Magee Michelle F
Georgetown University School of Medicine; Medstar Research Institute, 100 Irving St., NW, East Building, Room 4114, Washington, DC 20010, USA.
Am J Health Syst Pharm. 2007 May 15;64(10 Suppl 6):S15-20; quiz S21-3. doi: 10.2146/ajhp070103.
Evolving elements of best practices for providing targeted glycemic control in the hospital setting, clinical performance measurement, basal-bolus plus correction-dose insulin regimens, components of standardized subcutaneous (s.c.) insulin order sets, and strategies for implementation and cost justification of glycemic control initiatives are discussed.
Best practices for targeted glycemic control should address accurate documentation of hyperglycemia, initial patient assessment, management plan, target blood glucose range, blood glucose monitoring frequency, maintenance of glycemic control, criteria for glucose management consultations, and standardized insulin order sets and protocols. Establishing clinical performance measures, including desirable processes and outcomes, can help ensure the success of targeted hospital glycemic control initiatives. The basal-bolus plus correction-dose regimen for insulin administration will be used to mimic the normal physiologic pattern of endogenous insulin secretion. Standardized insulin order sets and protocols are being used to minimize the risk of error in insulin therapy. Components of standardized s.c. insulin order sets include specification of the hyperglycemia diagnosis, finger stick blood glucose monitoring frequency and timing, target blood glucose concentration range, cutoff values for excessively high or low blood glucose concentrations that warrant alerting the physician, basal and prandial or nutritional (i.e., bolus) insulin, correction doses, hypoglycemia treatment, and perioperative or procedural dosage adjustments. The endorsement of hospital administrators and key physician and nursing leaders is needed for glycemic control initiatives. Initiatives may be cost justified on the basis of the billings for clinical diabetes management services and/or the return- on-investment accrued to reductions in hospital length of stay, readmissions, and accurate documentation and coding of unrecognized or uncontrolled diabetes, and diabetes complications.
Standardized insulin order sets and protocols may minimize risk of insulin errors. The endorsement of these protocols by administrators, physicians, nurses, and pharmacists is also needed for success.
讨论在医院环境中提供目标血糖控制的最佳实践的不断发展的要素、临床绩效评估、基础-餐时加校正剂量胰岛素治疗方案、标准化皮下胰岛素医嘱集的组成部分以及血糖控制举措的实施策略和成本合理性。
目标血糖控制的最佳实践应涵盖高血糖的准确记录、患者初始评估、管理计划、目标血糖范围、血糖监测频率、血糖控制的维持、血糖管理咨询标准以及标准化胰岛素医嘱集和方案。建立临床绩效指标，包括理想的流程和结果，有助于确保医院目标血糖控制举措的成功。胰岛素给药的基础-餐时加校正剂量方案将用于模拟内源性胰岛素分泌的正常生理模式。标准化胰岛素医嘱集和方案用于将胰岛素治疗中的错误风险降至最低。标准化皮下胰岛素医嘱集的组成部分包括高血糖诊断的规范、指尖血糖监测频率和时间、目标血糖浓度范围、过高或过低血糖浓度的临界值（需提醒医生）、基础胰岛素和餐时或营养（即大剂量）胰岛素、校正剂量、低血糖治疗以及围手术期或操作过程中的剂量调整。血糖控制举措需要医院管理人员以及关键医生和护理领导的认可。基于临床糖尿病管理服务的计费和/或因缩短住院时间、再入院以及对未识别或未控制的糖尿病及糖尿病并发症进行准确记录和编码而产生的投资回报率，这些举措在成本方面可能是合理的。
标准化胰岛素医嘱集和方案可将胰岛素错误风险降至最低。这些方案还需要管理人员、医生、护士和药剂师的认可才能取得成功。
