Novel Inpatient Automated Self-Adjusting Subcutaneous Insulin Algorithm: Three-Year Experience. An observational study. Supplemental Materials

Achieving inpatient glycemic control in patients who are nil per os (NPO), on enteral tube feeds (TF), or total parental nutrition (TPN) remains extremely challenging. Objective:To determine if, for inpatients with hyperglycemia who are NPO, on TF, or on TPN, an automated self-adjusting subcutaneous rapid acting insulin algorithm (SQIA) we developed and programmed into the EMR leads to improvements in glucose control compared to conventional insulin treatment (CI).Design/Intervention/Setting/Patients:Retrospective cohort study using EMR data from 9/3/2020 to 9/2/2023, of all adult inpatients, comparing point-of-care (POC) glucose measurements between patients on SQIA versus CI and either NPO, or on TF, or on TPN. The analysis looked at the proportion of q4 hour POC glucose levels in the following ranges: hypoglycemia (<70 mg/dL), in range (71-180 mg/dL), moderate hyperglycemia (181-250 mg/dL), and severe hyperglycemia (>250 mg/dL). Results: There were 5,031 intervals (associated with 4310 hospitalizations) in which the patient was NPO or on TF or TPN and on the SQIA (73.5%) or CI (26.5%). The proportion of glucose values in the hypoglycemic and severely hyperglycemic ranges were significantly lower in the SQIA group vs. the CI group (hypoglycemia: 0.65% vs. 1.10%; difference −0.45%; −0.62 to −0.28%; p < 0.001; hyperglycemia: 5.40% vs. 6.65%; difference −1.25%; −2.03% to −0.46%; p = 0.002). With glucocorticoids, rates of severe hyperglycemia were lower for patients on the SQIA, particularly those receiving high-dose glucocorticoids (11.1% lower). ConclusionsPatients had a lower proportion of both hypoglycemic and severely hyperglycemic measurements when their blood glucose levels were managed using the SQIA than when managed using conventional physician-driven insulin orders.针对经口禁食（nil per os, NPO）、接受肠内管饲（enteral tube feeds, TF）或全胃肠外营养（total parental nutrition, TPN）的住院患者实现住院期间血糖控制，仍是极具挑战性的临床难题。**研究目的**：明确对于存在高血糖且处于经口禁食、肠内管饲或全胃肠外营养状态的住院患者，我们开发并集成至电子病历（Electronic Medical Record, EMR）中的皮下速效胰岛素自动调节算法（subcutaneous rapid acting insulin algorithm, SQIA），相较于常规胰岛素治疗（conventional insulin treatment, CI），是否能够改善血糖控制效果。**研究设计、干预方案、研究场景与研究对象**：本研究为回顾性队列研究，采用2020年9月3日至2023年9月2日的电子病历数据，纳入所有成年住院患者，对比接受SQIA与CI治疗、且处于经口禁食、肠内管饲或全胃肠外营养状态的患者的床旁检测（point-of-care, POC）血糖结果。分析指标为每4小时床旁血糖值在以下区间的占比：低血糖（<70 mg/dL）、血糖达标区间（71~180 mg/dL）、中度高血糖（181~250 mg/dL）及重度高血糖（>250 mg/dL）。**研究结果**：本研究共纳入5031个观察周期（对应4310次住院治疗），所有患者均处于经口禁食、肠内管饲或全胃肠外营养状态，其中73.5%接受SQIA治疗，26.5%接受CI治疗。与CI组相比，SQIA组的低血糖及重度高血糖值占比均显著更低：低血糖占比分别为0.65%与1.10%，差值为-0.45%（95%置信区间：-0.62%~-0.28%，p<0.001）；重度高血糖占比分别为5.40%与6.65%，差值为-1.25%（95%置信区间：-2.03%~-0.46%，p=0.002）。在接受糖皮质激素治疗的患者中，SQIA组的重度高血糖发生率更低，尤其是接受大剂量糖皮质激素的患者（发生率较对照组低11.1%）。**研究结论**：相较于由医师主导的常规胰岛素医嘱治疗，采用SQIA进行血糖管理的患者，其低血糖及重度高血糖的检测值占比均更低。