A quality improvement project reducing adverse events and improving adherence to guidelines surrounding VRIII usage.

Variable rate intravenous insulin infusions (VRIII) are frequently used in hospitals and incorrect use can lead to electrolyte imbalance, hypoglycaemia and adverse outcomes. The Joint British Diabetes Societies (JDBS) published guidelines in 2014 and recommended the use of a balanced fluid as substrate. There was no published data to demonstrate the superiority of this fluid in reducing adverse events. This quality improvement project aimed to review the existing practice at our Trust in accordance with JDBS guidelines. We predicted introducing this fluid would reduce adverse events and demonstrating this was a prerequisite condition from our Trust Medicines Management Committee to approve its long-term availability. We carried out an audit of our practice in 2015, at which time the JBDS recommended fluid (0.45% sodium chloride/5% dextrose with 0.15% potassium chloride) was not available in our Trust. Our VRIII guideline was re-written with recommendation for use of the balanced fluid, after procurement from pharmacy. Our primary areas for improvement as highlighted from the 2015 audit were correct substrate prescription and rate reduction of hypokalaemia (potassium <3.5 mmol/L) and hypoglycaemia (glucose <4 mmol/L) during VRIII use. Analysis of the pre-intervention (December 2016) and post-intervention (September-November 2017) data showed a significant increase in correct fluid use; 11% pre-intervention to 76% post-intervention (χ2, p<0.0001). The number of hypoglycaemic events per VRIII reduced from 0.73 (±1.78) to 0.28 (±0.84) (p<0.05) peri-intervention. Similarly, the number of hypokalaemic events per VRIII reduced from 0.15 (±0.54) pre-intervention to 0.05 (±0.25) post-intervention. There was also a significant reduction in number of VRIII episodes associated with a hyponatraemia event from 26% at baseline to 12% post-intervention (p<0.01). Some of these marked improvements were not sustained at 1-year post follow-up. We reduced adverse outcomes with a substantial net-cost saving during this period, through implementation of new and accessible guidelines, trust-wide education programmes and posters to raise awareness.

Understanding the principles of insulin use in type 1 and type 2 diabetes management.

The year 2021 marks 100 years since the Nobel Prize-winning discovery of insulin as a medical treatment for diabetes mellitus. Its discovery changed type 1 diabetes from a terminal condition with a short life expectancy to one of long-term management, with patients now often living long and fulfilling lives. Today, much of the advice, support and prescribing of insulin is undertaken by nurses, including general nurses and those specialising in diabetes. This article provides an overview of the principles of insulin use in the management of diabetes, with the aim of enhancing nursing knowledge and improving the care of patients with diabetes.

Effective management of hypoglycaemia.

Hypoglycaemia is a potentially serious complication of diabetes mellitus in which an individual's blood glucose drops to dangerously low levels. This can cause signs and symptoms such as sweating, confusion and unusual behaviour and, if untreated, may lead to unconsciousness and death. Hypoglycaemia is a side effect of some treatments for diabetes, whereby injected insulin or oral medicines that stimulate insulin secretion cause an abnormally low blood glucose level. Nurses have an important role in educating and empowering patients and their families and carers to manage diabetes to prevent hypoglycaemia, and to initiate prompt treatment of this complication.

Are they high on steroids? Tailored interventions help improve screening for steroid-induced hyperglycaemia in hospitalised patients.

Steroid-induced hyperglycaemia (SIH) is a common adverse effect in patients both with and without diabetes. This project aimed to improve the screening and diagnosis of SIH by improving the knowledge of healthcare professionals who contribute to the management of SIH in hospitalised patients. Monitoring and diagnosis of SIH were measured in areas of high steroid use in our hospital from May 2016 to January 2017. Several interventions were implemented to improve knowledge and screening for SIH including a staff education programme for nurses, healthcare assistants and doctors. The Trust guidelines for SIH management were updated based on feedback from staff. The changes to the guideline included shortening the document from 14 to 4 pages, incorporating a flowchart summarising the management of SIH and publishing the guideline on the Trust intranet. A questionnaire based on the recommendations of the Joint British Diabetes Societies for SIH was used to assess the change in knowledge pre-intervention and post-intervention. Results showed an increase in junior doctors' knowledge of this topic. Although there was an initial improvement in screening for SIH, this returned to near baseline by the end of the study. This study highlights that screening for SIH can be improved by increasing the knowledge of healthcare staff. However, there is a need for ongoing interventions to sustain this change.

Exubera inhaled insulin in patients with type 1 and type 2 diabetes: the first 12 months.

BACKGROUND: Following National Institute for Clinical Excellence approval of inhaled insulin Exubera (Pfizer, New York, NY) in 2006, we established a dedicated clinic in January 2007 to monitor the efficacy and safety of Exubera. Between January and October 2007, eight patients started Exubera: six because of needle phobia (DSM-IV criteria) and two with injection site problems. METHODS: Data were collected at the clinic over a 12-month period from February 2007 at 3-, 6-, 9-, and 12-month intervals. The clinic is jointly led by a consultant diabetologist and a diabetes specialist nurse within the secondary care setting. RESULTS: Inhaled insulin was well tolerated in all eight patients who had previously experienced significant problems with initiation or intensification of subcutaneous insulin injections. Mean hemoglobin A1c was 10.7% (range, 8.1-14.2%) at initiation, 8.3% (7.2-9.4%) at 3 months, 7.7% (6.9-9.0%) at 6 months, 7.4% (6.7-8.4%) at 9 months, and 7.5% (6.5-8.7%) at 12 months. At 6 months, six patients had a reduction in forced expiratory volume in the first second (FEV1) by 4-12%, whereas five patients had a reduction of 2-12% at 12 months. One developed dyspnea, with a 29% fall in FEV1, which was transient and secondary to an upper respiratory tract infection. Two patients with the highest starting and most improved hemoglobin A1c developed significant retinopathy. CONCLUSIONS: Our 12-month audit data demonstrate that the initiation of inhaled insulin in this difficult-to-treat group of patients resulted in a significant improvement in glycemic control. The subsequent withdrawal of an alternative and acceptable form of insulin treatment now presents a renewed challenge for our patients and healthcare professionals.

How to manage diabetes in advanced terminal illnesses.

Diabetes mellitus is increasing in incidence and is therefore being encountered more frequently during palliative care. Diabetes management in the early stages of terminal disease is normally the same as conventional care. However, in the later stages of terminal illness there are a number of problems that may arise due to diabetes treatment, including hypoglycaemia and hyperglycaemia, which may impair the patient's quality of life. This article will address some of these problems and their management.

Perioperative fasting and the management of type 2 diabetes.

Type 2 diabetes is the most common form of diabetes, affecting approximately 90 per cent of people with the condition. The global incidence of diabetes is rising and the number of people affected is projected to exceed 300 million by the year 2025 (World Health Organization, 2003). Type 2 diabetes results from insulin resistance and/or a relative lack of insulin production. It is progressive and many patients may require dietary modifications, oral hypoglycaemic medication, and/or insulin to obtain good glycaemic control. Good control has been shown to reduce the complications of diabetes (UK Prospective Diabetes Study Group, 1998).