Non-critical Care Settings Research Articles

Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting.

Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults. Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.

Changing to Basal-Bolus Insulin Therapy for the Inpatient Management of Hyperglycemia—A Natural Experiment

Objective: Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known versus newly diagnosed type 2 diabetes. Methods: This natural experiment compared outcomes in 10,120 non-critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators. Results: Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n = 234), who experienced a statistically significant decline in the incidence of complications (P<.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (P<.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (P<.01). Conclusion: Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non-critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined. Abbreviation: ICD-9 = International Classification of Diseases-Ninth Revision.

Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: An observational analysis.

Guidelines issued by the American Society of Regional Anesthesia and Pain Medicine suggest that ketamine infusions for acute pain management are advantageous as a primary treatment or as an opioid adjunct. Despite significant data regarding its use in adult patients, there remains a paucity of information related to its quality and side effect profile in pediatrics and how it can be effectively used. We aimed to summarize our practice of utilizing ketamine for pediatric pain management in non-critical care settings. Patients aged 0-21 years receiving low-dose ketamine infusions (≤0.3 mg/kg/hour) in inpatient care units over five years were retrospectively analyzed. Demographics, specific quality metrics, and side effects were quantified. About 172 patients received 270 subhypnotic ketamine infusions. The median duration of the infusions was 63.8 hours and 0.2 mg/kg/hour for the highest dose. The primary indication for ketamine was chronic pain exacerbation (83.3%). Despite similar opioid consumption, there was a significant reduction in mean verbal pain scores before (8.9 ± 1.9, P < .001) and after ketamine (6.5 ± 2.7, P < .001) use. Although there were 52 incidences of some side effect (neurologic excitability [10.4%]; over-sedation [7.4%]; rapid response team alerts [1.1%]), none resulted in termination of the infusion or escalations in care. Ketamine can effectively be used as part of a multimodal analgesic regimen in pediatric patients in non-critical care settings. Our five-year experience using low-dose ketamine infusions highlights an acceptable side effect profile, with no attributable escalations in care or serious adverse events.

1099-P: Sliding Scale Insulin Use in Noncritical Care Settings: Who Can Slide?

Despite recommendations of clinical guidelines, sliding scale insulin (SSI) is widely used for the inpatient management of patients with T2D. To understand if there is a population of patients for whom SSI may be an appropriate form of management, we utilized a large database from a single academic institution to define the frequency of SSI usage and determine factors that predict adequate glycemic control with SSI alone in the non-critical care setting. Among 15,348 patients with T2D (28% surgery, 72% medicine), 7,052 (45%) were managed with SSI and 8,296 (55%) with basal insulin. Average admission blood glucose (BG) and HbA1c were lower in patients treated with SSI (154.6±60.3 vs. 191.7±80.8 mg/dl, p&amp;lt;0.001; 7.0±1.5 vs. 8.5±2.1%, p&amp;lt;0.001). Charlson comorbidity score was higher in those treated with basal compared to SSI. Surgical patients were more likely to be treated with SSI than those on medicine services (53% vs. 43%, p&amp;lt;0.001). Hypoglycemia rates were lower with SSI vs. basal insulin (6.9% vs. 14%, p&amp;lt;0.001). Seventy-two percent of patients treated with SSI had an admission BG &amp;lt;180 mg/dl; of them, 93% maintained good glycemic control (mean hospital BG &amp;lt;180 mg/dl). After adjusting for age, gender, BMI, race, Charlson score, and setting (med vs. surg), patients treated with SSI admitted with BG &amp;lt;180 mg/dl had much higher odds of achieving good glycemic control compared to those admitted with BG 180-280 [OR 6.4 (95% CI 5.6, 7.3)] or &amp;gt;280 mg/dl [OR 42.2 (29.5, 60.5)]. Similar results were seen when comparing patients with admission A1c &amp;lt;7% to A1c 7-9% [OR 2.4 (1.9, 2.9)] or A1c &amp;gt;9% [OR 13.3 (8.8, 19.9)]. Conclusion: SSI is used in ~40% of non-critically ill patients, especially among those with mild/moderate hyperglycemia. Most patients with BG &amp;lt;180 mg/dl and A1c &amp;lt;7% treated with SSI maintain good glycemic control (mean hospital BG &amp;lt;180 mg/dl) while hospitalized, suggesting that basal insulin may not be necessary. Further RCT are needed to identify a subpopulation for whom SSI may be appropriate in the hospital. Disclosure A. Migdal: None. F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck &amp; Co., Inc. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. M. Fayfman: None. S. Cardona: None. G. Davis: None. H. Wang: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi US.

1245-P: The Association of Glucose Variability during the Last Day of Hospitalization and 30-Day Readmission in Adults with Diabetes

Objective: Thirty-day hospital readmission (30-day RA) rates are a metric of healthcare quality. Limited data is available, whether increased glucose variability (GV) during the last day of hospital stay is associated with an increased risk of 30-day RA. Design: Nationwide cohort of 1,042,859 admissions of patients with diabetes in the non-critical care setting in 129 Veteran Affairs hospitals, between 2001-2014. Coefficient of Variation (CV) was measured using point of care- glucometer values and was used as measurement of GV, divided into ten equal categories (tentiles). Covariates, including demographics, socio-economic and hospital related factors and up to 30 comorbidities were collected. Poisson regression was used to determine if CV during the last stay day of the hospitalization was associated with 30-day RA. Results: After adjusting for age, gender and race (Model 1), there was a gradual increase in 30-day RA ratio among admissions with higher CV. Following adjusting for all the covariates collected (Model 2), only admissions with the highest CV demonstrated an increased 30-day RA. The rate ratios and 95% CIs were 1.049 (1.026, 1.073, p&amp;lt;0.0001), 1.038 (1.015,1.061, p=0.0011), 1.065 (1.042,1.089, p&amp;lt;0.0001), for the 8th, 9th and the 10th tentiles respectively, compared to those with CV in the 1st tentile. In Model 3, after adjusting for covariates used in Model 2 and for hypoglycemia, results remained statistically significant for those admissions with the highest CV [rate ratios and 95% CIs are 1.044 (1.021,1.068, p=0.0001), 1.028 (1.006,1.052, p=0.014), 1.042 (1.018,1.067, p=0.0005) for the 8th, 9th and the 10th tentiles]. Conclusions: Higher glucose variability during the last day of hospitalization was associated with increased 30-day RA rates after adjustment for multiple covariates and hypoglycemia. Disclosure E. Spanakis: None. L.G. Singh: None. T. Siddiqui: None. J.D. Sorkin: None. G. Notas: None. M.F. Magee: Consultant; Self; Mytonomy. Research Support; Self; Lilly Diabetes, Mytonomy, Sanofi. Speaker's Bureau; Self; PRIMED. J.C. Fink: None. M. Zhan: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi US. Funding U.S. Department of Veterans Affairs (1I01CX001825-01)

1047-P: Can Closed-Loop Overcome High Day-to-Day Variability of Insulin Needs in Inpatients on General Wards?

Aim: To assess the ability of fully closed-loop insulin delivery to accommodate day-to-day variability in insulin requirements in noncritical care setting. Methods: We retrospectively analyzed insulin delivery during closed-loop studies in inpatients with hyperglycaemia requiring insulin on general wards (type 1 diabetes excluded). Coefficient of variation (CV) quantified day-to-day variability of insulin requirements over 5 to 15 days of closed-loop use. Participants were stratified into tertiles according to variability of insulin requirements. Results: Data from 487 days (55 participants) were analyzed. Participants with higher CV of insulin requirements had comparable mean glucose (149 vs. 153mg/dL; P=0.59; Table) and time in target glucose 100-180mg/dL (67.8 vs. 67.9%; P=0.99) to those with lower CV. There was no increase in hypoglycemia in those with higher CV (P=0.67). Those with higher CV were younger than those with lower CV (66 vs. 72years; P=0.037). Weight, gender, HbA1c, diabetes/insulin duration, use of steroids/dialysis/nutrition support were comparable (ns). Conclusions: Fully closed-loop insulin delivery can accommodate highly variable insulin requirements without compromising glucose control or increasing the risk of hypoglycaemia in inpatients receiving insulin therapy on general wards. Disclosure C.K. Boughton: None. L. Bally: None. H. Thabit: Research Support; Self; Dexcom, Inc. S. Hartnell: Advisory Panel; Self; Dexcom, Inc., JDRF. Speaker's Bureau; Self; Sanofi. D. Herzig: None. A. Vogt: None. E. Andereggen: None. Y. Ruan: None. M.E. Wilinska: None. M. Evans: Advisory Panel; Self; Dexcom, Inc., Medtronic, Roche Diabetes Care, Zucara Therapeutics Inc. Research Support; Self; MedImmune, Sanofi. Speaker's Bureau; Self; AstraZeneca. Other Relationship; Self; Abbott, Eli Lilly and Company, Novo Nordisk Inc. M.M. Wertli: None. A.P. Coll: None. C. Stettler: None. R. Hovorka: Advisory Panel; Self; Novo Nordisk A/S. Research Support; Self; Abbott, Dexcom, Inc., Medtronic. Speaker's Bureau; Self; Eli Lilly and Company, Novo Nordisk A/S. Other Relationship; Self; B. Braun Medical Inc., Medtronic.

1815. Effects of Syndrome-Based Antimicrobial Stewardship Prospective Audit and Feedback Interventions on Antimicrobial Use in an Urban Community Hospital

BackgroundEstablishing antimicrobial stewardship programs (ASP) in community hospitals with limited resources can be challenging. Many hospitals do not have infectious disease (ID) trained pharmacists (PharmD) available. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback at an urban community hospital.MethodsASP was implemented at a 151-bed urban community hospital in October 2017. PharmD training on syndrome-based treatment guidelines, including definitions, severity, empiric regimens, de-escalation, and duration was created. Prospective audit by PharmDs was established. This program was implemented and overseen by an ID physician. Days of therapy per 1,000 patient-days (DOT/1,000) was assessed 3 months before and after ASP. Prospective audit and feedback data were reviewed.ResultsAt 3 months, antimicrobial use decreased (370 vs. 350 DOT/1,000) while the proportion of oral antimicrobials used increased (32% vs. 43%). Antibiotic expenditures decreased by 11% ($42,500 vs. $37,900). Most cases reviewed by prospective audit (58%) fit pre-determined syndromes (Figure 1). Soft tissue and urinary tract infections were the most common syndromes. Interventions occurred in 53% of cases. De-escalation from broad-spectrum agents was more successful in noncritical care settings (Figure 2).Figure 1.ASP syndrome-based prospective audit and feedback.Figure 2.Antimicrobial use in medical surgical units after implementation of ASP.ConclusionSyndrome-based prospective audit and feedback was successfully implemented in an urban community hospital with non-ID trained PharmDs using ID physician leadership. Our program led to a decrease in antibiotic use, increase use of oral alternatives, and decreased antibiotic expenditures. Empiric use of broad-spectrum agents was common at our facility. ASP likely contributed to an increase in ceftriaxone and decrease in piperacillin–tazobactam use in medical-surgical floors. Stewardship in critically ill patients remains a challenge. Clear guidelines and access to an ID physician are necessary to provide adequate support for PharmDs without ID-specific training and can help curb antibiotic use. Expanding the list of syndromes may further impact antimicrobial use.Disclosures All authors: No reported disclosures.

Fully Closed-Loop Glucose Control in Noncritical Care Settings—A Randomised, Controlled Two-Centre Study

Automated fully closed-loop (CL) insulin delivery system without meal-bolusing was evaluated in medical and surgical non-critical care wards of two acute hospitals in Switzerland and United Kingdom. In a randomised controlled parallel design study, 136 adults with inpatient hyperglycaemia requiring subcutaneous (s/c) insulin were randomised to receive either CL-directed s/c insulin delivery (n=70) or conventional s/c insulin therapy as per local practice with masked continuous glucose monitoring (n=66) for up to 15-days. Participants consumed self-selected hospital meals and were matched for age (68±10 vs. 67±13 years; CL vs. control), HbA1c (7.8±2.5 vs. 8.0±1.9%) and BMI (32.7±8.2 vs. 32.3±8.1kg/m2). During CL, participant’s usual insulin and sulphonylurea therapy were withheld. In an intention to treat analysis, the proportion of time when sensor glucose was in target range from 5.6 to 10.0mmol/l was significantly higher during CL (p&amp;lt;0.001, Table). CL reduced time spent above target (p&amp;lt;0.001), and reduced mean and standard deviation of sensor glucose (p&amp;lt;0.001). Time spent hypoglycaemic was low and comparable. Total daily insulin delivery was not different. No severe hypoglycaemia or serious adverse events occurred in either group. In conclusion, fully closed-loop without meal-bolusing is safe, and may improve glucose control in a heterogeneous inpatient population.Closed-loop insulin delivery (n=70)Conventional insulin therapy (n=66)PTime spent at sensor glucose levels (%)5.6 to 10.0 mmol/l65.7±16.841.5±16.9&amp;lt;0.001&amp;gt;10.0 mmol/l23.7±16.649.5±22.8&amp;lt;0.001&amp;lt;5.6 mmol/l10.6±6.79.0±13.30.37&amp;lt;3.0 mmol/l0.0 (0.0, 0.1)0.0 (0.0, 0.0)0.80Mean sensor glucose (mmol/l)8.5±1.610.5±2.4&amp;lt;0.001SD of sensor glucose (mmol/l)2.6±1.03.2±1.1&amp;lt;0.001Total daily insulin (U)44.0 (27.5, 73.3)40.2 (26.5, 65.6)0.36Data are mean ± SD or median (IQR). Disclosure L. Bally: None. H. Thabit: None. S. Hartnell: Speaker’s Bureau; Self; Medtronic, Roche Pharma. E. Andereggen: None. Y. Ruan: None. M.E. Wilinska: None. M. Evans: Advisory Panel; Self; Novo Nordisk A/S, Eli Lilly and Company, Cellnovo, Roche Pharma. Speaker’s Bureau; Self; Abbott, Novo Nordisk A/S. M.M. Wertli: None. A.P. Coll: None. C. Stettler: None. R. Hovorka: Speaker’s Bureau; Self; Novo Nordisk A/S. Advisory Panel; Self; Novo Nordisk A/S. Speaker’s Bureau; Self; Eli Lilly and Company, AstraZeneca. Other Relationship; Self; B. Braun Medical Inc.. Research Support; Self; Medtronic. Other Relationship; Self; Medtronic. Research Support; Self; Abbott, JDRF, Diabetes UK, National Institute of Diabetes and Digestive and Kidney Diseases.

What's in this Issue

What's in this Issue

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non-critical care settings.

Emerging evidence shows that suboptimal glycaemic control is associated with increased morbidity and length of stay in hospital. Various guidelines for safe and effective inpatient glycaemic control in the non-critical care setting have been published. In spite of this, implementation in practice remains limited because of the increasing number of people with diabetes admitted to hospital and staff work burden. The use of technology in the outpatient setting has led to improved glycaemic outcomes and quality of life for people with diabetes. There remains an unmet need for technology utilisation in inpatient hyperglycaemia management in the non-critical care setting. Novel technologies have the potential to provide benefits in diabetes care in hospital by improving efficacy, safety and efficiency. Rapid analysis of glucose measurements by point-of-care devices help facilitate clinical decision-making and therapy adjustment in the hospital setting. Glucose treatment data integration with computerized glucose management systems underpins the effective use of decision support systems and may streamline clinical staff workflow. Continuous glucose monitoring and automation of insulin delivery through closed-loop systems may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia whilst reducing staff workload. This review summarizes the evidence with regard to technological methods to manage inpatient glycaemic control, their limitations and the future outlook, as well as potential strategies by healthcare organizations such as the National Health Service to mediate the adoption, procurement and use of diabetes technologies in the hospital setting.

Management of Type 1 Diabetes in the Hospital Setting.

The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings. Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.

How Low Can You Go? Reducing Rates of Hypoglycemia in the Non-critical Care Hospital Setting.

The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting. Strategies to reduce hypoglycemia rates should focus on the most common causes of iatrogenic hypoglycemia. Creating a standardized insulin order set with built-in clinical decision support can help reduce rates of hypoglycemia. Coordination of blood glucose monitoring, meal tray delivery, and insulin administration is an important and challenging task. Protocols and processes should be in place to deal with interruptions in nutrition to minimize risk of hypoglycemia. A glucose management page that has all the pertinent information summarized in one page allows for active surveillance and quick identification of patients who may be at risk of hypoglycemia. Finally, education of prescribers, nurses, food and nutrition services, and patients is important so that every member of the healthcare team can work together to prevent hypoglycemia. By implementing strategies to reduce hypoglycemia, we hope to lower rates of adverse events and improve quality of care while also reducing hospital costs. Future research should focus on the impact of an overall reduction in hypoglycemia to determine whether the expected benefits are achieved.

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings

Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent's respective hospital. Responses were obtained from 38 North American academic children's hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI). Patients with STEMI are typically hospitalized to monitor for serious complications such as arrhythmias, heart failure, and reinfarction. Optimal length of stay is unclear. Whether low risk patients can be safely discharged before 72 hr of hospitalization is unclear. Patients with STEMI who underwent successful PCI were retrospectively stratified using CADILLAC risk score to low risk (n = 123) and intermediate to high risk (n = 105). The primary outcome was adverse clinical events at day 3 or later. Secondary outcomes were adverse clinical events on day 1 and mortality rates at 30 days and 31 to 365 days. Low risk patients had lower major adverse clinical events at day 3 or later (0 vs. 11.4%, P = 0.0002) and lower total mortality at 1 year (0 vs. 4.8%, P = 0.02) than patients with intermediate to high risk. Low risk patients were also less likely to have a cardiovascular event during the first 24 hr when compared to those with an intermediate to high risk score (3.3% vs. 13.3%, P = 0.006). Low risk patients identified using CADILLAC risk score with STEMI treated successfully with primary PCI have a low adverse event rate on the third day or later of hospitalization suggesting that an earlier discharge is safe in properly selected patients. Monitoring in a noncritical care setting following primary PCI for STEMI may be feasible for selected patients. © 2016 Wiley Periodicals, Inc.

Forum for Injection Technique 2.0 Addendum 1: Insulin use in indoor settings.

Insulin is a frequently used drug in the indoor setting. Comprehensive recommendations for best practice in insulin injection technique have been published by the forum for injection technique (FIT), India. This addendum focuses on insulin use in indoor settings, and complements the FIT 2.0 recommendations. It discusses insulin use and disposal in critical care and noncritical care settings. It also highlights the need to ensure continuing nursing and medical education, and frame insulin policies for such use.

Interventions to prevent non-critical care hospital acquired pneumonia – a systematic review

BackgroundHospital-acquired pneumonia is a significant burden to healthcare systems around the world. Although there is a considerable body of evidence on prevention of ventilator associated pneumonia, less is known about strategies to prevent hospital-acquired pneumonia in non-critical care settings. ObjectiveTo systematically review the randomised controlled trial evidence for prevention of hospital-acquired pneumonia in non-critical care settings. MethodsWe searched EMBASE, CINAHL+, MEDLINE and the Cochrane Library. Seventeen different searches were conducted in parallel through each database. Studies were included if they were randomised controlled trials reporting hospital-acquired pneumonia as an endpoint. Studies were excluded if they were performed in critical care or community settings. All studies published up to the end of December 2014 were considered, with no language restrictions. Data were independently extracted by two authors and the Delphi risk of bias tool was applied to assess trial quality. ResultsFive thousand one hundred and one titles were identified across 17 searches. Only two studies were eligible for inclusion in the final review, one from a search of physical therapy interventions and one from a search of enteral feeding. The heterogeneity of the interventions did not permit meta-analysis. One trial suggested possible benefits to early mobilisation; the other trial suggested no benefit or harm from early enteral feeding via nasogastric tube. Both trials enrolled patients with acute stroke. No trials in non-stroke, non-critical care populations were eligible for inclusion in the review. ConclusionsThere is currently insufficient trial evidence on preventing non-critical care hospital-acquired pneumonia to make recommendations on practice.

33 * INTERVENTIONS TO PREVENT NON-CRITICAL CARE HOSPITAL ACQUIRED PNEUMONIA-A SYSTEMATIC REVIEW

Background: Hospital-acquired pneumonia is a significant burden to healthcare systems around the world. Although there is a considerable body of evidence on prevention of ventilator associated pneumonia, less is known about strategies to prevent hospital-acquired pneumonia in non-critical care settings. Objective: To systematically review the randomised controlled trial evidence for prevention of hospitalacquired pneumonia in non-critical care settings. Methods: We searched EMBASE, CINAHL+, MEDLINE and the Cochrane Library. Seventeen different searches were conducted in parallel through each database. Studies were included if they were randomised controlled trials reporting hospital-acquired pneumonia as an endpoint. Studies were excluded if they were performed in critical care or community settings. All studies published up to the end of December 2014 were considered, with no language restrictions. Data were independently extracted by two authors and the Delphi risk of bias tool was applied to assess trial quality. Results: Five thousand one hundred and one titles were identified across 17 searches. Only two studies were eligible for inclusion in the final review, one from a search of physical therapy interventions and one from a search of enteral feeding. The heterogeneity of the interventions did not permit metaanalysis. One trial suggested possible benefits to early mobilisation; the other trial suggested no benefit or harm from early enteral feeding via nasogastric tube. Both trials enrolled patients with acute stroke. No trials in non-stroke, non-critical care populations were eligible for inclusion in the review. Conclusions: There is currently insufficient trial evidence on preventing non-critical care hospitalacquired pneumonia to make recommendations on practice. 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. Available online at

Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review.

Although timely treatment of sepsis improves outcomes, delays in administering evidence-based therapies are common. To determine whether automated real-time electronic sepsis alerts can: (1) accurately identify sepsis and (2) improve process measures and outcomes. We systematically searched MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from database inception through June 27, 2014. Included studies that empirically evaluated 1 or both of the prespecified objectives. Two independent reviewers extracted data and assessed the risk of bias. Diagnostic accuracy of sepsis identification was measured by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR). Effectiveness was assessed by changes in sepsis care process measures and outcomes. Of 1293 citations, 8 studies met inclusion criteria, 5 for the identification of sepsis (n = 35,423) and 5 for the effectiveness of sepsis alerts (n = 6894). Though definition of sepsis alert thresholds varied, most included systemic inflammatory response syndrome criteria ± evidence of shock. Diagnostic accuracy varied greatly, with PPV ranging from 20.5% to 53.8%, NPV 76.5% to 99.7%, LR+ 1.2 to 145.8, and LR- 0.06 to 0.86. There was modest evidence for improvement in process measures (ie, antibiotic escalation), but only among patients in non-critical care settings; there were no corresponding improvements in mortality or length of stay. Minimal data were reported on potential harms due to false positive alerts. Automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and do not improve mortality or length of stay.

Effectiveness of basal bolus insulin (BBI) administration versus other insulin regimen administration methods for hospitalized adult, non-critical care patients with hyperglycemia: a systematic review protocol

Review question/objective What type of insulin regimen (basal bolus insulin or other insulin regimens) for hospitalized adult non-critical care patients is more effective in achieving lower overall mean blood glucose and fewer episodes of hypoglycemia? Inclusion criteria Types of participants This review will consider studies that include acute care, hospitalized, non-critical care patients, 18 years or older, females and males, with all types of conditions or diseases including surgical procedures, and at all stages of severity that required hyperglycemia management. Types of interventions This review will include studies that evaluated the effectiveness of basal bolus insulin protocol for hospitalized adult, non-critical care patients, which includes a combination of long and rapid acting insulin regimens as compared to insulin regimens using rapid acting or regular insulin alone for the treatment of hyperglycemia. Types of outcomes This review will consider studies that included the following outcome measures: •mean daily blood glucose levels; •overall mean blood glucose achieved during hospitalization; and •episodes of hypoglycemia.

Glucose control in non‐critically ill inpatients with diabetes: towards closed‐loop

Inpatient glycaemic control remains an important issue due to the increasing number of patients with diabetes admitted to hospital. Morbidity and mortality in hospital are associated with poor glucose control, and cost of hospitalization is higher compared to non-diabetes patients. Guidelines for inpatient glycaemic control in the non-critical care setting have been published. Current recommendations include basal-bolus insulin therapy, regular glucose monitoring, as well as enhancing healthcare provider's role and knowledge. In spite of growing focus, implementation in practice is limited, mainly due to increasing workload burden on staff and fear of hypoglycaemia. Advances in healthcare technology may contribute to an improvement of inpatient diabetes care. Integration of glucose measurements with healthcare records and computerized glycaemic control protocols are currently being used in some institutions. Recent interests in continuous glucose monitoring have led to studies assessing its utilization in inpatients. Automation of glucose monitoring and insulin delivery may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia, whilst reducing staff workload. This review summarizes the evidence on current approaches to managing inpatient glycaemic control; its utility and limitations. We conclude by discussing the evidence from feasibility studies to date, on the potential use of closed loop in the non-critical care setting and its implication for future studies.