Preliminary Experience with Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers: Safety, Efficacy, and Economic Analysis.
Schumer Ross A,Guetschow Brian L,Ripoli Marissa V,Phisitkul Phinit,Gardner Sue E,Femino John E
The Iowa orthopaedic journal
Background:Treatment of diabetes costs the United States an estimated $245 billion annually; one-third of which is related to the treatment of diabetic foot ulcers (DFUs). We present a safe, efficacious, and economically prudent model for the outpatient treatment of uncomplicated DFUs. Methods:77 patients (mean age = 54 years, range 31 to 83) with uncomplicated DFUs prospectively enrolled from September 2008 through February 2012. All patients received an initial sharp debridement by one of two orthopaedic foot and ankle fellowship trained surgeons. Ulcer dressings, offloading devices, and debridement procedures were standardized. Patients were evaluated every two weeks by research nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results:Average time to clinical healing was 6.0 weeks. There were no complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. The estimated cost savings in this model by having nurses perform CSWD was $223.26 per encounter, which, when extrapolated to national estimates, amounts to $1.56 billion to $2.49 billion in potential annual savings across six to ten-week treatment periods, respectively. Conclusion:CSWD of DFUs by nurses in a vertically integrated multidisciplinary team is a safe, effective, and fiscally responsible clinical practice. This clinical model on a national scale could result in significant healthcare savings. Surgeons and other licensed independent practitioners would have more time for evaluating and treating more complex and operative patients; nurses would be practicing closer to the full extent of their education and training as allowed in most states..
Effects of a Tailored Exercise Intervention in Acutely Hospitalized Oldest Old Diabetic Adults: An Ancillary Analysis.
Martínez-Velilla Nicolás,Valenzuela Pedro L,Sáez de Asteasu Mikel L,Zambom-Ferraresi Fabricio,Ramírez-Vélez Robinson,García-Hermoso Antonio,Librero-López Julian,Gorricho Javier,Pérez Federico Esparza,Lucia Alejandro,Izquierdo Mikel
The Journal of clinical endocrinology and metabolism
OBJECTIVE:To analyze the effects of a tailored exercise intervention in acutely hospitalized elderly diabetic patients. RESEARCH DESIGN AND METHODS:This is an ancillary analysis of a randomized controlled trial (RCT). A total of 103 acutely hospitalized elderly adults (mean age ~87 years) with type II diabetes were randomized to an intervention (exercise, n = 54) or control group (usual care, n = 49). The primary endpoint was change in functional status from baseline to hospital discharge as assessed with the Barthel Index and the Short Physical Performance Battery (SPPB). Secondary endpoints comprised cognitive function and mood status, quality of life (QoL), incidence of delirium, and handgrip strength. Exercise-related side effects, length of hospital stay, and incidence of falls during hospitalization were also assessed, as well as transfer to nursing homes, hospital readmission, and mortality during a 3-month follow-up. RESULTS:The median length of stay was 8 days (interquartile range, 4) for both groups. The intervention was safe and provided significant benefits over usual care on SPPB (2.7 [95% confidence interval (CI) 1.8, 3.5]) and Barthel Index (8.5 [95% CI: 3.9, 13.1]), as well as on other secondary endpoints such as cognitive status, depression, QoL, and handgrip strength (all P < 0.05). No significant between-group differences were found for the remainder of secondary endpoints. CONCLUSIONS:An in-hospital individualized multicomponent exercise intervention was safe and effective for the prevention of functional and cognitive decline in acutely hospitalized elderly diabetic patients, although it had no influence on other endpoints assessed during hospitalization or at the 3-month follow-up after discharge.
10.1210/clinem/dgaa809
Adult Patient Perspectives on Care for Type 1 and Type 2 Diabetes Across the Institute of Medicine's 6 Domains of Quality.
Halperin Ilana J,Mukerji Geetha,Maione Maria,Segal Phil,Wolfs Maria,Goguen Jeanette,Jeffs Lianne
Canadian journal of diabetes
OBJECTIVES:To gather patient perspectives on quality of care provided in diabetes clinics within the framework of the Institute of Medicine's 6 domains of quality. METHODS:A qualitative study including semi-structured interviews was conducted at 5 academic hospital sites. Transcripts were analyzed using a direct content approach for themes and subthemes with saturation of themes achieved. Purposive sampling was conducted at 5 diabetes clinics (n=47 interviews). RESULTS:The median age of participants was 50 years with a mean duration of diabetes of 14 years; 53% of participants were male, 57% had type 2 diabetes and 81% were using insulin. Patients ranked safety as the most important Institute of Medicine domain, followed by the domains effective, patient-centred, timely, equitable and efficient. Their expectations spanned the first 4 Institute of Medicine domains. They expressed a desire for a knowledgeable, caring, available and communicative team that assist with self-management and overall control of diabetes (effective, patient-centred and timely). They wanted to avoid diabetes complications, including hypoglycemia (safe and effective). They wanted to share in care planning and achieve personalized goals (patient-centred). Efficient and equitable care were not prioritized as highly, but many patients expressed concerns about the costs of medications and insulin supplies. CONCLUSION:Patients' views of high-quality diabetes care include all 6 domains of quality with a stronger emphasis on safe, effective and patient-centred care. Future evaluation of diabetes programs should incorporate a comprehensive and patient-informed approach to consideration of what constitutes high-quality care.
10.1016/j.jcjd.2017.03.005
Current perspectives on the use of continuous subcutaneous insulin infusion in the acute care setting and overview of therapy.
Lee Scott W,Im Richard,Magbual Richard
Critical care nursing quarterly
Continuous subcutaneous insulin infusion (CSII), also called the insulin pump, has emerged as a safe and effective therapy in the last 20 years. Utilization of CSII in several studies has shown reductions in hypoglycemia and improvement in glycemic control compared with multiple daily injections. Diabetes mellitus is often a comorbid condition in patients requiring critical care. Surprisingly, there exist no guidelines for use of CSII in the inpatient setting, and no tested protocols for management of CSII in the hospital. With solid evidence as to the benefits of this therapy in diabetes and the heightened attention to the importance of optimal inpatient glycemic control, guidelines and tested protocols for CSII use during hospitalization are warranted. We share our own guidelines for the inpatient management of the insulin pump which has allowed our hospital to address the unique challenges that pump users present with during acute illness. A general overview of the insulin pump's history, rationale for use, patient selection, and implementation is also discussed.
10.1097/00002727-200404000-00009
Metabolic control, healthcare satisfaction and costs 1 month after diagnosis of type 1 diabetes: a randomised controlled trial of hospital-based care vs. hospital-based home care.
Tiberg Irén,Carlsson Katarina Steen,Carlsson Annelie,Hallström Inger
Pediatric diabetes
Procedures for the initial management of children newly diagnosed with diabetes vary greatly worldwide and the evidence available is insufficient for conclusively determining the best process regarding hospital-based or home-based care. The aim of the study was to compare two different regimens for children with newly diagnosed type 1 diabetes; hospital-based care and hospital-based home care (HBHC), defined as specialist care in a home-based setting. A randomised controlled trial, including 60 children, took place at a university hospital in Sweden during the period of March 2008 to September 2011. After 2-3 d with hospital-based care, children from 3 to 15 yr of age were randomised to either continued hospital-based care for a total of 1-2 wk or to HBHC. This article presents results 1 month after diagnosis. No differences were shown in the daily mean glucose level or in its variability when the children received care but, after discharge, children who received HBHC showed lower mean plasma glucose values and lower variability compared to children who received hospital-based care. Children in HBHC had fewer episodes of hypoglycaemia during the first month after diagnosis. In the HBHC group, parents were more satisfied with the healthcare received and healthcare costs for the first month were 30% lower as compared to hospital-based care. The results 1 month after diagnosis support the HBHC programme as being a safe and cost-effective way of providing care. A follow-up will continue for 2 yr to evaluate which process was best for the majority of families over time.
10.1111/j.1399-5448.2012.00879.x
"How we do it": A qualitative study of strategies for adopting an exercise routine while living with type 1 diabetes.
Frontiers in endocrinology
Introduction:For people living with type 1 diabetes (T1D) the challenge of increasing daily physical activity (PA) is compounded by the increased risks of hypoglycemia and glucose variability. Little information exists on the lived experience of overcoming these barriers and adopting and maintaining an active lifestyle while living with T1D. Research Design and Methods:We conducted a patient-led qualitative study consisting of semi-structured interviews or focus groups with 22 individuals at least 16 years old living with T1D. We used existing patient co-researcher networks and snowball sampling to obtain a sample of individuals who reported being regularly physically active and had been diagnosed with T1D for at least one year. We used an interpretive description analysis to generate themes and strategies associated with maintaining an active lifestyle while living with T1D. We involved patient co-researchers in study design, data collection, and interpretation. Results:14 self-identified women and 8 self-identified men (ages 19-62, median age 32 years) completed the study, led by either a researcher, or a patient co-researcher and research assistant regarding their strategies for maintaining an active lifestyle. We identified five themes that facilitate regular sustained PA: (1) Structure and organization are important to adopt safe PA in daily life "I can't do spontaneous exercise. I actually need a couple hours of warning minimum"; (2) Trial and error to learn how their body responds to PA and food "Once you put the time and effort into learning, you will have greater success"; (3) Psychosocial aspects of PA "…because it's not just your body, it's your soul, it's your mind that exercise is for"; (4) Diabetes technology and (5) Education and peer support. Strategies to overcome barriers included (1) Technology; (2) Integrating psychosocial facilitators; (3) Insulin and carbohydrate adjustments; and (4) Planning for exercise. Conclusions:Living an active lifestyle with T1D is facilitated by dedicated structure and organization of routines, accepting the need for trial and error to understand the personalized glycemic responses to PA and careful use of food to prevent hypoglycemia. These themes could inform clinical practice guidelines or future trials that include PA interventions.
10.3389/fendo.2022.1063859
Whatever happened to foot care? Preventing amputations in patients with end stage renal disease.
Richbourg M J
EDTNA/ERCA journal (English ed.)
Lower extremity amputations in patients with diabetes are largely preventable through proper foot hygiene, routine foot surveillance, and patient education about proper foot care. Diabetics with end stage renal disease are at especially high risk for foot complications, but nephrology nursing has been largely silent about the importance of diabetic foot care. This article discusses the diabetic pathophysiology underlying the development of most foot complications and outlines the basic principles of safe and effective foot care.
An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting.
Rousseau Marie-Pierre,Beauchesne Marie-France,Naud Alex-Sandra,Leblond Julie,Cossette Benoît,Lanthier Luc,Grondin Frédéric,Bernier Frédéric
Canadian journal of diabetes
OBJECTIVE:Insulin is regularly used in hospitalized patients for glycemic control but is associated with significant risks. The goals of this study were to describe the strengths and weaknesses of a university health centre in the safe use of insulin, to collect improvement proposals from health professionals involved in the management of insulin therapy and to assess inpatient glycemic control. METHODS:This is a qualitative study. Physicians, nurses and pharmacists practising at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) for at least 2 years were invited to join focus groups on safe insulin treatment. Themes up for discussion were roles of professionals in insulin therapy, problems encountered, solutions put forward and strengths of the hospital. The Quality Hyperglycemia Score (QHS) was assessed using an existing cohort of inpatients who were prescribed insulin. RESULTS:A total of 5 focus groups were held in February and March of 2012, involving 31 healthcare professional participants. Several groups pointed out the same problems, namely, lack of access to useful information for optimal management of insulin therapy and lack of communication among personnel on different work shifts. Results of the QHS suggest room for improvement in blood glucose control at our institution. CONCLUSION:These focus groups allowed better identification of the management problems related to the use of insulin in our health institution and possible interventions to solve them. The QHS will be reassessed to measure quality of inpatient glycemic control over time.
10.1016/j.jcjd.2014.01.013
Preventing amputations in patients with end stage renal disease: whatever happened to foot care?
Richbourg M J
ANNA journal
Lower extremity amputations in patients with diabetes are largely preventable through proper foot hygiene, routine foot surveillance, and patient education about proper foot care. Diabetics with end stage renal disease are at especially high risk for foot complications, but nephrology nursing has been largely silent about the importance of diabetic foot care. This article discusses the diabetic pathophysiology underlying the development of most foot complications and outlines the basic principles of safe and effective foot care.
Reducing Diabetic Ketoacidosis Readmissions with a Hospital-School-Based Improvement Partnership.
American journal of medical quality : the official journal of the American College of Medical Quality
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in pediatric type 1 diabetes mellitus (T1D). Baseline data showed 139 of 182 DKA readmissions (76.4%) were due to missed basal insulin dosing. The team used quality improvement tools to implement a process change around basal insulin. The project utilized insulin degludec and school-based nurses when missed basal insulin was noted as a main driver for readmission. The DKA readmission rate averaged 5.25 per month from January 2017 to April 2019. The rate decreased to 3.64 per month during the intervention from May 2019 to March 2020, a 31% reduction over 11 months. This standardized approach for patients with T1D readmitted with DKA, using a school-based intervention and insulin degludec, reduced the number of DKA readmissions. This method is safe and effective for lowering DKA readmissions due to missed basal insulin in areas with reliable school nursing.
10.1097/JMQ.0000000000000115
Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial.
Journal of the American Medical Directors Association
OBJECTIVES:To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF). DESIGN:Prospective randomized clinical trial. SETTINGS AND PARTICIPANTS:Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF. METHODS:Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups. RESULTS:Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups. CONCLUSIONS AND IMPLICATIONS:The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.
10.1016/j.jamda.2024.01.031
Effect of Gua Sha therapy on patients with diabetic peripheral neuropathy: A randomized controlled trial.
Xie Xiaolan,Lu Liqiong,Zhou Xiaoping,Zhong Caitang,Ge Guo,Huang Huie,Zhang Xiaoming,Zeng Yingchun
Complementary therapies in clinical practice
OBJECTIVE:To examine the effect of Gua Sha therapy in the treatment of diabetic peripheral neuropathy (DNP). DESIGN:An open-label randomized controlled study was conducted with usual care as the control (60 subjects in Gua Sha group and 59 subjects in usual care group). Outcome measures included Toronto Clinical Scoring System (TCSS), Vibration Perception Threshold (VPT), Ankle Brachial Index (ABI), and fasting plasma glucose (FPG). There were 12 consecutive sessions of Gua Sha, one session per week. RESULTS:After the first cycle of Gua Sha intervention, only performance of sensory function measured by the VPT, and peripheral artery disease symptoms by the ABI were statistically significant differences between the two groups (both P values < 0.01), and the total TCSS score and the FPG level were no group differences (P = 0.14, and 0.25, respectively). At the eight-week and 12-week post intervention assessment, Gua Sha therapy significantly reduced severity of neuropathy symptoms, improved performance of sensory function, reduced peripheral artery disease, and better controlled plasma glucose by comparing with the control group (all P values < 0.01). The changes of mean scores of TCSS, VPT, ABI and the plasma glucose levels in the Gua Sha group showed a significant change from baseline to week 12, indicating that Gua Sha therapy induced progressive improvement in the management of DPN symptoms, sensory function, peripheral artery disease and glucose levels. No serious adverse events were reported in either arm. Gua Sha therapy in this study was effective, safe and well tolerated by patients. CONCLUSION:Gua Sha therapy appears to be effective at reducing the severity of DPN in a clinically relevant dimension, and at improving other health outcomes in patients with DPN. While this study found that Gua Sha therapy is a promising treatment in reducing the symptoms of patients with DPN, further, larger sample studies are required to confirm the effects of Gua Sha therapy in patients with DPN.
10.1016/j.ctcp.2019.03.018
Tuina for diabetes with obesity: Protocol for a systematic review and meta-analysis.
Medicine
BACKGROUND:Obesity is an independent risk factor for the occurrence and development of diabetes. Patients with diabetes combined with obesity will face serious burdens such as increase in insulin resistance and difficulty in blood glucose control. As a safe, effective, economical, and simple intervention, Tuina is more acceptable to the public than drugs. The objective of this systematic evaluation and meta-analysis is to evaluate the efficacy and safety of Tuina for diabetes with obesity. METHODS:We will search the following electronic databases: PubMed, Embase, Cochrane Library, Web of science, Chinese National Knowledge Infrastructure (CNKI), Sino Med, Wanfang, Chinese Clinical Trial Registry System, China Biomedical Literature Database (CBM). The time limit for retrieving studies is from establishment to November 2020 for each database. Randomized controlled clinical trials related to Tuina intervention on diabetes with obesity will be included. Data synthesis, sensitivity analysis, subgroup analysis as well as the assessment of bias risk will be conducted by using Stata V.13.0 and Review manager 5.3 software. RESULTS:This study will provide a quantitative and standardized evaluation for the efficacy of Tuina therapy on diabetes with obesity. CONCLUSION:This systematic review and meta-analysis will provide the high-quality evidence of whether Tuina is an effective intervention for diabetes with obesity. REGISTRATION NUMBER:INPLASY2020110106.
10.1097/MD.0000000000023918
Impact of Video Technology on the Comprehension of Patients With First Insulin Injection and the Efficiency of Nurse Education.
Zhu Jing,Shao Le-Wen,Yuan Jing-Yun,Zhu Liang,Chen Can-Hua,Hu Xin-Mei
Clinical nursing research
This study aims to compare the effectiveness of video and paper materials used for teach-back education on the first insulin injection for patients with diabetes. The study enrolled 110 patients hospitalized for diabetes who had received education on their first insulin injection in the endocrinology department. The patients were divided into an intervention group ( = 55) and a control group ( = 55) using convenience sampling. Video materials were employed for the teach-back education of the intervention group, while paper materials were employed for the teach-back education of the control group. We compared cases who answered correctly to the common parts (selection and management of injection devices, selection and rotation of injection sites, proper use of injection angles and pinching, insulin storage, injection-related complications and their prevention, selection of the correct needle length, and safe disposal of needles after use) for the first time, the number of educational sessions and total education duration between the two groups and employed the "" questionnaire to survey the two groups before and 28 days after the intervention. The intervention group had a shorter total education duration than the control group, a difference that was statistically significant ( < .001). The intervention group had more advantages over the control group in terms of rotation education at the injection site ( < .05). There was no statistically significant difference in the questionnaire scores between the two groups after the intervention ( > .05); however, both groups scored significantly higher than before the intervention, a difference that was statistically significant ( < .001). The teach-back method combined with video materials applied for educating patients on their first insulin injection could reduce the education duration by healthcare providers and improve the patients' psychological insulin resistance. The key to successfully teaching patients to self-administer insulin, and allowing them to master the steps involved, is to focus on "why" rather than "what" to do.
10.1177/10547738211036600
An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety.
Pasala Satish,Dendy Jared A,Chockalingam Vijayaratna,Meadows Renee Y
The Ochsner journal
BACKGROUND:Hypoglycemia is a major and preventable cause of morbidity and mortality in the hospital setting. Prevention of hypoglycemia in hospitalized patients relates to the practice climates and prescribing patterns of physicians, the development of safe and effective protocols, and the education of providers and nursing staff on hypoglycemia and its consequences. METHODS:Many hospitals use multidisciplinary committees to address issues of healthcare quality and patient safety. This article describes the creation of a subspecialty Hypoglycemia Committee, its design and function, and the steps taken to reduce hypoglycemia in a large, tertiary acute care hospital. RESULTS:The committee's initiatives included a systematic investigation of all severe hypoglycemic events, the development of a standalone hypoglycemia treatment protocol, reduction of sliding scale insulin therapy, revision of insulin order sets, and education of physicians and house staff. Hypoglycemic events have consequently decreased. CONCLUSION:The Hypoglycemia Committee is unique in that every case of severe hypoglycemia is reviewed by physicians, endocrinologists, and diabetes specialists. This multidisciplinary approach can effect measurable decreases in preventable hypoglycemic events.
Classification of Support Needs for Elderly Outpatients with Diabetes Who Live Alone.
Miyawaki Yoshiko,Shimizu Yasuko,Seto Natsuko
Canadian journal of diabetes
OBJECTIVES:To investigate the support needs of elderly patients with diabetes and to classify elderly patients with diabetes living alone on the basis of support needs. METHODS:Support needs were derived from a literature review of relevant journals and interviews of outpatients as well as expert nurses in the field of diabetes to prepare a 45-item questionnaire. Each item was analyzed on a 4-point Likert scale. The study included 634 elderly patients with diabetes who were recruited from 3 hospitals in Japan. Exploratory factor analysis was performed to determine the underlying structure of support needs, followed by hierarchical cluster analysis to clarify the characteristics of patients living alone (n=104) who had common support needs. RESULTS:Exploratory factor analysis suggested a 5-factor solution with 23 items: (1) hope for class and gatherings, (2) hope for personal advice including emergency response, (3) supportlessness and hopelessness, (4) barriers to food preparation, (5) hope of safe medical therapy. The hierarchical cluster analysis of subjects yielded 7 clusters, including a no special-support needs group, a collective support group, a self-care support group, a personal-support focus group, a life-support group, a food-preparation support group and a healthcare-environment support group. CONCLUSIONS:The support needs of elderly patients with diabetes who live alone can be divided into 2 categories: life and self-care support. Implementation of these categories in outpatient-management programs in which contact time with patients is limited is important in the overall management of elderly patients with diabetes who are living alone.
10.1016/j.jcjd.2015.09.005
Safety and feasibility of oral carbohydrate consumption before cesarean delivery on patients with gestational diabetes mellitus: A parallel, randomized controlled trial.
Liu Ningning,Jin Ying,Wang XiaoJuan,Xiang Zhenzhen,Zhang Le,Feng Suwen
The journal of obstetrics and gynaecology research
AIM:To investigate the safety and feasibility of taking low-concentration carbohydrate solution at 2 h before induction of anesthesia for gestational diabetes mellitus (GDM) patients. METHODS:GDM patients undergoing cesarean section were randomly assigned to experimental group (n = 43) and control group (n = 42). Two hours before induction of anesthesia, participants in experimental group orally received 300 mL low-concentration carbohydrate solution, while those in control group received equivalent warm water. Blood glucose and serum insulin were measured at 2 h before induction of anesthesia, right before induction of anesthesia, and the morning of postoperative day 1. Neonatal blood glucose level was monitored at birth. Maternal gastrointestinal function and well-being were assessed perioperatively. RESULTS:The levels of blood glucose and serum insulin right before induction of anesthesia in the experimental group were significantly higher than those in the control group. There were four cases with hypoglycemia in the experimental group and 19 cases in the control group right before induction of anesthesia (9.3% vs 45.2%, p < 0.001). The incidence of neonatal hypoglycemia was 2.3% in the experimental group and 7.1% in the control group with no significance. Hunger score of the participants between the two groups right before induction of anesthesia was significantly different. No aspiration, nausea, and vomiting occurred in both groups before, during, and after surgery. No significant difference was found in the time to the first flatus and abdominal distension between the two groups. CONCLUSION:Taking low-concentration carbohydrate solution is safe and feasible for patients with GDM undergoing elective cesarean section.
10.1111/jog.14653
A Nurse Practitioner-Led Multidisciplinary Diabetes Clinic for Adult Patients Discharged From Hospital.
Roschkov Sylvia,Chik Constance L
Canadian journal of diabetes
OBJECTIVES:In this study, we evaluated the feasibility of a nurse practitioner-led outpatient clinic (NPC) to facilitate the safe transition of patients with diabetes receiving insulin therapy between hospital and the community. METHODS:An NPC was set up to manage patients who had diabetes education in hospital and who were discharged on insulin. In addition to patient demographics and admission diagnosis, days seen postdischarge, duration of follow up, diabetes interventions and discharge care plan were recorded. For quality improvement, patients were asked to complete a questionnaire at the time of discharge from the NPC. RESULTS:Within a 12-month period, 71 patients with diabetes attended the NPC 3 to 21 days after discharge and they were followed for 1 to 98 days. Thirteen patients required management of hypoglycemia and 56 patients had adjustment of medications to basal/prandial insulin or switched to oral antihyperglycemic agents. Fifty-four patients were returned to the care of their family physicians and 18 patients required a referral to a diabetes specialist. A postclinic questionnaire indicated that the clinic enabled patients to improve management of their diabetes. However, communication of the diabetes management plan to the family physician was an identified concern. CONCLUSIONS:An NPC clinic can provide timely management and is a viable option to ensure safe transition of patients with diabetes from hospital back to their family physicians.
10.1016/j.jcjd.2020.10.016
DPP4 inhibitors and cardiovascular outcomes: safety on heart failure.
Xia Chang,Goud Aditya,D'Souza Jason,Dahagam CHanukya,Rao Xiaoquan,Rajagopalan Sanjay,Zhong Jixin
Heart failure reviews
Diabetes is an important risk factor for cardiovascular disease. However, clinical data suggests intensive glycemic control significantly increase rather than decrease cardiovascular mortality, which is largely due to the fact that a majority of oral anti-diabetic drugs have adverse cardiovascular effect. There are several large-scale clinical trials evaluating the cardiovascular safety of DPP4 inhibitors, a novel class of oral anti-diabetic medications, which have been recently completed. They were proven to be safe with regard to cardiovascular outcomes. However, concerns on the safety of heart failure have been raised as the SAVOR-TIMI 53 trial reported a 27% increase in the risk for heart failure hospitalization in diabetic patients treated with DPP4 inhibitor saxagliptin. In this review, we will discuss recent advances in the heart failure effects of DPP4 inhibition and GLP-1 agonism.
10.1007/s10741-017-9617-4
The importance of normoglycemia in critically ill patients.
DiNardo Monica M,Korytkowski Mary T,Siminerio Linda S
Critical care nursing quarterly
Hyperglycemia is a risk factor for adverse outcomes in acutely ill patients with and without diabetes. One third of all patients admitted to tertiary care facilities have hyperglycemia, with approximately 12% having had no prior history of diabetes. Hyperglycemia adversely affects fluid balance, predisposes to infection, morbidity following acute cardiovascular events, and increases the risk for renal failure, polyneuropathy, and mortality in ICU patients. Because traditional thought suggests hypoglycemia presents a more serious risk to critically ill patients than does hyperglycemia, clinicians are often less than aggressive in treating blood glucoses under 200 mg/dl. Current research, however, demonstrates that even modest degrees of hyperglycemia are associated with adverse outcomes in critically ill patients. Safe implementation of normoglycemia in intensive care patients can be labor intensive and requires well-formulated treatment strategies and interdisciplinary support. Therefore, understanding the importance of intensive glucose control, being comfortable with current clinical treatment modalities, and having the necessary resources to provide this type of care, are vital to critical care nursing practice today.
10.1097/00002727-200404000-00004
Elderly patients with type 2 diabetes mellitus-the need for high-quality, inpatient diabetes care.
Bourdel-Marchasson Isabelle,Sinclair Alan
Hospital practice (1995)
Elderly patients (aged > 70 years) with diabetes are at high risk of -hospitalization. We provide a detailed commentary about recent international clinical guidelines and a consensus statement devoted to elderly patients with type 2 diabetes mellitus in the context of hospitalization. In emergency departments, the 4 medication agents associated with the greatest number of patient adverse drug events are warfarin, oral glucose-lowering medications, insulin, and antiplatelet agents, all of which are commonly prescribed in older patients with diabetes. Comprehensive gerontological assessment, including review and, if indicated, discontinuation of all potentially unsafe or inappropriate patient medications should be done upstream to reduce the likelihood of adverse drugs events. Severe infections and ischemic heart disease are also frequent causes of acute admission into hospital in patients aged > 75 years. These patients are also likely to be malnourished and nutritional status should be monitored. Nutritional support, combined with specific products to avoid uncontrolled hyperglycemia must be implemented in patients at risk of malnutrition. Early exercise prescription may help patients maintain physical function and prevent the risk of falling. Clinical guidelines should be applied to achieve safe and effective patient target glucose levels. Insulin should be used earlier for its anabolic properties and patients closely monitored to reduce the risk of hypoglycemia and excessive hyperglycemia. The discharge plan needs to address full medical and social needs along with suitable follow-up to ensure a high level of patient safety.
10.3810/hp.2013.10.1080
Hospital management of diabetes.
Moghissi Etie S,Hirsch Irl B
Endocrinology and metabolism clinics of North America
The evidence continues to strengthen our understanding that improved glycemic control with the use of insulin therapy may significantly improve morbidity and mortality in hospitalized patients with hyperglycemia, with or without a previous diagnosis of diabetes. However, many questions remain concerning the impact and relative contributions of blood glucose and insulin per se. Nevertheless, the publication of numerous and consistent studies have made it clear that the topic of glycemic management in the hospital requires a larger priority among clinicians caring for these patients. The recently published guidelines by the American Association of Clinical Endocrinologists are the first formal recommendations on this topic,but national guidelines for blood glucose levels cannot take into account all of the different challenges facing different hospitals. This suggests that each institution will require individualization of protocols even though the ultimate metabolic goals are identical. Furthermore, it is not realistic to expect those unfamiliar with diabetes therapy to appreciate all of the nuances and vagaries of insulin treatment. Like any medical treatment, a significant amount of time will need to be invested by the providers involved with the.care of these patients before a mastery of the therapy can be achieved. Nevertheless, because the rewards to our patients can be significant, we need to strive to improve the systems where we work. Individual clinicians with vast experience in diabetes care cannot be successful for the inpatient with diabetes unless the hospital has systems in place to effectively and efficiently facilitate the management of the metabolic needs of this population. The main challenge now is the safe and effective implementation of these guidelines in both small and large hospitals given the limited level of re-sources available in today's medical environment. Therefore, our single most important recommendation is to ensure that all clinicians involved in the management of these patients are in agreement about general philosophies of diabetes management. We would recommend that there are "champions" for each discipline: endocrinology, cardiology, anesthesiology, surgery, nursing,and pharmacy, all of which have developed hospital-specific guidelines for glycemic management. These recommendations can be slowly adapted, one unit at a time, until the entire hospital has transitioned to a more "diabetes-friendly" environment. The ultimate goal of well-controlled glycemia with minimal hypoglycemia should be possible for most hospitals, and we hope this review will assist clinicians in achieving this objective. We await additional outcome research with carefully controlled studies to confirm the value of these recommendations at different levels of glycemic control. We believe that we can already state with confidence that the preliminary evidence shows that, like outpatient diabetes management,metabolic control matters during acute illness.
10.1016/j.ecl.2004.11.001
Outpatient initiation of insulin therapy in patients with diabetes mellitus.
Bruce D G,Clark E M,Danesi G A,Campbell L V,Chisholm D J
The Medical journal of Australia
Before insulin therapy is begun, patients with diabetes are often admitted to hospital. In a retrospective study we have reviewed the initiation of insulin therapy in 54 unselected outpatients (12 of whom were insulin-dependent), when the initial stabilization of therapy was performed predominantly by nurse educators. Most patients found the procedure satisfactory; only one subject indicated dissatisfaction with the regimen and only two indicated that they would have preferred admission to hospital. No patient experienced an acute hypoglycaemic or hyperglycaemic problem that required admission to hospital nor was emergency intervention required during the 12 months that followed the initial stabilization period of insulin therapy. Metabolic control, as measured by glycosylated haemoglobin levels, improved in the majority of both insulin-dependent and non-insulin-dependent patients after 12 months of insulin therapy. A retrospective cost analysis that compared the cost of the outpatient procedure with the cost (hospital-bed costs only) of initiating insulin therapy in a similar group of patients who were admitted to hospital, indicated a saving of $1857 for each outpatient. We conclude that the outpatient initiation of insulin therapy is feasible where the facilities for education about diabetes exist, that it is safe, achieves satisfactory metabolic control, is acceptable to most patients, and offers a considerable saving in costs.
10.5694/j.1326-5377.1987.tb120120.x
Evaluation of an implemented new insulin chart to improve quality and safety of diabetes care in a large university hospital: a follow-up study.
Kopanz Julia,Sendlhofer Gerald,Lichtenegger Katharina,Semlitsch Barbara,Riedl Regina,Pieber Thomas R,Tax Christa,Brunner Gernot,Plank Johannes
BMJ open
OBJECTIVES:To evaluate structure, documentation, treatment quality of a new implemented standardised insulin chart in adult medical inpatient wards at a university hospital. DESIGN:A before-after study (3 to 5 months after implementation) was used to compare the quality of old versus new insulin charts. SETTING:University Hospital Graz, Austria. PARTICIPANTS:Healthcare professionals (n=237) were questioned regarding structure quality of blank insulin charts. INTERVENTIONS:A new standardised insulin chart was implemented and healthcare professionals were trained regarding features of this chart. Data from insulinised inpatients were evaluated regarding documentation and treatment quality of filled-in insulin charts (n=108 old insulin charts vs n=100 new insulin charts). MAIN OUTCOMES AND MEASURES:The primary endpoint was documentation error for insulin administration. RESULTS:Healthcare professionals reported an improved structure quality of the new insulin chart with a Likert type response scale increase in all nine items. Documentation errors for insulin administration (primary endpoint) occurred more often on old than new insulin charts (77% vs 5%, p<0.001). Documentation errors for insulin prescription were more frequent on old insulin charts (100% vs 42%) whereas documentation errors for insulin management rarely occurred in any group (10% vs 8%). Patients of both chart evaluation groups (age: 71±11 vs 71±12 years, 47% vs 42% women, 75% vs 87% type 2 diabetes for old vs new charts, respectively) had a mean of 4±2 good diabetes days. Overall, 26 vs 18 hypoglycaemic episodes (blood glucose (BG) <4.0 mmol/L (72 mg/dL), p=0.28), including 7 vs 2 severe hypoglycaemic episodes (BG <3.0 mmol/L (54 mg/dL), p=0.17) were documented on old versus new insulin charts. CONCLUSIONS:The implementation of a structured documentation form together with training measures for healthcare professionals led to less documentation errors and safe management of glycaemic control in hospitalised patients in a short time follow-up. A rollout at further medical wards is recommended, and sustainability in the long-term has to be demonstrated.
10.1136/bmjopen-2020-041298
Diabetes to Go-Inpatient: Pragmatic Lessons Learned from Implementation of Technology-Enabled Diabetes Survival Skills Education Within Nursing Unit Workflow in an Urban, Tertiary Care Hospital.
Magee Michelle F,Baker Kelley M,Bardsley Joan K,Wesley Deliya,Smith Kelly M
Joint Commission journal on quality and patient safety
BACKGROUND:Diabetes survival skills education (DSSE) focuses on core knowledge and skills necessary for safe, effective, short-term diabetes self-care. Inpatient DSSE delivery approaches are needed. Diabetes to Go (D2Go) is an evidence-based DSSE program originally designed for outpatients. METHODS:Implementation science principles were used to redesign D2Go for delivery by staff on medicine and surgery units in a tertiary care hospital to adults with type 2 diabetes (T2DM) using a tablet-based e-learning platform. Implementation efficacy was evaluated from staff and patient engagement perspectives. The Practical, Robust Implementation and Sustainability Model (PRISM) guided redesign. The team conducted qualitative evaluation (implementation barriers and facilitators); program redesign (via stakeholder feedback and education and human factors principles); implementation design for tablet delivery and patient engagement by unit staff; and a prospective implementation feasibility study. RESULTS:Among 596 T2DM patients identified on three medical/surgical units, 415 (69.6%) were program eligible. Of those eligible, 59 (14.2%) received, accessed, and engaged with the platform; and among those, 43 (72.9%) completed the intervention, representing just 10.4% of those eligible. Multilevel implementation barriers were encountered: staff (receptivity, time, production pressures, culture); process (electronic health record [EHR] integration, patient identification, data tracking, bedside delivery); and patient (receptivity, acuity, availability, accessibility). Most completers required technology support. CONCLUSION:Time constraints, limited EHR integration, and patient barriers markedly impeded implementation of the delivery of diabetes education at the bedside, despite stated staff interest. As a result, uptake and adoption of a tablet-based DSSE e-learning program in a high-acuity care setting was limited.
10.1016/j.jcjq.2020.10.007
Knowledge of diabetes and the practice of diabetes self-management during Ramadan fasting among patients with type 2 diabetes in Malaysia.
Diabetes & metabolic syndrome
BACKGROUND AND AIMS:To assess the level of diabetes knowledge and its association with diabetes self-management practices during Ramadan fasting among patients with type 2 diabetes (T2D). METHODS:A cross-sectional study was conducted involving a sample of Malaysian patients with T2D. Patients aged 18 years and above, and attending an outpatient diabetic unit of a government hospital were recruited between February and April 2021. A self-administered questionnaire was utilized to assess diabetes knowledge and diabetes self-management practices. RESULTS:A total of 306 participants completed the questionnaire. Most of them were females (54.2%) and above 55 years old (75.1%). Resultantly, knowledge of diabetes was considered average among 52% of the participants. Only 9.5% of them avoided the consumption of sweet foods during iftar. Practicing late suhoor (p = 0.012) and self-monitoring of blood glucose (SMBG) (p = 0.026) during Ramadan were significantly associated with a better diabetes knowledge score. Education level (p = 0.000), working status (p = 0.030), and monthly income (p = 0.000) were significantly associated with participants' knowledge level of diabetes. A higher proportion (72.2%) of the participants completed fasting for a month during Ramadan 2020. Meanwhile, hypoglycemia was the main reason (38.8%) for incomplete fasting. CONCLUSIONS:These findings reflect the need to improve patients' knowledge of diabetes and diabetes self-management practices, especially during Ramadan. Such objectives could be achieved by considering the associated factors identified in this study.
10.1016/j.dsx.2022.102655
Safe care for people with diabetes in hospital.
Clinical medicine (London, England)
Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm - however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.
10.7861/clinmed.2019-0255
Addressing Hospital-Acquired Hypoglycemia.
The American journal of nursing
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.
10.1097/01.NAJ.0000751116.58400.46
Safe and appropriate use of insulin and other antihyperglycemic agents in hospital.
Cornish William
Canadian journal of diabetes
Ensuring safe and appropriate use of antihyperglycemic agents in hospital is a challenge. It requires that the contraindications and precautions to the use of non-insulin agents be observed, the incidence of hypoglycemia and severe hyperglycemia be minimized, and the risk of medication errors (including inappropriate prescribing) be reduced. Insulin is a high-alert medication with an increased risk for causing patient harm when prescribed inappropriately or administered in error. Reduction in the risk for medication error requires close attention to the many detailed steps in the various phases of the medication-use process. Hypoglycemia is often caused by failure to adjust antihyperglycemic therapy in response to a reduction in nutritional intake. Treatment needs to be more closely linked to patients' nutritional status, and nursing staff should be empowered to initiate prompt reversal of hypoglycemia. Hyperglycemia commonly results from reliance on sliding-scale insulin as the sole method of controlling blood glucose or failure to optimize treatment by increasing the dose of insulin. Suboptimal prescribing of insulin may be due to a lack of knowledge and expertise on the part of the prescriber or fear of causing hypoglycemia. Strategies for improvement of glycemic control include education of care providers on the safe and appropriate use of insulin, establishment of standardized protocols (i.e. order sets) for insulin use and provision of clinical decision aids at the point of care to guide prescribers. Considering the challenges and obstacles faced by hospitals, establishment of a multidisciplinary committee is recommended for the purpose of directing efforts at quality improvement of diabetes care within the hospital.
10.1016/j.jcjd.2014.01.002
Patient Self-Management of Diabetes Care in the Inpatient Setting: Pro.
Journal of diabetes science and technology
Patients should be allowed to manage their diabetes in the hospital. Diabetes mellitus is a common and sometimes difficult to control medical issue in hospitalized patients. Oftentimes patients who have been controlling their diabetes well as an outpatient are not allowed to continue this management on the inpatient setting, which can lead to hypo- and hyperglycemia. Involving the patient in his or her diabetes care, including self-management in select patients, may provide a safe and effective way of improving glycemic control and patient satisfaction. This may particularly benefit the dosing and coordination of meal-time.
10.1177/1932296815590827