The challenge of diabetes as a secondary diagnosis.

The potential for serious diabetes-related problems is always present with the person with diabetes, regardless of the primary diagnosis. This article addresses specific clinical management issues of chronic and acute diabetes complications with the most current research and evidence-based home care nursing recommendations. Additionally, the American Diabetes Association 2001 Standards of Care for prevention and detection of complications are adapted to the home care setting.

An inpatient diabetes QI program.

OBJECTIVE: The goal of this study was to establish a continuous quality improvement (CQI) program for diabetes which would identify patterns in the problems of care encountered by hospitalized patients with diabetes and improve the in-hospital process of diabetes care delivery. RESEARCH DESIGN AND METHODS: The laboratory information system in an acute and tertiary care 1,000-bed urban teaching hospital provided us on a daily basis with a list of patients on the medical service having blood glucose (BG) levels < 40mg/dl or > 450mg/dl and positive serum acetones. We performed concurrent implicit chart review when BG levels were hypoglycemic (< 40mg/dl) or hyperglycemic (> 450mg/dl on two occasions) or when diabetic ketoacidosis (DKA) was present (acetones were > 1+) using preset indicators for documentation and appropriate medical management. Data were expressed as the ratio of number of cases in compliance with the indicator over total number of cases identified. A test for trend in proportions was used to assess compliance with the indicators over time. RESULTS: Documentation of nursing unit-based capillary blood glucose (CBGM) and insulin infusion monitoring improved significantly over time (p < 0.001 for both). The medical management of hypoglycemia, hyperglycemia and DKA improved (p = 0.1) over the three-year period. Identification of recurrent multidisciplinary process problems in the management of DKA, intravenous insulin infusion constitution and delivery, CBGM determination in the setting of anemia, and recognition of clinical settings conducive to the development of hypo- and hyperglycemia were identified and addressed with standardization in documentation, an insulin infusion protocol, administrative rules, and staff education. CONCLUSIONS: Efforts to standardize specific clinical and documentation processes had a positive impact on the care of hospitalized patients with diabetes and resulted in an institutional effort to improve inpatient diabetes care with a CQI team.

Mortality in hospitalized patients with hypoglycemia and severe hyperglycemia.

BACKGROUND: We designed a study to determine the incidence, cause, and implications of hypoglycemia (< or = 2.7 mmol/L, 49 mg/dL) and severe hyperglycemia (> or = 22.2 mmol/L, 400 mg/dL) in in-patients at an urban tertiary medical center. METHODS: A daily computer search of the Laboratory Information System identified all hospitalized patients with hypoglycemia and severe hyperglycemia during a 49-day period. Chart review was used to assess demographic information, risk factors, and epidemiologic variables. The eventual outcome of the hospitalization was obtained by follow-up. RESULTS: The incidence of hypoglycemia was 1.5%, and of hyperglycemia, 1.9%. Seventy-six percent of the hypoglycemic patients and 16% of the hyperglycemic patients had no prior history of diabetes. The mortality rate for hypoglycemic patients was 22.2%; for hyperglycemic patients it was 11.1%. For all other hospitalized patients it was 2.3% (p < 0.0001). Mortality rates for the black and Hispanic patients who were hypoglycemic (30% and 46%) were significantly higher than for white patients (6%, p < 0.01). CONCLUSIONS: Hypoglycemia and severe hyperglycemia are not uncommon in hospitalized patients and serve as metabolic markers for patients at increased risk for inhospital mortality. Early identification of at-risk patients and the impact of aggressive treatment of their underlying disease processes should be evaluated in future studies.

Teaching diabetes self-management skills: a high-technology approach.

There is, indeed, an explosion of knowledge in the field of diabetes self-management. Special care must be taken in evaluating specific devices before recommending any of them to a patient. In doing so, it is important to consider Owen Edwards' reflections in Elegant Solutions: "Aside from nature's creations, there are no perfect solutions. Everything humanity concocts comes with some cost attached. Solutions that seem flawless at first may have repercussions no one ever anticipated". A multidisciplinary approach is needed to create a diabetes management program to meet the unique needs of each patient. Ongoing education of the patient is essential to assure the best level of diabetes care available.