Development of a Protocol for Capillary Blood Glucose Testing in Nursing Home and Rehabilitation Settings

Assessment of Glycemic Control in Nursing Home Residents with Diabetes

OBJECTIVE

To describe glycemic control in nursing home residents with diabetes and to evaluate the relevance of HbA1c in the detection of hypoglycemia risk.

DESIGN AND METHODS

Diabetes treatment, geriatric assessment, blood capillary glucose (n= 24,682), and HbA1c were collected from medical charts of 236 southern France nursing home residents during a 4-month period. Glycemic control was divided into four categories: tight, fair, and moderate or severe chronic hyperglycemia using the High Blood Glucose Index or the analysis of blood glucose frequency distribution. Hypoglycemia episodes were identified by medical or biological records.

RESULTS

Glucose control was tight in 59.3 % and fair in 19.1 % of the residents. Chronic exposure to hyperglycemia was observed in 21.6 % of the residents (severe in 9.7 % and moderate in 11.9 %). Hypoglycemia was noticed in 42/236 (17.8%), in all categories of glycemic control. Relative hypoglycemia risk was significantly (P = 0.0095) higher in residents with moderate chronic hyperglycemia compared with those with tight control. The majority of residents with hypoglycemia (39/42) or chronic hyperglycemia (45/51) were insulin-treated. The relative risk of hypoglycemia was not significantly associated with HbA1c values.

CONCLUSION

Hypoglycemia risk in nursing home residents is observed in all categories of glycemic control. In tight control, the potency of antidiabetic treatment should be reduced. In chronic hyperglycemia, diet and treatment should be reevaluated in order to reduce glucose variability. HbA1c is not sufficient for hypoglycemia risk detection; capillary blood glucose monitoring is warranted for nursing homes residents with diabetes.

Implementing diabetes care guidelines in long term care

OBJECTIVE

The objectives of this article are to (1) describe the outcomes of a diabetes care program in a long term care facility dedicated to diabetes excellence and (2) compare the relevant outcome variables of research published between 2007 and 2012 with the results found in the studied facility.

DESIGN

Three-year retrospective chart review of the facility's residents with comparison to extant literature.

PARTICIPANTS

A total of 224 resident charts within the studied facility were reviewed. Residents with a diagnosis of diabetes, or who were on diabetes medications, or whose fasting blood sugars exceeded 126 mg/dL on 2 occasions, and whose length of stay exceeded 6 months, were tracked for adherence to diabetes guidelines (n = 48). Participant outcomes from relevant studies in the literature were compared to these 48 participants' outcomes.

INTERVENTION

All levels of staff in the studied facility were educated in general diabetes care. A nurse practitioner was contracted to provide medical care for all diabetic residents (with primary care provider approval). A scorecard for adherence to diabetes guidelines was completed by the nurse practitioner. Over a 3-year period following the education program and scorecard implementation, a chart review of all residents was completed by a consulting diabetes educator/nurse practitioner/nurse faculty member and 6 undergraduate nursing students.

RESULTS

In general, the nursing home in the present study compared favorably with other relevant studies, demonstrating lower A1C levels, tracking blood sugars more regularly, monitoring blood pressure and lipids more regularly, having a greater percentage of patients on lipid-lowering medications among those in need, more appropriate use of sliding scale insulin, greater adherence to recommendations regarding diet, and had more patients who fit criteria on preventive anticoagulation.

DISCUSSION

The results for the studied facility were very similar, often better, when compared with the most current nursing home literature. Areas of weakness provided focused strategic planning for the facility. Regrettably, the research is sparse, and evidence supporting guideline adherence data is often missing, making data comparison difficult. This model of care, linking health care agencies with academia, could offer a supportive and affordable method for identifying responses to evidence-based care guidelines.

CONCLUSION

This narrative review points to the need for continued work in the application of evidence-based guidelines in long term care, specifically in the area of interventions that must be adjusted to the needs of the nursing home population, with increased awareness in maintaining or improving quality of life.

Diabetes Management in the Nursing Home

Purpose

Diabetes mellitus is a disease with debilitating potential. Growing numbers of elderly individuals are being admitted to under-resourced nursing homes with this often complicated, time-intensive, and costly diagnosis. The purpose of this systematic review of the literature was to determine the trends in diabetes management in nursing homes over the last decade including the use of clinical practice guidelines and the evaluation of management outcomes.

Methods

Ten medical, nursing, psychological, legal, and business databases were searched for articles written in English between 2000 and 2010 addressing diabetes management in nursing homes or long-term care settings. They were analyzed to determine diabetes management characteristics, use of clinical practice guidelines, resident outcomes associated with different regimens, and implications for improved management and outcomes.

Results

A total of 20 studies from 6 countries, primarily the United States, including both qualitative and quantitative designs and a combined sample of 779 707 residents, met the inclusion criteria. The majority of the studies described frequencies of various management practices and found rare clinical practice guideline adherence.

Conclusion

A severe lack of research relating management practices to health and quality-of-life outcomes was evident as was a lack of the voice of the resident in determining the diabetes regimen. Clear implications were found for improvement in diabetes management education for residents, families, and all health care providers in this setting.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Status of diabetes management in the nursing home setting in 2008: a retrospective chart review and epidemiology study of diabetic nursing home residents and nursing home initiatives in diabetes management

PURPOSE

Diabetes mellitus (DM) is associated with significant morbidity and mortality, and can present with atypical signs and symptoms in elderly residents of nursing homes who often have altered functional and cognitive capacity representing a particularly challenging population to manage. Researchers conducted this study to better understand the current status of DM management in the long-term care facility from the perspective of the facility (use of guidelines, policies, and so forth) as well as that of a resident.

METHODS

Thirteen nursing home facilities in 6 states were studied. A 13-question survey instrument was used to collect data from interviews of the directors of nursing and medical directors. A 26-question data collection form was also used to perform a retrospective chart review of studied residents.

RESULTS

Data from the interview surveys showed that only 15% of facilities studied had a policy for the use of treatment algorithms to manage residents with DM. In addition, only 1 of 13 facilities had a quality improvement tool to evaluate compliance with current policies. In regard to hemoglobin A1C (A1C) testing, only 7.1% of facilities had a house policy in place. Furthermore, only 1% of studied residents had an established target for their A1C despite American Diabetes Association (ADA), American Geriatrics Society (AGS), and American Medical Directors Association (AMDA) guidelines recommending target values and monitoring frequency for A1C testing. The survey instrument also found that just 30.8% of facilities had a policy in place for blood glucose monitoring. Data from the chart review shows that only 57% of residents in this study were taking aspirin or clopidogel bisulfate, although prevention of cardiovascular disease (CVD) is recommended by the American Heart Association (AHA) and ADA in persons with diabetes who are older than 40. Data from this study indicate serious hypoglycemia occurs only occasionally in the nursing home because hypoglycemic episodes requiring hospitalization occurred in only 1% of studied residents. Furthermore, researchers found each of these residents were sent to the hospital only once in the preceding 6 months. One unanticipated finding of the study reports the incidence of delusions from patients' Minimum Data Set (MDS) was 87.63% compared with the national average of 3.7%.

CONCLUSION

Data obtained through this study demonstrates numerous opportunities for improvement in the quality of care for nursing home residents with DM. A multidisciplinary approach is required to properly manage this complex disease in a challenging elderly population. The development of protocols and tools that embrace the latest strategies and treatment algorithms for the management of DM in the geriatric resident are necessary, while implementation of a quality improvement tool can help facilities to further improve on management of DM in the long-term care setting.

Implementation of guidelines for type 2 diabetes mellitus in a post-acute geriatric setting

BACKGROUND AND AIMS

Several health organizations have developed guidelines for type 2 diabetes mellitus, but it is known that population aging poses challenges to their application. We evaluated the reasons for not implementing guidelines for type 2 diabetes mellitus (DM) in patients admitted to a post-acute geriatric ward.

METHODS

209 patients (78.8+/-6.9 years old, female 72.7%) affected by DM, consecutively admitted in a Geriatric Evaluation and Rehabilitation Unit (GERU) between 2003 and 2005 for 32.2+/-11.5 days. The GERU geriatricians generated an algorithm for DM management following the guidelines proposed by the American Diabetes Association (2001) and the California Healthcare Foundation/American Geriatric Society (2003). The fit between medical choices and the guideline or the reasons for non-implementation were recorded on clinical charts.

RESULTS

Guidelines were implemented in 82.3% of cases. The main reason for non-application was the physician's judgment of the patient's clinical condition. Subjects in the non-implementation group had worse functional status, their somatic comorbidity was more severe, and their clinical condition more unstable. They were also affected by more serious psychological and behavioral symptoms associated with dementia. In a multivariate logistic regression analysis, adjusting for age, gender, cognitive, functional status, and number of drugs, the burden of comorbidity was the only independent determinant for not implementing the guidelines (OR 2.27, 95% CI 1.36-3.81, p=0.002).

CONCLUSIONS

although the guidelines for DM have previously been adapted to a geriatric setting, they are not applied in a significant percentage of old frail patients. Severe comorbidity is the main limitation for applying guidelines, but also polypharmacy, disability, cognitive impairment, and behavioral disturbances are factors taken into consideration before starting treatment of a very old patient affected by diabetes.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.