Use of a real-time, algorithm-driven, publicly displayed, automated signal to improve insulin prescribing practices


      • Remote monitoring of blood glucose and insulin orders improved glycemic control.
      • An automated, publicly displayed signal improved insulin prescribing practices.
      • Insulin therapy for hyperglycemia in the absence of diabetes increased hypoglycemia.
      • Algorithm-driven treatment recommendations were safe and effective for patients with diabetes.



      The clinical andon board (CAB) is a novel electronic surveillance and communication system, which alerts providers to and prompts treatment of dysglycemia. This investigation was designed to determine the CAB’s effectiveness in supporting adherence to standardized evidence-based protocols, as well as improving glycemic control.


      This study was a retrospective pre/post analysis of insulin orders and blood glucose values. We used a Student’s t-test for continuous variables and Chi2 for all other variables. This study included patients 18 years or older admitted to the hospital medical service as an inpatient with a length of stay greater than 24 h and less than 90 days. We used Pearson’s correlation coefficient to evaluate the relationship between CAB and blood glucose.


      The rate of compliance in prescribing basal insulin for patient with diabetes increased from 56% to 77% (p < 0.001). Similarly, compliance rates for prescribing correctional insulin in patients without diabetes increased from 15% to 37% (p < 0.001). Performance on the CAB was linearly related to blood glucose (p = 0.004), and there was a small statistically (not clinically) significant improvement in mean blood glucose values.


      This approach is effective in alerting and engaging providers to prescribe insulin in a standardized manner with potential to improve glycemic control.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Diabetes Research and Clinical Practice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cook C.B.
        • Kongable G.L.
        • Potter D.J.
        • Abad V.J.
        • Leija D.E.
        • Anderson M.
        Inpatient glucose control: a glycemic survey of 126 U.S. hospitals.
        J Hosp Med. 2009; 9: E7-E14
        • Clement S.
        • Braithwaite S.S.
        • Magee M.F.
        • Ahmann A.
        • Smith E.P.
        • Schafer R.G.
        • et al.
        Management of diabetes and hyperglycemia in hospitals.
        Diabetes Care. 2004; 2: 553-591
        • American Diabetes Association
        Diabetes care in the hospital: standards of medical care in diabetes-2018.
        Diabetes Care. 2018; 41: S144-S151
        • Varghese P.
        • Gleason V.
        • Sorokin R.
        • Senholzi C.
        • Jabbour S.
        • Gottlieb J.E.
        Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.
        J Hosp Med. 2007; 4: 234-240
        • Nirantharakumar K.
        • Marshall T.
        • Kennedy A.
        • Narendran P.
        • Hemming K.
        • Coleman J.J.
        Hypoglycaemia is associated with increased length of stay and mortality in people with diabetes who are hospitalized.
        Diabet Med. 2012; 29: e445-e448
        • Franco T.
        • Aaronson B.
        • Brown L.
        • Blackmore C.
        • Rupp S.
        • Lee G.
        Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia.
        BMJ Open Qual. 2017; 6e000059
        • Desimone M.E.
        • Blank G.E.
        • Virji M.
        • Donihi A.
        • DiNardo M.
        • Simak D.M.
        • et al.
        Effect of an educational inpatient diabetes management program on medical resident knowledge and measures of glycemic control: a randomized controlled trial.
        Endocr Pract. 2012; 2: 238-249
        • Nirantharakumar K.
        • Chen Y.F.
        • Marshall T.
        • Webber J.
        • Coleman J.J.
        Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: systematic review.
        Diabet Med. 2012; 6: 698-708
        • Munoz M.
        • Pronovost P.
        • Dintzis J.
        • Kemmerer T.
        • Wang N.Y.
        • Chang Y.T.
        • et al.
        Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice.
        Jt Comm J Qual Patient Saf. 2012; 38: 195-206
        • Drincic A.T.
        • Akkireddy P.
        • Knezevich J.T.
        Curr Diab Rep. 2018; 18: 10
        • Rushakoff R.J.
        • Sullivan M.M.
        • MacMaster H.W.
        • et al.
        Association between a virtual glucose management service and glycemic control in hospitalized adult patients: an observational study.
        Ann Intern Med. 2017; 166: 621-627
        • Kenney C.
        Transforming Heath Care Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience.
        Productivity Press, New York, NY2011
        • Umpierrez G.E.
        • Smiley D.
        • Zisman A.
        • Prieto L.M.
        • Palacio A.
        • Ceron M.
        • et al.
        Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).
        Diabetes Care. 2007; 9: 2181-2186
      1. Ohno, Taiichi, Toyota Production System: Beyond Large-Scale Production. Diamond, Inc Tokyo, Japan 1978. (English translation by Productivity, Inc., Portland, OR).

        • McGaughey J.
        • Alderdice F.
        • Fowler R.
        • Kapila A.
        • Mayhew A.
        • Moutray M.
        Outreach and early warning systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards.
        Cochrane Database Syst Rev. 2007; 3: CD005529
        • Reed C.C.
        • Richa J.M.
        • Berndt A.E.
        • Beadle R.D.
        • Gerhardt S.D.
        • Stewart R.
        • et al.
        Improving glycemic control with the adjunct use of a data management software program.
        Adv Crit Care. 2012; 4: 362-369
        • Ivers N.M.
        • Grimshaw J.M.
        • Jamtvedt G.
        • Flottorp S.
        • O'Brien M.A.
        • French S.D.
        • et al.
        Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care.
        J Gen Intern Med. 2014; 11: 1534-1541