Connect Care Manual - Glucose & Insulin Management

Glycemic Monitoring and Managment

The need to manage blood glucose levels is common among patients served in emergency, acute care, critical care and peri-operative settings. A number of tools have been developed to facilitate improved glycemic management for inpatients. These divide into those that facilitate surveillance and others that facilitate intervention. All are available when an inpatient chart is opened in the clinical information system (CIS).

Glycemic Monitoring

Clinician-facilitated Data

Three tools help appreciate inpatients’ blood glucose response to problems and interventions.

Glucose Management Summary

The first two, an overview snapshot block and a glucose management summary, are part of the “Summary” section of an inpatient chart. The "Glucose" tab in the inpatient chart Summary activity opens and displays the glucose management summary.

- - Guide: Inpatient Glycemic Monitoring
  - Demo: Workflow QuickStep - Inpatient Glycemic Monitoring

Glucometer Monitoring Patient List Column

The third tool is a "Glucometer Overview" column that can be added to any "My List" Patient List. This column lets emergency and inpatient prescribers review glucometer point of care testing (POCT) results directly from the Patient List, making it easier to identify patients who need diabetes medication review and titration.

The column shows coloured dots representing glucometer readings taken over the current and previous day. A gray dot shows for patients who do not have recent readings but have diabetes documented in their encounter diagnosis, problem list or medical history.

Hovering over a dot produces a popup display of glucose readings over the last 3 days, as well as their most recent Hemoglobin A1C. If patient-reported (MyChart) glucometer readings are available, a link appears and can be selected to open a full glucose management summary.
Double-clicking on the dot opens a popup display of the glucose management summary described above, with no need to open the chart.
Dot colours reflect the percentage of glucometer readings within the Diabetes Canada recommended glucose targets while in hospital (4-10 mmol/L) during the current and/or previous day.

The Glucometer Overview column is also available within a patient list column "block" that includes both an icon reflecting recent new lab results and the glucometer overview dot. The column block ("Lab Notifications") is part of the "MD Ward Rounds" and the "MD ED Consults" provincial My List templates, which can be applied to any custom patient list.

The glucometer column, alone or within the Lab Notifications block, can be manually added to any prescriber’s Patient List (see tip sheet for details).

Tip: Glucometer Overview Patient List Column

Patient-facilitated Data

Another set of tools allows blood glucose monitoring data from patient devices to be reviewed and incorporated into the Connect Care chart.

Patient Glucometer Result - Patient Entered

Patients can use the MyChart patient portal to enter their own capillary blood glucose measurements. They can transcribe data from a personal glucometer. In some cases, personal glucometers that integrate with smartphone apps can share data with Connect Care via standard interfaces (Apple Health for iPhones and iPads).

Patient captured and reported data can be viewed within the Glucose Management Summary described above.

In order for this functionality to be available to patients, a few requirements must be met:

Patient
must have an active MyChart account, having followed instructions for activating the patient portal after securing an Alberta.ca Account.
- - - Manual: Patient Portal
    - Tip: MyChart Patient Access
Prescriber
must "order" an appropriate patient portal flowsheet for a patient who will enter or interface blood glucose information.
- - - Manual: Patient Portal
    - Tip: Capturing Patient-entered Health Data

Patient Glucometer Result - Clinician Entered

Admitted patients may be enabled to manage their own insulin therapy in hospital, or to obtain their own glucometer recordings using their own device, but have a qualified clinician enter the data to Connect Care. Inpatient diabetes self-management data appears in the Glucose Management Summary described above but does not inform the Glucometer Management patient list column.

Guide: Diabetes Inpatient Management

Glycemic Intervention - Basal Bolus Insulin Therapy (BBIT)

Connect Care supports the Basal Bolus Insulin Therapy (BBIT) protocol to help clinicians determine patients’ insulin requirements and the optimal types and timings of insulin administration.

A good place to get oriented to Connect Care insulin management is through the BBIT navigator, even though this is typically used as part of an insulin ordering sequence. Thereafter, the process for completing BBIT orders and taking advantage of embedded decision supports makes more sense.

Glycemic Intervention - Pre-procedure and Post-procedure

Most patients with hyperglycemia can be managed with the BBIT protocol for subcutaneous insulin administration peri-operatively, even when unable to eat (NPO). There are a number of additional considerations when navigating surgical intervention and anesthesia.

"Preprocedure Management of Patients with Diabetes" Order Sets are available for both adult and pediatric inpatients. These gather into one place all the booking, monitoring, testing, diet, fluid and insulin options that clinicians may choose from while aligning with evidence-informed peri-operative care.

Tip: Perioperative Insulin Management

Glycemic Intervention - NPO IV Insulin Management

A "NPO and Perioperative IV Insulin Management" Order Panel is embedded in the preprocedure diabetes Order Set and can be used independently (standalone panel) or in conjunction with the Oder Set. While the BBIT subcutaneous insulin protocol remains strongly recommended, even when patients are unable to eat (NPO), there may be situations in which NPO patients require intravenous insulin outside of the context of a pending procedure.

Tip: Perioperative Insulin Management