Automating Insulin Doses to Improve Patient Care
A custom computer program at Children’s Hospital Los Angeles is translating into enhanced patient safety, streamlined workflow—and fewer finger sticks for children with diabetes.
The program is a new insulin calculator that is seamlessly integrated into the hospital’s electronic health record (EHR) system. Launched in May, the calculator automatically generates insulin doses for inpatients with diabetes, vastly reducing the need for individual, one-off orders.
“Automating this process promotes patient safety by helping to prevent medication errors,” says Troy McGuire, MD, Chief Health Information Officer at Children’s Hospital Los Angeles, who developed the calculator. “And the program comes right up in the medication administration window of the electronic medical record, so it’s truly within the nursing workflow.”
A safer, streamlined process
Previously, when children with diabetes were hospitalized, orders for insulin were generated manually.
For example, a nurse would check the child’s blood sugar and then contact the inpatient physician, providing the blood sugar reading and the exact number of carbohydrates the child was about to eat. The doctor would then calculate the amount of insulin to give, write the order, and the nurse would administer the dose.
“Each insulin dose required a phone call to the doctor, and this would happen six to eight times a day,” says Lily Chao, MD, MS, Interim Director for Clinical Diabetes at Children’s Hospital Los Angeles.
The process was not only time-consuming, but if the doctor was busy managing other patients with active medical issues, the insulin order could be delayed by 30 or 40 minutes. By then, the blood sugar reading would be out of date—and the child would need another finger stick to re-check it.
The new insulin calculator has vastly streamlined this process. Now, at the start of a hospitalization, the doctor inputs the patient’s specific insulin and glucose parameters into the EHR calculator. Each time the child’s blood sugar is checked, the nurse inputs that reading into the calculator. If the child is about to have a meal, the amount of carbohydrates about to be consumed is also entered. The calculator then generates the specific amount of insulin that the child needs.
For added safety, a second registered nurse double-checks the number.
“Nurses no longer have to wait for the inpatient doctor to be available,” Dr. Chao says. “They can punch in the numbers, see what the calculator generates, and then give the appropriate amount of insulin without delay.”
The calculator also enhances patient safety. “With manual calculation, there is always the risk of making a mistake,” she adds. “And because the calculator knows the last time the child received insulin, it helps to prevent giving insulin doses too close together.”
Integration and education
Dr. McGuire worked with Jennifer Raymond, MD, MCR, Chief of the Center for Endocrinology, Diabetes and Metabolism, to develop the customized calculator, which is based on a similar computer program he had created while at Seattle Children’s Hospital.
“The calculator itself doesn’t do anything more than algebra,” he says. “The innovation was attaching a little Java script applet into the EHR medication administration window. That integration is the key.”
Another key to success has been education and training for medical staff in advance of the program rollout. The hospital’s inpatient nursing education team has also delivered at-the-bedside training sessions for nurses when needed.
“The hospitalists, residents and nurses loved the idea of moving to this system, where we had scheduled, pre-planned orders,” Dr. McGuire says. “One of the main drivers of this, in addition to patient safety, was physician and staff satisfaction.”
The team is now developing a separate calculator for patients who need diluted doses of insulin, as well as a program to compute “correction-only” doses for specific patient populations, such as those undergoing bone marrow transplants.
“We are continuing to investigate technology to help us manage patients with diabetes,” Dr. Chao says. “By automating certain processes, we not only can promote patient safety, but we can also improve the hospital experience for children and their families.”