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

INTRODUCCIÓN Y OBJETIVOS: La eficacia y seguridad de los protocolos de manejo de la hiperglucemia hospitalaria con pautas basal-bolo están ampliamente demostradas, pero su implementación es insuficiente. El objetivo del estudio fue valorar la implantación y determinar la eficacia y seguridad de un protocolo de manejo de la hiperglucemia hospitalaria basado en la terapia basal-bolo y la incorporación de una enfermera consultora. MATERIAL Y MÉTODOS: La evaluación se realizó en 10 unidades de hospitalización. Se revisaron retrospectivamente los datos durante la hospitalización y a los 90 días tras el alta de 400 pacientes postimplantación y 200 pacientes preimplantación del protocolo. El grado de satisfacción de los profesionales se valoró mediante un cuestionario a los 12 meses de la implantación. RESULTADOS: La proporción de pacientes con pauta basal-bolo en el ingreso fue superior en el grupo postimplantación (58% frente a 9%, p < 0,001). La media de las glucemias prepandiales y al acostarse durante el ingreso fue menor en el grupo postimplantación (164 ± 41mg/dl frente a 196 ± 50 mg/dl, p < 0,001). La proporción de pacientes con glucemias > 300 mg/dl fue menor (36,3% frente a 50,5%; p < 0,001) y con glucemias < 70 mg/dl fue superior (15% frente a 9%, p = 0,040) en el grupo postimplantación. La adición e intensificación de la insulina fue la principal modificación del tratamiento al alta y se observó reducción significativa de la HbA1c a los 3 meses del alta en la fase postimplantación (p = 0,04). La valoración del protocolo por parte de los profesionales fue de 4,5 en una escala de 1 a 5. CONCLUSIONES: La incorporación de una enfermera consultora experta en diabetes como elemento central del programa de manejo de la hiperglucemia consigue que la mayoría de los pacientes hospitalizados con hiperglucemia reciban tratamiento con una pauta basal-bolo y una mejora del control glucémico durante la hospitalización y tras el alta

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 ± 41 mg/L vs. 196 ± 50 mg/dL, P < 0.001). After implementation, there were less patients with blood glucose levels > 300 mg/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

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.

Changes in Insulin Requirements From the Onset of Continuous Subcutaneous Insulin Infusion (CSII) Until Optimization of Glycemic Control.

The aim was to evaluate changes in insulin requirements from onset of continuous subcutaneous insulin infusion (CSII) until glucose optimization in type 1 diabetes and to determine patient characteristics to be considered when CSII is implemented. We retrospectively analyzed 74 type 1 diabetic patients over a follow-up of 5 months after starting CSII. Patients without a decrease in HbA1c levels at the end of follow-up were excluded. We compared total daily doses (TDD), basal/bolus distribution, basal diurnal/nocturnal proportion, number of basal segments, and HbA1c levels in relation to sex, age, body mass index (BMI), diabetes duration, and indication for CSII. At follow-up, HbA1c decreased by 0.75%, TDD decreased by 18%, basal rate was 60% of TDD, and diurnal basal rate was 60% of total basal rate. Insulin requirements were higher in males and in obese patients. Female patients and patients with longer diabetes duration showed a higher percentage of basal insulin. The number of basal segments was 4.9 ± 2.9. Basal requirements were higher in the second half of the nocturnal period. The dawn phenomenon was more relevant in men. Improvements in glycemic control were more marked in younger patients, in patients with higher HbA1c, in patients using more basal segments, and in patients initiating CSII for glucose control before pregnancy. Sex, diabetes duration, and BMI should be considered when initiating CSII. Our findings may help clinicians in clinical decision making regarding CSII therapy.

Perinatal maternal and neonatal outcomes in women with gestational diabetes mellitus according to fetal sex.

BACKGROUND: Male sex is a well-known risk factor for unfavorable perinatal outcomes. Fetal sex has been considered only occasionally in diabetic pregnancy. OBJECTIVE: Our aim was to evaluate perinatal outcomes in women with gestational diabetes mellitus (GDM) according to fetal sex. METHODS: We conducted a retrospective review of all singleton pregnancies of women with GDM progressing to >22 weeks and delivering in our center between 1981 and 2007. Evaluated maternal characteristics included anthropometrics, obstetric history, GDM diagnosis characteristics (ie, gestational age, blood glucose values), HbA(1c) (after diagnosis and in the third trimester). Outcomes variables were cesarean section (CS), gestational hypertension, preterm birth, abnormal Apgar, large and small for gestational age newborns, obstetric trauma, major and minor malformations, neonatal hypoglycemia, jaundice, respiratory distress, polycythemia, hypocalcemia, perinatal mortality, and a composite outcome. We used a descriptive and multiple logistic regression analysis (backwards method). RESULTS: A total of 2299 pregnancies were included (1125 female and 1174 male infants). Maternal characteristics were essentially similar in male and female newborns. For outcomes, unadjusted figures were higher in pregnancies of male newborns in 14 of 16 perinatal outcomes, but significance was only reached for CS. The logistic regression analyses revealed male sex as an independent predictor of CS (odds ratio = 1.48; 95% CI, 1.15-1.90) and neonatal hypoglycemia (odds ratio = 2.13; 95% CI, 1.02-4.43). CONCLUSIONS: In this group of women with GDM, perinatal outcomes in pregnancies of male newborns differ in only 2 of 16 evaluated variables: an increased frequency of CS and neonatal hypoglycemia. Male newborns of mothers with GDM could benefit from increased awareness of neonatal hypoglycemia.

Nurse-based management in patients with gestational diabetes.

OBJECTIVE: To compare the rate of insulin treatment and perinatal outcome in women with gestational diabetes mellitus (GDM) under endocrinologist-based versus diabetes nurse-based metabolic management. RESEARCH DESIGN AND METHODS: In a retrospective analysis, maternal characteristics, rate of insulin treatment, and perinatal outcome of patients with GDM delivering between 1 January 1995 and 30 June 1997 (n = 244) receiving endocrinologist-based care were compared with those delivering between 1 July 1997 and 31 December 1999 (n = 283) who received diabetes nurse-based care. The diabetes nurse's role was similar to that of an advanced practice nurse in the U.S. There were no changes in the metabolic goals and instruments or in obstetric and neonatal management. Quantitative data were compared with the Mann-Whitney U test and categorical data, with Fisher's exact test. RESULTS: Maternal characteristics (age, BMI, family history of diabetes, prior glucose intolerance, gestational age, and blood glucose at diagnosis of GDM) did not differ between groups treated during the two periods. Rates of insulin treatment and perinatal outcome (hypertension, preterm delivery, cesarean section, low Apgar score, macrosomia, small- and large-for-gestational-age newborns, obstetric trauma, major malformations, hypoglycemia, hypocalcemia, polycythemia, jaundice, respiratory distress, and mortality) were also similar in both groups. CONCLUSIONS: Comparison of periods of endocrinologist-based and diabetes nurse-based metabolic management of women with GDM showed no differences in the rate of insulin treatment and perinatal outcome. This supports a more active role of nurses in the management of women with GDM.