1,278 research outputs found
Clinical decision support systems in the care of hospitalised patients with diabetes
This thesis explored the role of health informatics (decision support systems) in caring for hospitalised patients with diabetes through a systematic review and by analysing data from University Hospital Birmingham, UK.
Findings from the thesis: 1) highlight the potential role of computerised physician order entry system in improving guideline based anti-diabetic medication prescription in particular insulin prescription, and their effectiveness in contributing to better glycaemic control; 2) quantify the occurrence of missed discharge diagnostic codes for diabetes using electronic prescription data and suggests 60% of this could be potentially reduced using an algorithm that could be introduced as part of the information system; 3) found that hypoglycaemia and foot disease in hospitalised diabetes patients were independently associated with higher in-hospital mortality rates and longer length of stay; 4) quantify the hypoglycaemia rates in non-diabetic patients and proposes one method of establishing a surveillance system to identify non diabetic hypoglycaemic patients; and 5) introduces a prediction model that may be useful to identify patients with diabetes at risk of poor clinical outcomes during their hospital stay
Integral-based filtering of continuous glucose sensor measurements for glycaemic control in critical care
Hyperglycaemia is prevalent in critical illness and increases the risk of further
complications and mortality, while tight control can reduce mortality up to 43%.
Adaptive control methods are capable of highly accurate, targeted blood glucose
regulation using limited numbers of manual measurements due to patient discomfort
and labour intensity. Therefore, the option to obtain greater data density using
emerging continuous glucose sensing devices is attractive. However, the few such
systems currently available can have errors in excess of 20-30%. In contrast, typical
bedside testing kits have errors of approximately 7-10%. Despite greater measurement
frequency larger errors significantly impact the resulting glucose and patient specific
parameter estimates, and thus the control actions determined creating an important
safety and performance issue. This paper models the impact of the Continuous
Glucose Monitoring System (CGMS, Medtronic, Northridge, CA) on model-based
parameter identification and glucose prediction. An integral-based fitting and filtering
method is developed to reduce the effect of these errors. A noise model is developed
based on CGMS data reported in the literature, and is slightly conservative with a
mean Clarke Error Grid (CEG) correlation of R=0.81 (range: 0.68-0.88) as compared to a reported value of R=0.82 in a critical care study. Using 17 virtual patient profiles
developed from retrospective clinical data, this noise model was used to test the
methods developed. Monte-Carlo simulation for each patient resulted in an average
absolute one-hour glucose prediction error of 6.20% (range: 4.97-8.06%) with an
average standard deviation per patient of 5.22% (range: 3.26-8.55%). Note that all the
methods and results are generalisable to similar applications outside of critical care,
such as less acute wards and eventually ambulatory individuals. Clinically, the results
show one possible computational method for managing the larger errors encountered
in emerging continuous blood glucose sensors, thus enabling their more effective use
in clinical glucose regulation studies
Risk and Reward: Extending stochastic glycaemic control intervals to reduce workload
peer reviewedBackground
STAR is a model-based, personalised, risk-based dosing approach for glycaemic control (GC) in critically ill patients. STAR provides safe, effective control to nearly all patients, using 1-3 hourly measurement and intervention intervals. However, the average 11-12 measurements per day required can be a clinical burden in many intensive care units. This study aims to significantly reduce workload by extending STAR 1-3 hourly intervals to 1 to 4-, 5-, and 6- hourly intervals, and evaluate the impact of these longer intervals on GC safety and efficacy, using validated in silico virtual patients and trials methods. A Standard STAR approach was used which allowed more hyperglycaemia over extended intervals, and a STAR Upper Limit Controlled approach limited nutrition to mitigate hyperglycaemia over longer intervention intervals.
Results
Extending STAR from 1-3 hourly to 1-6 hourly provided high safety and efficacy for nearly all patients in both approaches. For STAR Standard, virtual trial results showed lower % blood glucose (BG) in the safe 4.4-8.0 mmol/L target band (from 83% to 80%) as treatment intervals increased. Longer intervals resulted in increased risks of hyper- (15% to 18% BG > 8.0 mmol/L) and hypo- (2.1% to 2.8% of patients with min. BG < 2.2 mmol/L) glycaemia. These results were achieved with slightly reduced insulin (3.2 [2.0 5.0] to 2.5 [1.5 3.0] U/h) and nutrition (100 [85 100] to 90 [75 100] % goal feed) rates, but most importantly, with significantly reduced workload (12 to 8 measurements per day). The STAR Upper Limit Controlled approach mitigated hyperglycaemia and had lower insulin and significantly lower nutrition administration rates.
Conclusions
The modest increased risk of hyper- and hypo- glycaemia, and the reduction in nutrition delivery associated with longer treatment intervals represent a significant risk and reward trade-off in GC. However, STAR still provided highly safe, effective control for nearly all patients regardless of treatment intervals and approach, showing this unique risk-based dosing approach, modulating both insulin and nutrition, to be robust in its design. Clinical pilot trials using STAR with different measurement timeframes should be undertaken to confirm these results clinically
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