Transcript Evidence informed Glucose Monitoring Practice after Stroke by Liz

Evidence informed glucose
monitoring practice after stroke
Liz Laird, Lecturer of Nursing
Alison Beattie, Stroke Service Coordinator, WHSCT
Background
Each year, 152,000 people suffer a new stroke in the UK.
Nurses have a major role in the assessment, monitoring
and treatment of adults with stroke. Hyperglycaemia is
commonly observed among adults admitted to hospital with
acute stroke.
Theories of post stroke hyperglycaemia
 Diabetes mellitus
 Undiagnosed diabetes mellitus and pre-diabetes
syndromes.
 Physiological stress response.
Research Aim:
to explore glucose derangement among a stroke cohort,
and establish an evidence base to inform glucose
monitoring practice.
Methods
Systematic reviews of:
 Descriptive cohort studies (Laird et al. 2013a)
 Randomised controlled trials (Laird et al. 2013b)
Retrospective cohort study
 Review of medical and nursing records of 112
adults with acute stroke and TIA, consecutively
admitted to the three hospitals in WHSCT
(Mitchell et al. 2012, Laird et al. 2013c).
Findings from systematic reviews
 20 - 30% adults with acute stroke have history of diabetes mellitus.
 Almost 25% of adults without a history of diabetes will experience
hyperglycaemia at some point in the first week of stroke.
Patterns of hyperglycaemia:
 transient hyperglycaemia,
 persisting hyperglycaemia, and
 delayed hyperglycaemia.
Delayed hyperglycaemia - difficult to control.
 Undiagnosed diabetes mellitus/ pre diabetes syndromes affecting one
third of stroke cohorts, if followed up after discharge.
 No evidence to support intensive intravenous insulin therapy regimes in
routine acute stroke care.
Stroke guidelines (RCP 2008, 2012)
 Monitor glucose closely in the acute phase of stroke
 Maintain blood glucose concentration between 4 and 11mmol/L.
Recent Research
 Middleton et al.’s (2011) cluster randomised controlled trial in
Australia indicated that nurse led interventions that included
enhanced monitoring and management of glucose in the acute
phase of stroke, mediates towards more positive clinical
outcomes.
Cohort study n = 112
Age Range: 24 - 99 years; mean age 74 ± 13.
Gender: Men n = 51(46%); Women n = 61(54%).
Diabetes Mellitus status:
Type 1, n = 2(2%); Type 2, n = 16 (15%).
Stroke Type:
Ischaemic stroke n = 95 (85%)
Primary Haemorrhagic stroke n = 17 (15%).
Findings - Hyperglycaemia
 Total of 41 (37%) adults experienced hyperglycaemia
(glucose > 7.8mmol/l) at some point in first five days.
Note that only 18 of the cohort had DM. Two adults
were diagnosed with DM during hospital episode.
 Hyperglycaemia was a persisting trend.
 Glucose was under-monitored
Findings - Hypoglycaemia
 Total of 11 (10%) adults experienced hypoglycaemia (glucose <
4.0mmol/l) at some point in first five days. Hypoglycaemia range
1.8 - 3.9mmol/L.
 None of these adults had received insulin therapy.
 Those affected were predominantly women.
 Only 2 of these adults had DM. The 6 adults who experienced
hypoglycaemia at the lower threshold of glucose < 3.5mmol/l, did
not have a history of diabetes.
Diabetes mellitus status and opportunity for
near patient glucose monitoring
A history of diabetes mellitus prompted point of care glucose
monitoring. Only 15 (16%) of the 94 adults without a history of
diabetes mellitus received such monitoring.
There was a significant difference in number of days of near patient
glucose monitoring for those with diagnosed diabetes (M = 15.88
days) and those without (M = 1.74 days, p=.034).
Stroke unit care
 We compared glucose concentrations in days 1 to 5 between
adults treated and those not treated in a stroke unit, and
differences were not significant.
 All the adults who received active intervention to control
hyperglycaemia on days 1 to 5 were treated in stroke units with the
exception of one patient treated in a cardiology ward.
 Adults in stroke units were more likely to have HbA1c tested.
 A significantly higher proportion of adults treated in stroke units had
fasting glucose tested than adults not treated in stroke units (80.6%
versus 60%, p=0.036).
Glucose derangement - readiness for rehab
 Glucose derangement has an adverse impact on conscious level,
cognition, and cardiovascular function. It is also associated with
impaired immunity, higher infection rate and fluid balance
deregulation.
 Symptoms of glucose derangement can mimic stroke/worsening
stroke.
 Impossible to determine fitness for rehab, if glucose is outside
recommended range.
Introducing Stroke unit and team SWAH
Ward 5 Stroke Unit
 19 bedded unit – Single rooms
 Provides direct admission for all
hyper-acute and acute stroke patients
 Provides acute rehabilitation
Consultants:
 Dr Kelly, Dr Keegan, Dr Bhaumick
Nursing Staff
 Sr McIIveen
 Senior Nurse Mary Robinson
 Stroke Specialist Nurse Sheila Grimes
May – June 2013 – Glucose screening
On Admission
 43 adults admitted to SWAH stroke unit with a confirmed
diagnosis of stroke
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43 patients (100%) screened for blood glucose within 24hrs
37 patients (77%) screened for HbA1c
5 patients(12%) history diabetes – 1x type I DM / 4x type II DM
1 patient (2%) newly diagnosed - type II DM
Glucose Derangement
Glucose >7.8mmol
Glucose >11mmol
No patient with glucose results <4mmol
HbA1c 7mmol or above
How were they monitored?
6 diabetic
11 patients
5 non-diabetic
Commenced on
Blood Glucose
monitoring chart
1 –xfer to RVH
1 – 2/5
1 – 3/5
2 – 4/5
4 had intervention
1 started oral agent
3 sliding scale insulin
Practice change
 Initial Trust wide response – to strengthen admission procedures
for all people admitted with stroke.
 The Stroke admission proforma (developed at Erne) was rolled
out to all hospitals in the Trust and this improved all initial
assessment and monitoring processes not only those relating to
glucose.
 In the earlier cohort study, 84% patients had glucose recording for
day 1, now 100% tested – a significant improvement.
 In the earlier cohort study, 8% patients had HbA1c tests, now 77%
- a significant improvement.
 In the earlier cohort study, 3.5% patients were prescribed sliding
insulin therapy, now 7%.
No room for complacency
 There is no consistency with the monitoring of deranged blood
glucose for non-diabetic patients
 When looking for evidence of communication to GP’s at point of
discharge, there was no evidence to show any communication
from secondary care to primary care on blood glucose that
fluctuated or raised HbA1c.
References

Department of Health Advisory Committee on Diabetes. Use of HbA1c in the diagnosis of diabetes mellitus in the UK. The
implementation of World Health Organization guidance 2011. Diabetic Medicine 2012; 29 (11):1350-7.

Laird EA, Coates VE, Chaney D. Systematic review of descriptive cohort studies on the dynamic of glycaemia among adults with
admitted to hospital with acute stroke. Journal of Advanced Nursing 2013a; DOI: 10.1111/j.1365-2648.2012.06094.x.

Laird EA, Coates, VE. Systematic review of randomized controlled trials to regulate glycaemia after stroke. Journal of Advanced Nursing
2013b; DOI: 10.1111/j.1365-2648.2012.06091.x
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Laird EA, Coates VE, Ryan AA, McCarron MO, Lyttle D, McCrum-Gardner (2013) Hypoglycaemia risk among a hospitalised stroke
patient cohort: a case for increased vigilance in glucose monitoring. Journal of Clinical Neuroscience doi.org/10.1016/j.jocn.2013.03.031
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Lee M, Saver JL, Hong KS, Song S, Chang KH, Ovbiagele B. Effect of pre-diabetes on future risk of stroke: meta-analysis. British
Medical Journal 2012; 344:e3564. doi: 10.1136/bmj.e3564.
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Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C, Drury P, Griffiths R, Wah Cheung N, Quinn C, Evans, M, Carilhac, D,
Levi C. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute
stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378 (9804);1699 – 1706.
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Mitchell EA, Coates VE, Ryan AA, McCarron MO, Lyttle D, McCrum-Gardner E. Hyperglycaemia monitoring and management in stroke
care: policy vs. practice. Diabetic Medicine 2012; 29: 1108-1114.
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Royal College of Physicians. National Clinical Guidelines for Stroke 4th edn. London: RCP 2012.