Closing the loop

Closed-loop algorithms can be found in every aspect of everyday modern life. Automation and control are used constantly to provide safety and to improve quality of life. Closed-loop systems and algorithms can be found in home appliances, automobiles, aviation and more. Can one imagine nowadays driving a car without ABS, cruise control or even anti-sliding control? Similar principles of automation and control can be used in the management of diabetes mellitus (DM). The idea of an algorithmic/technological way to control glycaemia is not new and has been researched for more than four decades. However, recent improvements in both glucose-sensing technology and insulin delivery together with advanced control and systems engineering made this dream of an artificial pancreas possible. The artificial pancreas may be the next big step in the treatment of DM since the use of insulin analogues. An artificial pancreas can be described as internal or external devices that use continuous glucose measurements to automatically manage exogenous insulin delivery with or without other hormones in an attempt to restore glucose regulation in individuals with DM using a control algorithm. This device as described can be internal or external; can use different types of control algorithms with bi-hormonal or uni-hormonal design; and can utilise different ways to administer them. The different designs and implementations have transitioned recently from in silico simulations to clinical evaluation stage with practical applications in mind. This may mark the beginning of a new era in diabetes management with the introduction of semi-closed-loop systems that can prevent or minimise nocturnal hypoglycaemia, to hybrid systems that will manage blood glucose (BG) levels with minimal user intervention to finally fully automated systems that will take the user out of the loop. More and more clinical trials will be needed for the artificial pancreas to become a reality but initial encouraging results are proof that we are on the right track. We attempted to select recent publications that will present these current achievements in the quest for the artificial pancreas and that will inspire others to continue to progress this field of research.     

Closing the loop: best practices for cross-setting communication at ED discharge

Purpose

This study aimed to develop emergency department best practice guidelines for improved communication during patient care transitions.

Basic Procedures

To our knowledge, there are no specific guidelines for communication at the point of transition from the emergency department to the community. In Rhode Island, we used a multistage collaborative quality improvement process to define best practices for emergency department care transitions. We reviewed the medical literature, consensus statements, and materials from national campaigns; gathered preferences from emergency medicine and primary care clinicians; and created guidelines that we vetted with emergency medicine clinicians and other key stakeholders.

Main Findings

Because we did not find any guidelines that globally addressed care transitions from the emergency department, we drew from studies on patient discharge instructions and extrapolated from the evidence base available for other, related settings. Our key outcome is a set of care transition best practices for emergency departments, which can be implemented to establish measurable, communitywide expectations for cross-setting clinician-to-clinician communication. They include obtaining information about patients' outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions.

Principal Conclusions

The best practices provide feasible standards for evaluating and improving how patients transition out of the emergency department and can provide a framework for emergency department leaders expanding their collaboration with community partners, particularly in the context of emerging payment models. They also catalyze introspection and debate about how to improve communication and accountability across the care continuum.     

Closing the safety loop: evaluation of the National Patient Safety Agency's guidance regarding wristband identification of hospital inpatients

Rationale, aims and objectives  Wristbands are essential for accurate patient identification. Some evidence suggests that missing wristbands is not an infrequent occurrence in acute hospitals. The National Patient Safety Agency (NPSA) has developed guidance on patient identification for hospitals in England and Wales. Here we report an evaluation of the uptake of the guidance.
Method  The evaluation was designed as a 'pre–post' intervention survey. Fifty hospitals (response rate 67%) responded to the 'pre-guidance' part and 40 hospitals (response rate 43%) responded to the 'post-guidance' part.
Results  The majority of the hospitals use wristbands to identify inpatients. Fifty-eight per cent of the hospitals in the 'pre-guidance' survey and 50% of them in the 'post-guidance' survey reported not having a patient identification policy before receiving the guidance. Only one hospital reported not having developed such a policy in the 'post-guidance' survey. Ninety-eight per cent of the hospitals reported that their policies are consistent with the guidance. Relevant training to staff is provided in about a quarter of the organizations, both before and after the guidance. Problems in implementing the guidance were reported by 23% of the hospitals, and included difficulties with staff or patient attitudes, or with the guidance itself, or difficulty to identify a lead staff member.
Conclusion  Overall, implementation of NPSA guidance regarding inpatient identification was satisfactory. The reported problems should be taken into account, as they likely apply to a range of patient safety interventions. Limitations of evaluating intervention uptake, rather than efficacy, and relying on self-report are discussed.