## 4 Case Studies
### Glucose Management Protocol Case Study
\begin{table}
\begin{tabular}{c c c} \hline \hline \multicolumn{3}{c}{**Blood Glucose Decreased \(>\) 30\% or Increased**} \\ \hline \multirow{2}{*}{**Blood Glucose (mmol/L)**} & **Insulin Perfusor Setting** & \multirow{2}{*}{**Action**} \\  & **(50 units/50 mL NaCl 0.9\%)** & \\ \hline \(<\)3.5 & stop & act according hypoglycemia protocol \\ \hline
3.5–4.5 & \(-\)1.0 unit/h & check glucose after 30 min \\ \hline
4.5–7.0 & no changes & \\ \hline
7.0–8.8 & +0.5 unit/h & \\ \hline
8.0–9.0 & +1.0 unit/h & \\ \hline
9.0–10 & +1.5 unit/h & \\ \hline
10–15 & +2.0 unit/h & 2 units insulin as bolus \\ \hline \(>\)15 & +3.0 unit/h & 4 units insulin as bolus \\ \hline \multicolumn{3}{c}{**Blood Glucose Decreased \(<\) 30\%**} \\ \hline \multirow{2}{*}{**Blood Glucose (mmol/L)**} & **Insulin Perfusor Setting** & \multirow{2}{*}{**Action**} \\  & **(50 units/50 mL NaCl 0.9\%)** & \\ \hline \(<\)3.5 & stop & act according hypoglycemia protocol \\ \hline
3.5–4.5 & stop, if glucose \(>\) 5 mmol/L then & check glucose every 15 min till \\  & start with half of the last dose & glucose \(>\) 5 mmol/L \\ \hline
4.5–7 & half the dosage & \\ \hline
7–10 & \(-\)1 unit/h & \\ \hline \(>\)10 & no changes & \\ \hline \(<\)3.5 & stop & 50 mL glucose 50\% in 10 min and \\  & & check glucose level \\ \hline \(>\)4.5 (after 1 st glucose bolus) & start with last setting \(-\)1 unit/h & check glucose after 30 min \\ \hline \(<\)4.5 (after 1 st glucose bolus) & keep perfusor stopped & 30 mL glucose 50\% in 10 min and \\  & & check glucose level \\ \hline \(>\)4.5 (after 2 st glucose bolus) & start with last setting \(-\)2 unit/h & \\ \hline \(<\)4.5 (after 2 st glucose bolus) & keep perfusor stopped & 50 mL glucose 50\% in 10 min and \\  & & consult the doctor \\ \hline \end{tabular}
\end{table} 
Table 2: Perfusor adaptation scheme for glucose management protocol used in the study. In ward \(B\), the protocol was still in use, and its physical (paper) version was available in the workplace. All nurses confirmed that they were aware of the protocol and most of them were following the protocol to a large extent. We received data from those two wards \(A\) and \(B\), containing the glucose-management-related activities from years 2014 and 2015. The data included the blood glucose results and changes in the insulin perfusor settings as well as the information regarding insulin and glucose bolus (injections). There were 297 patients in Ward \(A\) and 274 patients in Ward \(B\). The frequency of glucose measurement activity was not stated in the protocol (except for the hypoglycemia case); therefore, we also assessed the compliance regarding the medication dosage, i.e., insulin perfusor settings, insulin bolus and glucose bolus. In order to measure fuzzy compliance levels, the healthcare providers defined clinically accepted and non-accepted deviations by proving two threshold values (completely acceptable deviation and completely unacceptable deviation) for each of the actions (insulin perfusor settings, insulin bolus and glucose bolus) so that a trapezoidal membership function could be defined. Those values are presented in Table 3. The degree of compliance with an activity was defined as the minimal value of compliance with respect to the three medication types. The results of different compliance measures are shown in Table 4. The very low values of the strict compliance for Ward \(B\) were surprising in comparison to the results of the interview, as both the coordinator and nurses believed that they were following the protocol. The fuzzy compliance results are naturally much higher. The fuzzy compliance (average based) [13] of 83% indicated that not all activities are within the acceptable deviation threshold. The newly proposed methods look at the compliance, also taking into account \"per patient\" compliance. In the example, we have used three quantifiers: many (Trap[0.5, 0.7, 1, 1]), most (Trap[0.6, 0.8, 1, 1]), and almost all (Trap[0.8, 0.9, 1, 1]).