In-patient management of diabetes mellitus and patient satisfaction

Patient-reported outcome instruments for assessing the involvement of children and adolescents with type 1 diabetes in their treatment: a scoping review protocol

OBJECTIVE

The objective of this review is to identify available patient-reported outcome instruments used to assess the involvement of children and adolescents with type 1 diabetes in their treatment. Specifically, this review will examine the content, structure, and application of these instruments.

INTRODUCTION

It is considered meaningful to involve children and adolescents living with a chronic health condition, such as type 1 diabetes, in their own treatment. Despite a growing interest in patient involvement within pediatric health care, including the use of patient-reported outcomes, only a few patient-reported outcome instruments have been developed and are used to evaluate the experiences of children and adolescents with type 1 diabetes of being involved in their own treatment.

INCLUSION CRITERIA

This scoping review will examine patient-reported outcome instruments used to assess the experiences of children and adolescents (11 to 18 years of age) with type 1 diabetes of being involved in their own care. Patient-reported outcome instruments measuring parents' or clinicians' experiences of involvement will be excluded.

METHODS

The proposed review will follow JBI guidelines and all stages will involve 2 or more reviewers. PubMed, Embase, CINAHL, PsycINFO, JSTOR, and MedNar will be searched without limitations on the year or language of publication. Literature that is not written in English will be translated. Data extraction, charting, and analysis will be guided by a template developed for this review that focuses on the content, structure, and application of the patient-reported outcome instruments. Any modifications to the extraction template will be detailed in the review, and data will be presented in a descriptive format.

Perioperative diabetes care: room for improving the person centredness

AIMS

Person centredness is an important principle for delivering high-quality diabetes care. In this study, we assess the level of person centredness of current perioperative diabetes care.

METHODS

We conducted a survey in six Dutch hospitals, among 690 participants with diabetes who underwent major abdominal, cardiac or large-joint orthopaedic surgery. The survey included questions regarding seven dimensions of person-centred perioperative diabetes care.

RESULTS

Complete data were obtained from 298 participants. The survey scores were low for many of the dimensions of person centredness. The dimensions 'information', 'patient involvement' and 'coordination and integration of care' had the lowest scores. Only half the participants had received information about perioperative diabetes treatment, and approximately one-third had received information about the effect of surgery on blood glucose values, target glucose values and glucose measurement times. Similarly, half the participants had an opportunity to ask questions preoperatively, and only one-third of the participants felt involved in the decision-making regarding diabetes treatment. Most participants knew neither the caregiver in charge of perioperative diabetes treatment nor whom to contact in case of diabetes-related problems during their hospital stay.

CONCLUSIONS

Current perioperative diabetes care is characterized by a lack of patient information and limited patient involvement. These results indicate that there is ample room for improving the person centredness of perioperative diabetes care.

Pilot trial of diabetes self-management education in the hospital setting

AIMS

Diabetes self-management education (DSME) is recommended for all patients with diabetes. Current estimates indicate that <50% of patients receive DSME, increasing risk for hospitalization which occurs more frequently with diabetes. Hospitalization presents opportunities to provide DSME, potentially decreasing readmissions. To address this, we investigated the feasibility of providing DSME to inpatients with diabetes.

METHODS

Patients hospitalized on four medicine units were randomized to receive DSME (Education Group) (n=9) prescribed by a certified diabetes educator and delivered by a registered nurse, or Usual Care (n=12). Participants completed Diabetes Knowledge Tests (DKT), Medical Outcomes Short Form (SF-36), Diabetes Treatment Satisfaction Questionnaire (DTSQ), and the DTSQ-inpatient (DTSQ-IP). Bedside capillary blood glucoses (CBG) on day of admission, randomization and discharge were compared.

RESULTS

There were no group differences in demographics, diabetes treatment, admission CBG (186±93 mg/dL vs. 219±84 mg/dL, p=0.40), DKT scores (Education vs. Usual Care 48±25 vs. 68±19, p=0.09), SF-36, and DTSQ scores (28±6 vs. 25±7, p=0.41). Patients receiving education reported more satisfaction with inpatient treatment (83±13 vs. 65±19, p=0.03), less hyperglycemia prior to (2.7±4.5 vs. 4.5±1.4, p=0.03) and during hospitalization (3.9±1.9 vs. 5.5±1.2, p=0.04); and had lower mean discharge CBG (159±38 mg/dL vs. 211±67 mg/dL, p=0.02).

CONCLUSIONS

Inpatient diabetes education has potential to improve treatment satisfaction, and reduce CBG.

Determining in-patient diabetes treatment satisfaction in the UK--the DIPSat study

AIMS

To measure in-patient diabetes treatment satisfaction and its relationship to in-patient diabetes care.

METHODS

In a cross-sectional study, diabetes in-patient specialist nurses at 58 UK hospitals asked insulin-treated in-patients with diabetes to complete the recently updated Diabetes Treatment Satisfaction Questionnaire for In-patients and a general questionnaire; 1319 in-patients completed these questionnaires.

RESULTS

Satisfaction with the general diabetes treatment items in the Diabetes Treatment Satisfaction Questionnaire for In-patients was high, but there were high levels of extreme dissatisfaction with meal choices, meal quality and lack of similarity of hospital meals to normal domestic choices--23% would never or rarely have made similar meal choices at home. Hyperglycaemia or hypoglycaemia was reported for much of the in-patient stay (20% and 7%, respectively) and 26% reported at least one severe hypoglycaemic episode; these groups had lower satisfaction with the timing of medication in relation to meals (P < 0.003). More frequent in-patient hyperglycaemia or hypoglycaemia were associated with significantly poorer overall satisfaction scores and negative well-being scores (both P < 0.0001). Previous experience of a multiple daily insulin injection regimen was associated with more dissatisfaction than other regimens (P < 0.01). Multiple regression models explained 36% of variability in overall treatment satisfaction, with most (22.4%) accounted for by satisfaction with time spent with a diabetes in-patient specialist nurse (P < 0.0001). Self-administration of insulin was independently associated with higher treatment satisfaction (P < 0.006) in this model.

CONCLUSIONS

The DIPSat programme describes the complex relationships between diabetes in-patient treatment satisfaction and in-patient diabetes care.

Managing inpatient hyperglycemia in a resource-constrained county hospital: the Parkland Memorial Hospital experience

Diabetes is a common comorbidity among hospitalized patients and has been linked to increased length of stay, morbidity, and mortality. In addition, multiple pathophysiological factors contribute to incident hyperglycemia in a sizable proportion of inpatients without previously diagnosed diabetes. Insulin is the mainstay of therapy for inpatient management of diabetes and hyperglycemia. In this article, we discuss initial treatment planning and insulin initiation for established and treatment-naïve patients with diabetes who are being treated with human and analog-based insulin therapy. As a publicly funded and cost-conscious hospital, we rely on human insulin for first-line therapy and generally find good results, reserving more costly insulin analogs for patients with type 1 diabetes. We also describe a novel continuous insulin-infusion protocol, the Parkland glucose insulin infusion protocol, which controls severe hyperglycemia safely and effectively in hospitalized patients who are unable to tolerate oral nutrition or are in other complicated clinical situations. We outline transitions from intravenous to subcutaneous insulin and other planning and diabetes education necessary to facilitate discharge. Lastly, we discuss steps for the development and implementation of a continuous intravenous insulin-infusion protocol at the institutional level.

Inpatient management of adults and children with type 1 diabetes

Type 1 diabetes poses unique inpatient challenges because of the risks of diabetic ketoacidosis, uncontrolled hyperglycemia, and hypoglycemia. Although newer insulin analogs and insulin pumps provide means for improved glycemic control, they can be daunting for nonexperts. This article focuses on inpatient and perioperative insulin management of stable, nonketotic, nonpregnant adults and children with type 1 diabetes. These principles can also be applied to patients with steroid-induced hyperglycemia.

Psychometric validation and use of a novel diabetes in-patient treatment satisfaction questionnaire

AIMS

To develop the first psychometrically validated Diabetes Treatment Satisfaction Questionnaire for in-patients (DTSQ-IP) and examine determinants of in-patient diabetes treatment satisfaction.

METHODS

We studied 366 in-patients with insulin-treated diabetes at a single UK centre. We developed a 19-item DTSQ-IP to assess in-patient diabetes treatment satisfaction, and collected data on in-patient length of stay (LOS) and in-patient care at the same time.

RESULTS

Psychometric analyses including Principal Components Analysis and Cronbach's alpha reliability coefficient showed that a single satisfaction score (excluding two items scored individually) can be computed for the entire DTSQ-IP, indicating very good internal consistency reliability (0.92). The DTSQ-IP detected considerable dissatisfaction with meal choice and timing (13.7% of in-patients would never have chosen similar meals at home), and with in-patient hypoglycaemia (35.3% felt that their blood glucose was too low most of the time). In-patients on surgical wards, women, and those long established on insulin were significantly more dissatisfied, particularly with competence of hospital staff. Patients who administered their own insulin were not significantly less dissatisfied overall, but were so with the choice of meals (P = 0.005). Multiple regression analysis produced a model accounting for 8.2% of variability in DTSQ-IP (r = 0.29; P = 0.0058) and 21.7% of variability in LOS (r = 0.46; P = 0.0001).

CONCLUSIONS

The DTSQ-IP is a novel, psychometrically validated and sensitive tool that adds to the DTSQ portfolio. The DTSQ-IP facilitates efforts to assess and improve treatment satisfaction in in-patients with diabetes.

Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service

AIMS

To compare diabetes bed occupancy and inpatient length of stay, before and after the introduction of a dedicated diabetes inpatient specialist nurse (DISN) service in a large UK Hospital.

METHODS

We analysed bed occupancy data for medical or surgical inpatients for 6 years (1998-2004 inclusive), with a DISN service in the final 2 years. Excess bed days per diabetes patient were derived from age band, specialty, and seasonally matched data for all inpatients without diabetes. We also analysed the number of inpatients with known diabetes who did not have diabetes recorded as a discharge diagnosis.

RESULTS

There were 14,722 patients with diabetes (9.7% of all inpatients) who accounted for 101 564 occupied bed days (12.4% of total). Of these, 18 161 days (17.8%) were excess compared with matched patients without diabetes, and were concentrated in those < 75 years old. Mean excess bed days per diabetes inpatient under 60 years of age was estimated to be 1.9 days before the DISN appointment, and this was reduced to 1.2 bed days after the appointment (P = 0.03). This is equivalent to 700 bed days saved per year per 1000 inpatients with diabetes under 60 years old, with an identical saving for those aged 61-75 years (P = 0.008), a saving of 1330 diabetes bed days per year by one DISN. Excess diabetes bed occupancy was 167 excess bed days per year per 1000 patients with diabetes in the local population after the DISN appointment. One quarter of the known Type 2 diabetes population were admitted annually, but one quarter of patients had no diagnostic code for diabetes.

CONCLUSIONS

Diabetes excess bed occupancy was concentrated in patients < 75 years old, and this was reduced notably following the introduction of a DISN service.

Management of incidental hyperglycaemia in acute medical emergencies

AIMS

To assess whether compliance with management guidelines for hyperglycaemia in acute medical emergencies was affected by prior diagnosis of diabetes, and to assess the effect of an educational campaign upon management.

METHODS

Prospective study of management of adult patients admitted to an acute medical admissions unit in 2002, with repeat in 2003 after an educational campaign.

RESULTS

The management of 251 patients in 2002 and 357 patients in 2003 was examined. In patients with no prior diagnosis of diabetes, unsatisfactory management was observed in 60% compared with only 30% of those with known diabetes (P < 0.02). In 2003 these proportions fell to 46 and 16%, respectively, but remained significantly different (P < 0.02). Overall, 30 of 70 (42.9%) patients with hyperglycaemia were managed strictly according to the guidelines in 2002 compared with 33 out of 59 (55.9%) in 2003 (P = 0.14). Satisfactory management was delivered in 55.7% in 2002 and 78% in 2003 (P < 0.01).

CONCLUSIONS

The reluctance of doctors to manage incidental hyperglycaemia in acute medical admissions was especially common when the patient was not known to have diabetes. This was only modestly improved by an educational campaign, even though this group are known to have a greater response in terms of morbidity and mortality. Widespread debate of this issue is required to minimize morbidity and mortality due to hyperglycaemia.

Inpatient management of diabetes: survey in a tertiary care centre

AIMS

Good glycaemic control in hospitalised patients with diabetes mellitus improves wellbeing and aids recovery. This survey aimed to: (1) assess glycaemic control in patients with diabetes admitted to hospital for reasons other than diabetes, (2) compare the glycaemic control in patients treated in medical and surgical units, and (3) see the impact of specialists' input on glycaemic control.

METHODS

The first 150 patients admitted to hospital were identified; those with acute metabolic complications of diabetes mellitus, acute myocardial infarction, pregestational or gestational diabetes, and patients in different intensive care units were excluded. Case notes were reviewed with particular attention to glycaemic control, frequency of blood monitoring, complications, and the actions taken to improve glycaemic control.

RESULTS

Four of the 150 patients died in hospital. When subcutaneous insulin was used glycaemic control was good in 48%, suboptimal in 15%, and poor in 37% of patients. The results were not significantly different with subcutaneous or intravenous insulin. There was also no difference in glycaemic control among medical and surgical patients. Patients managed by designated specialists had better control than those managed by physicians (p<0.001). Hypoglycaemia was documented in 20% and two patients developed non-ketotic hyperosmolar coma while in hospital. In a few cases treatment at discharge was not changed despite poor control while in hospital.

CONCLUSION

More attention should be given to improving glycaemic control in patients hospitalised for reasons other than diabetes. Particular care should be taken to modify the dose of insulin needed to get good glycaemic control; control was better with specialists' input. A follow up survey will be conducted.