Type 2 Diabetes, Type 2 Diabetes Mellitus (T2DM), Hyperglycemia, Insulin Dependent Diabetes
Conditions
Keywords
Type 2 Diabetes, Electronic Prompt, Emergency Department Diabetes, Practice Advisory
Brief summary
The goal of this clinical trial is to improve the processes of Type 2 Diabetes (T2D) care coordination and treatment in the emergency department (ED) by utilizing clinical decision support mechanisms in the electronic health record (EHR). The main question is whether electronic prompts triggered by hyperglycemia and elevated A1c results in providers providing earlier treatments and faster time to subsequent primary care appointment and greater reduction in hemoglobin A1c (HA1c). ED clinicians will receive alerts called Our Practice Advisories (OPA's) through the EPIC EHR. The 1st OPA triggers when a random point-of-care (POC) glucose is ≥250 mg/dL, prompting a suggested additional HA1c order. A 2nd OPA triggers if the resulting HA1c is ≥10%, prompting consideration of further care coordination in the Observation Unit. Investigators will compare the outcomes post-intervention compared to pre-intervention.
Detailed description
Type 2 Diabetes (T2D) is a growing public health crisis with rates of diabetes steadily increasing over the last 10 years. The ED is commonly the first point of contact for individuals who present with symptoms of hyperglycemia, often with very severe (HbA1C \> 10%) underlying diabetes. However, there is currently no national guideline or clinical policy for the ED management of patients who are not in diabetic ketoacidosis (DKA) or in a hyperglycemia hyperosmolar state (HHS). The investigators hypothesize that there are two subgroups who may benefit from greater care coordination initiated from the ED: patients who are newly-diagnosed with severe T2D and patients whom T2D is poorly-controlled despite medication adherence. This study designs electronic prompt practice advisories that nudge ED providers towards more aggressive treatment pathways. It is currently unknown whether alert tools can improve the delivery and coordination of care of patients with severe T2D presenting to the ED.
Interventions
DIAGNOSTIC_TESTHemoglobin A1c
Prompt to order A1c
BEHAVIORALObservation Unit
Electronic prompt nudging ED provider to consider admitting patient to the Observation Unit for care coordination and more aggressive glycemic control
Sponsors
Rutgers, The State University of New Jersey
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
PREVENTION
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
21 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Moderate hyperglycemia, (glucose ≥250 mg/dL) * Patients who arrive in the emergency department * Not pregnant or peri-partum * Not SARS-COV-2 PCR positive in past 7 days
Exclusion criteria
* Diabetic ketoacidosis (pH \< 7.20, HCO3 \< 15, AG \> 25) * Diabetic foot ulcer or skin complications * Hyperglycemic hyperosmolar state with neurologic impairment * Patients who leave against medical advice (AMA), elope from the ED, or are transferred to another facility
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Care Coordination: Follow-Up Care | From date of ED encounter until 4 weeks after | % Patients achieving: A T2D-related appointment within 4 weeks |
| Physiologic Response | From date of ED encounter to 4 months after | % Patients achieving: HbA1c 1% reduction in 3 months |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Care Coordination: Insurance | Within 3 weeks of ED encounter | Inclusion: patients with NO insurance Measure % Patients achieving new insurance |
| Care Coordination: Medication Prescription | 3 days | Inclusion: patients discharged from the ED or observation Unit % subjects prescribed a diabetes medication |
| Care Coordination: Medication Change | 3 days | Inclusion: patients discharged from the ED or observation Unit % subjects with a change in diabetes medication regimen |
| Care Coordination: Appointment | 3 months | Time (days) to next appointment related to T2D, calculated as \[Appt date\] - \[ED encounter date\] |
| Care Coordination: Disposition | Within 1 day of ED encounter date | number of patients discharged, number of patients admitted to observation unit, number of patients admitted to hospital |
| Physiologic: Serum Glucose | 1 day | Serum glucose concentration change from beginning to end of ED encounter |
| Physiologic: Hemoglobin A1c percentage | 6 months | Serum hemoglobin A1c (%) |
| Physiologic: Diagnosis | 1 day | Proportion of subjects with newly diagnosed Type 2 Diabetes, proportion of subjects with poorly controlled, established Type 2 Diabetes |
| Physiologic: ED medications | 1 day | % subjects receiving (1) intravenous fluids, (2) insulin, (3) other diabetes medications while in the ED |
| Physiologic: A1c Orders | 1 day | Proportion of patients with hemoglobin A1c ordered in the ED |
| Care Coordination: Length of stay | 1 day | Length of stay (minutes) of subject ED encounter |
Countries
United States
Contacts
Primary ContactPaul Peng, MD PhD MS
Outcome results
None listed