Strict versus liberal insulin therapy in the cardiac surgery patient: An evidence-based practice development, implementation and evaluation project.

BACKGROUND: Hyperglycemia post-cardiac surgery is associated with poor clinical outcomes. Recent studies suggest maintaining liberal glycemic control (<180mg/dL) using a continuous insulin infusion (CII) versus strict control achieves optimal outcomes and prevents hypoglycemia. PURPOSE: To develop, implement and evaluate a nurse managed liberal CII protocol. METHODS: Retrospective review of 144 strict CII patient records and 147 liberal CII patient records. RESULTS: Mean blood glucose was 159.8mg/dL (liberal CII) compared to 143.3mg/dL (strict CII) (p≤0.001). No surgical site infections occurred in either group. Mean ICU length of stay was 4.5days (liberal) versus 4.4days (strict) (p=0.74). Two 30-day mortalities occurred for the liberal cohort compared to no deaths in the strict group (p=0.49). Hypoglycemia incidence within 24h after surgery was 0.1% (liberal) compared to 0.3% (strict) compared to (p=0.16). CONCLUSION: Use of a nurse managed liberal CII resulted in similar outcomes with fewer incidents of hypoglycemia.

International Uptake of a Proven Intervention to Reduce Death and Dependency in Acute Stroke: A Cross-Sectional Survey Following the QASC Trial.

BACKGROUND: Uptake of proven interventions requires dedicated resources that may only result in local implementation, thus precluding international practice change. We explored international uptake through online dissemination of the fever, sugar, and swallow (FeSS) protocols from the Quality in Acute Stroke Care (QASC) trial, which showed decreased death and dependency by 15.7% 90-day poststroke. AIMS: To identify: (a) the clinical discipline of healthcare professionals who downloaded the QASC resources; (b) the purpose for downloading; (c) successful implementation of any or all the FeSS protocols; (d) barriers to implementation; and (e) associations with self-reported successful implementation. METHODS: A cross-sectional, online survey of those who downloaded the QASC resources between October 2011 and August 2013. Associations between implementation and participant characteristics were determined. RESULTS: One-hundred and fifty-nine people from 21 countries participated. Nurses were the largest group to download the resources (n = 54, 38%), with the primary purpose to inform clinical practice (n = 97, 64%). Less than half (n = 77, 48%) downloaded, and less than a quarter (n = 38, 24%) attempted to implement all three protocols. Of those personally involved in implementation (n = 50) half reported doing so successfully for one or more protocols (n = 27, 54%) with 10 (20%) reporting successful implementation of all three protocols. Only about half (n = 13, 48%) used the proven implementation strategy with about one-third (n = 10, 29%) confirming successful uptake via audit. Implementation barriers were potential increase in nursing workload (n = 28, 56%) and lack of medical staff engagement (n = 27, 53%). Higher autonomy was associated with greater likelihood of implementation of all three protocols (p = .038). LINKING EVIDENCE TO ACTION: The QASC intervention required use of all three protocols. However, less than half downloaded them all and implementation was not guided by the proven implementation strategy. While encouraging that these resources were being used to drive practice change, piecemeal implementation of a proven intervention is unlikely to improve patient outcomes.

Shift in responsibilities in diabetes care: the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT).

AIMS: To investigate the feasibility, safety and efficacy of the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT), which consists of nurse-driven correctional therapy, in addition to physician-guided basal therapy, and is carried out by trained ward nurses. METHODS: Data on 210 patients with diabetes consecutively admitted in the 5-month period after the introduction of N-DIABIT (intervention group) were compared with the retrospectively collected data on 200 consecutive patients with diabetes admitted in the 5-month period before N-DIABIT was introduced (control group). Additional per-protocol analyses were performed in patients in whom mean patient-based protocol adherence was ≥ 70% (intervention subgroup, n = 173 vs. control subgroup, n = 196). RESULTS: There was no difference between the intervention and the control group in mean blood glucose levels (8.9 ± 0.1 and 9.1 ± 0.2 mmol/l, respectively; P = 0.38), consecutive hyperglycaemic (blood glucose ≥ 10.0 mmol/l) episodes; P = 0.15), admission duration (P = 0.79), mean number of blood glucose measurements (P = 0.21) and incidence of severe hypoglycaemia (P = 0.29). Per-protocol analyses showed significant reductions in mean blood glucose levels and consecutive hypoglycaemia and hyperglycaemia in the intervention compared with the control group. CONCLUSIONS: Implementation of N-DIABIT by trained ward nurses in non-intensive care unit diabetes care is feasible, safe and non-inferior to physician-driven care alone. High protocol adherence was associated with improved glycaemic control.

Low-dose intensive insulin therapy in patients with Acute Coronary Syndrome accompanied by Left Ventricular Failure: audit of two UK hospitals.

AIMS AND OBJECTIVES: To determine whether a low-dose intravenous insulin regimen reduces blood glucose levels at a timely rate and associated side effects among patients with Acute Coronary Syndrome and Left Ventricular Failure. BACKGROUND: Induced hypoglycaemia and the associated risks have questioned the benefits of intensive insulin therapy in patients presenting with raised blood glucose levels and Acute Coronary Syndromes. Local audit data identified that patients with Acute Coronary Syndrome and Left Ventricular Failure experienced more hypoglycaemic episodes than those with Acute Coronary Syndrome alone. Consequently, a new regimen of low-dose insulin for this group was implemented and audited over 12 months. DESIGN: Audit. METHODS: Thirty-six consecutive patient notes with a diagnosis of Acute Coronary Syndrome and blood glucose of ≥10 mmol/l treated with a new insulin therapy regimen were analysed. Data were extracted using a standardised form and entered into an Excel spreadsheet for analysis. RESULTS: The mean age of the sample was 70 years with 66% of subjects being men and 50% presenting with Acute Coronary Syndrome and Left Ventricular Failure. The low-dose regimen was effective in achieving normoglycaemia, (range 4-8 mmol/l) for a consecutive six-hour period. This was achieved in 72% of patients and within a median time of 13 hours. CONCLUSION: The audit suggests that a low-dose insulin regimen can effectively stabilise blood glucose in patients presenting with both Acute Coronary Syndrome and Left Ventricular Failure. The importance of regularly monitoring blood sugar levels is vital and highlights the role of nurses in minimising patient risk and promoting safety. RELEVANCE TO PRACTICE: Nurses are instrumental in the safe implementation of intensive insulin guidelines. Close monitoring of patients is essential, enabling timely adjustments to treatments and ensuring patient safety. Regular audits allow nurses to evaluate care provision and continue to drive practice forward.

Hyperglycemia in the Hospital Setting.

Nurses who understand contributing factors to insulin action and uncontrolled glucose and insulin action can assist in promoting optimal care. Common barriers to glucose control and current best practices in the acute care setting are reviewed.

Assessment and management of the septic patient: part 2.

Sepsis has gained increasing publicity in recent years, and there is now a strong focus of clinical education and training following the Surviving Sepsis Campaign. The assessment and management of a septic patients is far from simple and requires a systematic approach in both identifying and managing the condition. This second part explores sepsis care bundles and the research that underpins each of the interventions. These discussions will enable nurses to understand why each component of the sepsis care bundle is important and thus enable them to rapidly prioritise care, as early effective interventions have been shown to optimise patient outcomes.

Barriers and enablers to implementing clinical treatment protocols for fever, hyperglycaemia, and swallowing dysfunction in the Quality in Acute Stroke Care (QASC) Project--a mixed methods study.

BACKGROUND: The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. AIM: To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. METHODS: Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted. RESULTS: A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial. LINKING EVIDENCE TO ACTION: The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.

Glycemic control in a medical intensive care setting: revision of an intensive care unit nurse-driven hyperglycemia protocol.

The purpose of this study was to determine whether the addition of rapid-acting insulin bolus for enteral feed coverage and a reduction in basal insulin improve glycemic control and decrease hypoglycemia in a medical intensive care unit. A quasi-experimental posttest design assessing glucose control postimplementation of a revised nurse-driven ICU hyperglycemia protocol was conducted on a 16-bed medical intensive care unit at a multicenter hospital system. A daily report of all patients on the ICU hyperglycemia protocol was automated for the inpatient diabetes management team, and pertinent data were collected. Univariate statistics were conducted for all variables. The variability in blood glucose based on different clinical variables was compared using t tests. The hypoglycemic rate was only 0.72%, and no glucose value was less than 40 mg/dL. In addition, the mean glucose value throughout the study was 160.9 ± 35.6 mg/dL. Findings from this study will hopefully provide insight on an effective way to control glucose within a medical intensive care unit as well as reduce hypoglycemia rates within this setting.

Acute ischemic stroke and hyperglycemia.

To increase the comprehension about the profound effects of hyperglycemia within the first 48 hours poststroke on the outcomes of acute ischemic stroke, the authors reviewed multiple studies and literature reviews. Research supports the detrimental effects of hyperglycemia on the morbidity and mortality of patients diagnosed with acute ischemic stroke. The studies that were examined revealed that although further research is necessary, controlling hyperglycemia is overall beneficial to support superior clinical outcomes. The purpose of this article was to discuss the importance of not only glucose control but also the vital role of nurses in controlling glucose levels efficiently and immediately during the first 48 hours poststroke.

Systematic review of randomized controlled trials to regulate glycaemia after stroke.

AIM: This article presents the results of a systematic review of randomized controlled trials on the regulation of glycaemia among adults admitted to hospital with acute stroke. BACKGROUND: Hyperglycaemia is commonly observed in acute stroke. International stroke guidelines recommend that hyperglycaemia is treated after stroke. Nurses have a key role in the monitoring and management of glycaemia. DESIGN: Systematic review. DATA SOURCES: A search for randomized controlled trials was conducted in MEDLINE and PubMed electronic databases, and original papers published between January 1996-June 2011 were identified. The search was performed using the terms 'stroke', 'hyperglycaemia', and 'treatment' combined. Searching of citations from identified studies was also used to supplement electronic searches. The search was limited to adults and English language publications. REVIEW METHODS: A systematic review was conducted for eight studies, meeting the inclusion criteria that: (i) insulin protocols were subjected to randomized controlled trial; and that (ii) only adults admitted to hospital with acute stroke were sampled. The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting standards. RESULTS: Intensive insulin therapy regimes have been investigated in a total of eight trials. Intravenous insulin therapy significantly lowers glucose levels when compared with controls but adherence to glucose monitoring and treatment protocols appeared to pose considerable challenge on nurses in routine stroke care. Trials conducted to date have been on poor to sound quality. CONCLUSION: There is currently no substantive evidence to support aggressive glucose lowering in the acute phase of stroke. Well-conducted, large randomized controlled trials are required.

Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial.

BACKGROUND: We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). METHODS: In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. FINDINGS: 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8-25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2-5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). INTERPRETATION: Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. FUNDING: National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

Nurse workload in implementing a tight glycaemic control protocol in a UK hospital: a pilot time-in-motion study.

AIMS AND OBJECTIVES: The cumulative time that critical care nurses spend implementing a tight glycaemic control (TGC) protocol was estimated in a time-in-motion (TiM) study conducted in a hospital in the UK. BACKGROUND: TGC protocols were introduced to the critical care setting to reduce hyperglycaemic events in high-risk patients. The time burden to critical care nurses of implementing such protocols has not yet been studied in the UK. DESIGN: A prospective TiM pilot study was conducted in an eligible UK intensive care unit by four protocol-trained observers over five consecutive weekdays from 3 to 7 November 2008. Three nurses were also interviewed on site to gather their attitudes and perceptions about the benefits of and time associated with administering a TGC protocol. METHODS: Independent observers shadowed nurses, observing when a blood glucose measurement was taken, when each predefined subtask was completed and the duration of each task. Semistructured interviews with nurses were conducted in-person and one-on-one by a trained study member. RESULTS: Considered together, the episodic median duration of all TGC activities was 6·65 min. Across a total shift, nurses devoted approximately 7% of their time to administering a TGC protocol. Nurses perceived that a TGC protocol is beneficial to patient safety and outcomes in a critical care setting but acknowledged that the tasks can be mildly to moderately tedious. CONCLUSIONS: This TiM analysis indicated that the additional responsibility of implementing a TGC protocol represents a substantive commitment of nursing time in a critical care setting. RELEVANCE TO CLINICAL PRACTICE: The episodic data of our pilot study in the UK contributes further evidence that TGC protocols may be arduous to maintain and constitute a substantial investment of nursing time.

[Effectiveness and safety of goal directed nurse-led blood glucose control in an intensive care unit: a prospective observational study]. / Eficacia y seguridad del control de glucemia guiado por objetivo y dirigido por el personal de enfermería en una unidad de cuidados intensivos: un estudio prospectivo observacional.

OBJECTIVE: to evaluate the effectiveness and safety of a nurse-led blood glucose control protocol in a medical ICU. METHOD: a descriptive, prospective study was carried out for a period of 13 months. All blood glucose values from patients on insulin therapy for intensive glycemic control were recorded daily. RESULTS: A total of 12,677 blood glucose determinations were performed on the 69 patients under glycemic control; 57.9% of the determinations had predetermined study target values for blood glucose (100-140 mg/dl) and 68.8% of the determinations had physiological blood glucose values (80-140 mg/dl); no values under 40 mg/dl were obtained, and only 0.2% were between 40-60 mg/dl. CONCLUSIONS: For an adequate blood glucose control using intensive insulin therapy, individual management of insulin infusion regimen is essential, adjusted to the characteristics of each patient. A nurse-led intervention has allowed better results to be obtained in comparison with other studies in which different protocols for insulin infusion are used.

Reflections on reducing insulin to lose weigh.

Diabulimia is not a recognised medical condition, although it is thought to affect one-third of women with type 1 diabetes. Diabulimia involves deliberately omitting or reducing insulin dosages to lose weight. This article reports the reflections of women with long-duration type 1 diabetes who said that they had manipulated their insulin in the past to lose weight. Many were now dealing with serious heart and neuropathic complications, which they felt were a result of their diabulimia.

Influence of Optimal Management of Hyperglycemia and Intensive Nursing on Blood Glucose Control Level and Complications in Patients with Postoperative Cerebral Hemorrhage.

Background: Cerebral hemorrhage, also known as hemorrhagic stroke, is a common clinical cerebrovascular disease, accounting for about 10%-30% of stroke, with high morbidity and mortality. Objective: To observe the effect of optimal management of hyperglycemia and intensive nursing on blood glucose control level and complications in patients with postoperative cerebral hemorrhage. Methods: One hundred and eight patients with postoperative cerebral hemorrhage comorbid with stress hyperglycemia admitted to our neurosurgery department from February 2019 to February 2022 were selected and divided into a general group of 54 cases and an optimized group of 54 cases by simple random method. The general group was managed with conventional care, while the optimized group developed optimized management of hyperglycemia for intensive care. The indexes related to blood glucose control, electrolytes, National Institutes of Health Stroke Scale (NIHSS) scores, Barthel Index (BI) scores, and time to achieve blood glucose standard, insulin pumping time, patient satisfaction, and prognosis were compared between the two groups. Results: Before intervention, there was no statistical significance in the comparison of blood glucose control-related indicators and electrolytes between the two groups (P > 0.05). After 7 d and 14 d of intervention, the fasting blood glucose and 2 h postprandial blood glucose in the two groups were lower than before, while K+ and Na+ were higher than before (P < 0.05). The blood glucose indexes at the same time point in the optimized group were found to be lower than those in the general group by statistical analysis, but electrolytes were not statistically significant when compared with the general group (P > 0.05). In the optimized group, the time to achieve blood glucose standard (6.59 ± 1.94) d and insulin pumping time (7.14 ± 1.89) d were shorter than those in the general group [(7.48 ± 2.12) d and (8.58 ± 2.14) d], insulin dosage (748.85 ± 63.61) U was less than that in the general group (923.54 ± 84.14) U, and the incidence of hypoglycemia (3.70%) was lower than that in the general group (16.67%), and the satisfaction rate (92.59%) was higher than that of the general group (77.78%), which was statistically significant (P < 0.05). Before intervention, there was no significant difference in NIHSS score and BI score between the two groups (P > 0.05). After 7 d and 14 d of intervention, the NIHSS scores of the two groups were lower than before, while the BI scores were higher than before, and the NIHSS scores of the optimized group at the same time point were all lower than those of the general group, and the BI scores were higher than those of the general group (P < 0.05). The incidence of pulmonary infection (11.11%) and rebleeding (7.41%) in the optimized group were lower than those in the general group (25.93% and 22.22%), while deep vein thrombosis, multiple organ dysfunction syndrome (MODS), and death within 28 d was not statistically significant when compared with the general group (P > 0.05). Conclusion: Optimal management of hyperglycemia and intensive nursing can effectively control the blood sugar level of patients after cerebral hemorrhage, reducing insulin dosage, and the occurrence of hypoglycemia, pulmonary infection, and rebleeding.

Case discussion in blood glucose variability.

Stress-induced hyperglycemia has been associated with poor outcomes and death in critically ill patients. Blood glucose (BG) variability, a component of stress-related hyperglycemia has recently been reported as a significant independent predictor of intensive care unit and hospital mortality. We sought to evaluate three cases in which intensive insulin therapy was administered using a standardized insulin dosing protocol to normalize the BG and reduce glycemic variability. Point-of-care BG values and other clinical measures were obtained from the medical record of three patients who received intensive insulin therapy. This was a convenience sample of three patients where the BG level had stabilized on a consistent intravenous insulin dose rate for up to 20 hours in a surgical trauma intensive care unit. Data were collected manually and electronically using the Remote Automated Laboratory System-Tight Glycemic Control Module (RALS-TGCM) BG management and monitoring system. Each case presentation describes a critically ill, nondiabetic patient, requiring continuous intravenous insulin therapy for hyperglycemia. In each instance, BG variability was present in a worsening patient condition after a period of normalization of hyperglycemia with intensive insulin therapy. Although decreasing BG variability is an important aspect of hyperglycemia management, new onset events of variability may be a sentinel warning or occur as a physiologic response to a worsening patient condition. If so, these events warrant rapid investigation and treatment of the underlying problem.

Addressing Hospital-Acquired Hypoglycemia.

BACKGROUND: Hospitalized patients who have diabetes often experience hospital-acquired hypoglycemia, a potentially serious adverse event; as a result, management of this condition has become an important quality of care indicator in the inpatient environment. A growing body of research and evidence-based clinical guidelines support proper timing of point of care (POC) blood glucose (BG) measurements, mealtime insulin administration, and meal delivery to reduce the incidence of both hypoglycemic and hyperglycemic events. Monitoring and improving the timing of these three patient care interventions are recognized as a crucial step in the safe and effective care of patients with diabetes. PURPOSE: The objective of the QI project was to improve the timing of mealtime insulin administration related to bedside BG monitoring and meal delivery for patients with diabetes who receive mealtime insulin; a secondary goal was to decrease the number of episodes of recurrent hypoglycemia. The overall strategy was to change staff members' approach to mealtime insulin management from a series of individual tasks to a process-oriented collaborative approach. METHODS: Nurses on the medical-surgical unit at one hospital within a large health system formed a QI team with staff members in information technology and food and nutrition services. The team implemented an eight-week QI pilot project (July 3 to August 26, 2017) using a multidisciplinary approach to coordinate between POC BG measurement, mealtime insulin administration, and meal delivery. RESULTS: More than two years after the hospital-wide rollout of the practice change, follow-up analysis has shown that, on both noncritical and critical care units, recurrent hypoglycemia has decreased. For example, comparing data obtained in a six-month period before the pilot project (November 2016 through April 2017) with the same six-month period in 2018 and 2019, more than a year after the pilot project, the percentage of patient stays (admissions) on noncritical care units in which there was a recurrence of hypoglycemia fell from 41.8% (of 1,162 total hospital admissions) to 35.1% (of 792 total hospital admissions); similarly, the percentage of patient stays on critical care units in which recurrent hypoglycemia occurred decreased from 36.8% to 22.8%. CONCLUSIONS: Findings suggest that ensuring a consistent 30-minute window between POC BG measurement and meal delivery enabled nursing staff to perform timely POC BG measurements and administer a more optimal mealtime insulin dose. Increasing interdisciplinary communication, collaboration, and awareness of best practice guidelines relating to proper mealtime insulin administration resulted in a sustained improvement in timing between POC BG measurements and mealtime insulin administration and between mealtime insulin administration and meal delivery.

Factors contributing to poor glycaemic control in diabetic patients at Mopani District.

Diabetes mellitus is not only a major burden in the developed world, it is also an increasing health problem in less developed countries. Although health education could be a tool to achieve better glycaemic control, it is important to understand that health education should be adjusted to patients' literacy, cultural environment and economic status. Among other factors, lack of money has an influence on the outcome of diabetes mellitus. Thus the purpose of the study is to identify factors contributing to poor glycaemia control in diabetic patients. Data was collected using self-report questionnaire on a convenient sample of 32 diabetic patients and unstructured, open-ended interviews on eight patients' in order to allow them freedom of expressing themselves with regard to factors that contribute to poor glycaemic control on diabetic patients. Data was then analysed using a computer program called Statistical Package for Social Sciences. The socioeconomic factors appeared to have significant influence on glycaemic control among participants, for instance 75% of the total subjects (32) indicated that they experienced problems of accessing health care services due to lack of money. Ignorance related to where to seek support system such as educational programme, and nutrition counselling were factors that were identified to contribute to diabetic patients' poor glycaemia control. Permission to conduct the study was obtained from the Provincial Department of Health and the managers of the institutions where the study was conducted. Recommendations for dealing with the identified factors have been formulated.

Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant. / Implantación de un programa para el manejo de la hiperglucemia en la hospitalización con la incorporación de la enfermera consultora.

BACKGROUND AND AIMS: The efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. MATERIAL AND METHODS: Evaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation. The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. RESULTS: The proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P<0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164±41mg/L vs. 196±50mg/dL, P<0.001). After implementation, there were less patients with blood glucose levels >300mg/dL (36.3% vs. 50.5%, P<0.001) and more patients with values <70mg/dL (15% vs. 9%, P=0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P=0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. CONCLUSIONS: Incorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach.

AIMS: A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal-bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery. METHODS: Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal-bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score. RESULT: Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76] and of systemic infections (OR 0.18; 95% CI 0.07-0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis. CONCLUSIONS: The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.