may be used to anticipate individuals with a higher chance for prolonged hospitalization to plan the necessary interventions for these specific situations. Considering both the benefits and disadvantages of longer and shorter stays, the pooled estimates for independent factors may be used by mental healthcare providers and patients for informed decision-making. The results from this study will also update results presented in previous studies and identify the strengths and limitations from the current available evidence.Systematic review registrationPROSPERO ID CRD42020172840.
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Project description:Background: Barriers to mealtime insulin include complexity, fear of injections, and lifestyle interference. This multicenter, randomized controlled trial evaluated efficacy, safety, and self-reported outcomes in adults with type 2 diabetes, inadequately controlled on basal insulin, initiating and managing mealtime insulin with a wearable patch versus an insulin pen. Methods: Adults with type 2 diabetes (n = 278, age: 59.2 ± 8.9 years), were randomized to patch (n = 139) versus pen (n = 139) for 48 weeks, with crossover at week 44. Baseline insulin was divided 1:1 basal: bolus. Using a pattern-control logbook, subjects adjusted basal and bolus insulin weekly using fasting and premeal glucose targets. Results: Glycated hemoglobin (HbA1c) change (least squares mean ± standard error) from baseline to week 24 (primary endpoint) improved (P < 0.0001) in both arms, -1.7% ± 0.1% and -1.6% ± 0.1% for patch and pen (-18.6 ± 1.1 and -17.5 ± 1.1 mmol/mol), and was maintained at 44 weeks. The coefficient of variation of 7-point self-monitoring blood glucose decreased more (P = 0.02) from baseline to week 44 for patch versus pen. There were no differences in adverse events, including hypoglycemia (three severe episodes per arm), and changes in weight and insulin doses. Subject-reported treatment satisfaction, quality of life, experience ratings at week 24, and device preferences at week 48 significantly favored the patch. Most health care providers preferred patch for mealtime insulin. Conclusions: Bolus insulin delivered by patch and pen using an algorithm-based weekly insulin dose titration significantly improved HbA1c in adults with type 2 diabetes, with improved subject and health care provider experience and preference for the patch.
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Project description:BACKGROUND: Hospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS). OBJECTIVE: The purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay. DESIGN: Pre and post observational study assessing the impact of MDR during its first year of implementation. SETTING: The Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents. METHODS: Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling. RESULTS: Institution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06-1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1-0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5-0.7) days for all medicine DRGs (p < .001). CONCLUSIONS: Resident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay.
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Project description:Aims/introductionCurrently, the impact of hospital-wide glycemic control interventions on length of hospital stay (LOS) and readmission rates are largely unknown. We investigated the impact of a 4-year hospital-wide remote glycemic management program on LOS and 30-day readmission rates among hospitalized adults who received glucose monitoring.Materials and methodsIn this retrospective study, hospitalized patients who received glucose monitoring were classified into groups 1 (high glucose variability), 2 (hypoglycemia), 3 (hyperglycemia) and 4 (relatively stable). The monthly percentage changes, and average monthly percentage changes of hyperglycemia, hypoglycemia and treat to target were determined using joinpoint regression analysis.ResultsA total of 106,528 hospitalized patients (mean age 60.9 ± 18.5 years, 57% men) were enrolled. We observed a significant reduction in the percentage of inpatients in poor glycemic control groups (groups 1, 2 and 3, all P < 0.001), and a reciprocal increase in the relatively stable group (group 4) from 2016 to 2019. We found a significant reduction in LOS by 11.4% (10.5-9.3 days, P = 0.002, after adjustment for age, sex, and admission department). The 30-day readmission rate decreased from 29.9% to 29.3%, mainly among those in group 4 in 2019 (P < 0.001 after adjustment of sex, age, admission department and LOS).ConclusionsImproved glycemic control through a hospital-wide electronic remote glycemic management system reduced LOS and 30-day readmission rates. Findings observed in this study might be associated with the reduction in cost of avoidable hospitalizations.
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Project description:To evaluate the impact of an educational strategy on potentially inappropriate medications (PIMs) and length of stay in hospitalized elderly patients.An open study, with two cross-sectional surveys interspersed with an educational program (PRE phase and POST phase), has been performed in order to compare the PIMs number before and after the introduction of an educational strategy. The study included 2 phases: PRE, in which patients were enrolled as control group; POST, in which an educational strategy on the PIMs use was introduced among physicians, and patients were enrolled as intervention group.Italian residential rehabilitation Centre. Inclusion criteria were ≥ 2 active chronic diseases and the current use of ≥ 4 medications. The educational strategy consisted of a 3-day course on strategies to prevent PIMs and a computerized tool running on a Personal Digital Assistant (PDA) device to check for PIMs.The primary was the PIMs number, the secondary the length of stay.A total of 790 patients, 450 controls and 340 cases, were enrolled. According to the Beers criteria, 52.3% of the study population received ≥ 1 PIMs, 18.73% ≥ 2, and 2.4% ≥ 4 PIMs. A significant reduction of PIMs (P = 0.020) and length of stay (P < 0.0001) were seen in the intervention group. At multivariate analysis, PIMs significantly correlated with age, drugs number, and the intervention, and the length of stay significantly correlated with disease count, comorbidities, and intervention. These data suggest that our educative instrument may be useful in reducing the PIMs number and length of hospitalization in elderly with a high number of drugs and comorbidities.
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Project description:BACKGROUND:Previous studies have demonstrated that opioids are often prescribed and associated with complications in outpatients with cirrhosis. Less is known about opioids among hospitalized patients with cirrhosis. We aimed to describe the patterns and complications of opioid use among inpatients with cirrhosis. METHODS:This retrospective cohort study included adult patients with cirrhosis admitted to a single hospital system from 4/4/2014 to 9/30/2015. We excluded hospitalizations with a surgery, invasive procedure, or palliative care/hospice consult in order to understand opioid use that may be avoidable. We determined the frequency, dosage, and type of opioids given during hospitalization. Using bivariable and multivariable analyses, we assessed length of stay, intensive care unit transfer, and in-hospital mortality by opioid use. RESULTS:Of 217 inpatients with cirrhosis, 118 (54.4%) received opioids during hospitalization, including 41.7% of patients without prior outpatient opioid prescriptions. Benzodiazepines or hypnotic sleep aids were given to 28.8% of opioid recipients. In the multivariable model, younger age and outpatient opioid prescription were associated with inpatient opioids. Hospitalization was longer among opioid recipients (median 3.9 vs 3.0 days, p = 0.002) and this difference remained after adjusting for age, cirrhosis severity, and medical comorbidities. There was no difference in intensive care unit transfers and no deaths occurred. At discharge, 22 patients were newly started on opioids of whom 10 (45.5%) had opioid prescriptions at 90 days post-discharge. CONCLUSION:In non-surgical inpatients with cirrhosis, opioid prescribing was common and associated with prolonged length of stay. A high proportion of patients newly discharged with opioid prescriptions had ongoing prescriptions at 90 days post-discharge.
| S-EPMC7043759 | biostudies-literature