Technology in diabetes care has come a long way in a short period of time. Since the introduction of the home blood glucose (BG) meter and analog insulins, diabetes care has made great strides. With continuous glucose monitoring (CGM) and insulin infusion pumps, diabetes care is advancing and quickly moving toward an artificial pancreas to replace the normal islet cell function. As such, the future for individuals with diabetes is bright with the promise of better treatments and the ongoing research for a cure.
Capillary BG monitoring became an inpatient standard of care in the 1980s, although regulations now stipulate where and how these devices may be used in the inpatient setting. At the same time, additional questions are arising around how other diabetes technologies are being used for patients in the hospital setting and how nurses can leverage available technologies.
Data Input & Access
First, and foremost, it is important to keep in mind that no technology replaces the nurse’s knowledge of diabetes care. A nurse has to be knowledgeable about patient care and the technology to keep patients safe. Beyond the nurse’s knowledge, the next most important function of technology is being able to input and access the data. Electronic health records (EHRs) are dependent upon the build to provide a usable dashboard of information and trend data over time. This means having easily assessable information containing all factors contributing to diabetes control in one location. These metrics should include:
- BG levels and associated medications given over time;
- nutritional intake including oral, total parental nutrition, or tube feedings;
- laboratory data impacting or reflecting glucose control (i.e., creatinine, bicarb, A1c, etc.);
- hypoglycemia and applicable treatments; and
- medications impacting glucose control (i.e., steroids, atypical antipsychotics, calcineurin inhibitors, etc.).
Additionally, through the EHR, nurses should have easy access to longitudinal data across encounters and on demand real-time reports. The computer technology and EHR should allow for quick login that includes single sign-on/tap and go and links within patient records to outside sources.
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Caring for patients with diabetes, or any chronic disease, particularly newly diagnosed, can be time-consuming for nurses, but technology can be leveraged to help nurses provide care in an efficient and organized manner. A time and motion study by Hendrich, Chow, Skierczynski and Lu in 2008, found collecting, entering, and accessing data consumed a large portion of nurses’ time, thus leaving them with considerably less time available for patient care. 1
Streamlined Data Collection
Implementing burdensome EHRs that do not fit the clinician’s workflow or needs has proven to be unsuccessful. It is critical for nurses to not only have access to the data necessary to care for the patient, but also reliable, easily retrievable and replicable information to ensure proper care. The EHR should be able to present patient data in a usable way manner to organize and potentially direct nursing care.
Data can be useful to pre-populated teaching plans based on diagnosis and medications can be individualized. Clinical decision support can be provided and embedded in various formats, such as a nurse’s note, from the record. For example, an automatic nursing note of a hypoglycemic event would pre-populate the BG values, medication provided (D50W or glucose tab/gel), and the follow-up BG. The nurse completes the note with any precipitating event, symptoms, and response, all of which could be chosen from a drop-down list.
Improving the Workflow
Inpatient care for a patient with diabetes involves a complex workflow with BG testing, insulin administration, and nutrition coordination. Testing the BG no more than 30-45 minutes prior to the meal, giving rapid acting insulin immediately before the meal, and assuring the patient has their food and is eating adequately are critical to good BG control. Different members of the care team often complete the separate components; the coordination of these activities is challenging, particularly in the setting of room service meals. This is another opportunity to use technology to enhance the process.
Wireless BG meters can send data directly to the patient’s record. Tray delivery alerts can be established. Smart orders using integration to turn on and off meal time insulin if NPO can be developed. With this additional information, the nurse has the data necessary to administer insulin in a timely manner, matching the patient’s glucose and nutritional needs, thus enhancing BG control.
Evidence-based algorithms to determine initial insulin orders and ongoing dosing of insulin, individualized to the patient, have been developed. Through full integration with the EHR, the software assesses the patient’s response to prior insulin levels and adjusts the next dose based on the patient’s response rather than having fixed doses or waiting for a provider to review the record and write new orders. In turn, the technology does the total dose calculation, eliminating potential calculation errors and the human emotional response to changing blood glucoses, saving nurses and providers time, and allowing them to provide patients with precise care individualized for their needs.
EHRs have processes running in the background that have the potential to enhance clinical decisions and patient outcomes through reminders and alerts of evidence-based standards and practice. Developing processes that integrate technology and practice are vital to implementing useful systems that are meaningful to clinical decision-making. Care alerts (or pop ups) that are evidence-based and critical to patient safety can play an important role in diabetes care. Such alerts include treatment of hypoglycemia, preventing administration of insulin doses too close together, and reminders of change in nutritional status. However, alerts must be judicious to avoid alert fatigue.
Future of Glucose Monitoring
But what about the future? How can technology be leveraged moving forward for inpatient diabetes care and reduce work for nurses? The use of CGM in the inpatient setting is being explored. Nurses could access the patient’s BG at any given point in time to determine the best treatment course. With information available instantly, patients with changing BG levels could be flagged for intervention in real-time and adjustments of IV insulin infusion could take place (in a manner similar to how the artificial pancreas trials are showing subcutaneously).
Currently available “smart” infusion pump data can be integrated with EHRs and the data from a wireless BG meter, or CGM could be aggregated with previous data and used to determine the precise insulin changes needed in the insulin infusion with the help of an integrated algorithm for insulin titration. The clinical scenario would look like:
- CGM sends the BG to the HER.
- Algorithm determines how the insulin infusion should be changed.
- New infusion rate is sent wirelessly to the infusion pump.
- The nurse accepts the recommended change on the pump.
- Time, BG, and insulin infusion rate is automatically documented in the flowsheet and medication administration record.
As technology advancements that better diabetes care get closer, it is important nurses, providers, and patients are prepared to best leverage this information to improve patient outcomes.
1. Hendrich, A. et al. A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time? RCHE Publications. June 2008. http://docs.lib.purdue.edu/rche_rp/50/
Melanie E. Mabrey is vice president of clinical practice for Gytec and consulting associate for Duke University School of Nursing, Durham, N.C. Janet L Apter is a nurse informatician, clinical informatics project specialist and consulting associate at Duke University School of Nursing.