Problem and Significance

Hyperglycemia can increase morbidity and mortality in hospitalized patients. It is known that controlling hyperglycemia reduces both morbidity and mortality during hospitalization while improving short, intermediate, and long-term outcomes.

Purpose

This study assessed the current practice of morning diabetes management in a university hospital by noting specific times of glucose monitoring, insulin administration, and delivery of breakfast to determine whether these variables effected glucose control and patient safety. Specifically, we sought to determine whether timing of insulin administration before breakfast related to development of prelunch hyperglycemia.

Overall Questions

Does current diabetes management in terms of intervals between glucose monitoring, time of insulin administration, and the time of breakfast impact on subsequent adverse outcomes?

Hypotheses

(1) The longer the interval between blood glucose monitoring and insulin injection, the more likely the patient will have an adverse outcome. (2) The longer the interval between insulin injection in the morning and starting breakfast, the more likely the patient will have an adverse outcome. (3) The longer the interval between blood glucose testing and breakfast, the more likely the patient will have an adverse outcome.

Design and Methods

A quantitative, descriptive, correlational, nonexperimental, prospective design. The practice of morning diabetes management was studied as it was practiced. This study explored relationships among the variables of interest.

Setting and Participants

A nonprobability convenience sample of 40 diabetic hospitalized adults in a 376-bed tertiary, urban, academic medical center.

Study Results/Outcomes

40 adult diabetic patients were divided into either group 1 (breakfast <45 minutes after receiving insulin) or group 2 (breakfast >45 minutes after receiving insulin). Data collected included the interval between blood glucose monitoring and insulin administration, insulin administration and start of breakfast, and blood glucose monitoring and breakfast. Main outcome was prelunch glucose; a value less than 180 mg/dL was deemed acceptable. Mean prelunch glucose value for group 2 was significantly higher than group 1 (243 +/- 90 vs 172 +/- 93, P = .033). Eighty percent of patients in group 2 had prelunch glucose more than 180 mg/dL, and 20% had a prelunch glucose of less than 180 mg/dL, whereas 43% of patients in group 1 had glucose values more than 180 and 57% had glucose values less than 180, P = .026. Logistical regression analysis showed a 5.3 times higher risk of having a prelunch blood glucose value more than 180 mg/dL in patients who had breakfast less than 45 minutes after receiving insulin as compared to those who received insulin less than 45 minutes prior to breakfast (RR = 5.3[95% CI = 1.2-25, P = .031]). Other variables collected were not associated with prelunch hyperglycemia.

Conclusions/Implications for Nursing

Feeding breakfast longer than 45 minutes after insulin administration induces unacceptable blood sugar control in hospitalized diabetic patients. Proper linkage of feeding with insulin administration may improve glycemic control in hospitalized patients, necessitating a change in how diabetic care is delivered. Possible alterations in sequential care include synchronizing nursing scheduled monitoring and insulin administration to the time of food delivery. The CNS is well suited to work with the various health care practitioners, hospital systems, and patients to design, implement, and evaluate necessary changes that can improve quality of care and patient safety.

Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.