A multifaceted approach in leveraging electronic health record tools for safe inpatient use of concentrated U-500 insulin.

PURPOSE: The Institute for Safe Medication Practices classifies subcutaneous insulin as a high-risk medication. Concentrated U-500 insulin carries additional risks in comparison to conventional U-100 insulin, as the 5-fold more concentrated nature of this product, limitations to insulin pen dosing, and various devices for dose measurement may lead to miscommunication of patient-reported doses, resulting in downstream errors in ordering, verification, or administration. We describe a multifaceted approach to leveraging technical tools within the electronic health record (EHR) for U-500 insulin use. SUMMARY: At Cleveland Clinic, the U-500 insulin use process evolved in a number of phases using EHR tools. Phase 1 included new clinical decision support and documentation tools during order entry, including a customized alert that fired during order entry recommending that the prescriber order a consult with endocrinology and requiring the prescriber to provide the patient's home insulin measuring device and the source of the patient's reported home dose. In order verification, a customized alert fired directing the pharmacist to contact the patient or patient's nurse and validate the information provided by the prescriber. Phase 2 involved transitioning dispensing of patient-specific doses from tuberculin syringes to U-500 insulin syringes. Phase 3 transitioned to use of U-500 insulin pens and included automatic dose rounding of ordered doses down to the nearest 5 units, and an additional customized pharmacist alert intended for cost conservation was added to fire if the patient had a recent administration of U-500 insulin documented, directing the pharmacist to determine whether the nurse needed a new pen dispensed. CONCLUSION: Cleveland Clinic successfully implemented customized tools and processes within the EHR pertaining to the prescribing, verification, dispensing, and administration of U-500 insulin.

Collaboration of Hospital Pharmacists and Hospitalists to Address Glycemic Control of General Medicine Patients: Implementation of a Pilot Inpatient Diabetes Management Program.

This study examined the clinical benefits of a collaborative pharmacist-physician inpatient diabetes management program that included daily blood glucose assessment and the recommendation and implementation of American Diabetes Association-recommended insulin regimens.

The use of anti-factor Xa monitoring in a selection of patients receiving enoxaparin at a large academic medical center.

Therapeutic enoxaparin is commonly used over heparin because of its favorable pharmacokinetic profile and ease of administration. Monitoring of the anticoagulant response, if necessary, is done with anti-factor Xa levels. Currently, it is suggested that monitoring may be beneficial in patients who are overweight and those with renal dysfunction. This study aimed to characterize the use of enoxaparin at a large-academic medical center in patients >150 kg, <45 kg and in those with renal dysfunction, and to describe the rate of anti-factor Xa monitoring in these patients. There were 273 patients included in the study: n = 96 for <45 kg arm, n = 111 for >150 kg arm and n = 66 for renal dysfunction arm. Less than 30 % of patients in each arm had low molecular weight heparin anti-factor Xa levels drawn. Of these only half were drawn as peak levels (4 h post dose). Overall rates of anti-factor Xa monitoring was low. It was found that obese patients achieved therapeutic anticoagulation with lower than recommended doses; underweight patients were often subtherapeutic on the recommended doses; and patients with renal dysfunction tended to have therapeutic to subtherapeutic anti-factor Xa levels. Ultimately, this evaluation showed that enoxaparin has unpredictable pharmacokinetics in these three high-risk patient populations and anti-factor Xa monitoring may be necessary to ensure therapeutic levels and appropriate dosing.

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel.

PURPOSE: Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. SUMMARY: Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel's consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. CONCLUSION: A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.