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Evidence informed glucose monitoring practice after stroke

Evidence informed glucose monitoring practice after stroke. Liz Laird, Lecturer of Nursing Alison Beattie, Stroke Service Coordinator, WHSCT. Background.

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Evidence informed glucose monitoring practice after stroke

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  1. Evidence informed glucose monitoring practice after stroke Liz Laird, Lecturer of Nursing Alison Beattie, Stroke Service Coordinator, WHSCT

  2. 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.

  3. Research Aim: to explore glucose derangement among a stroke cohort, and establish an evidence base to inform glucose monitoring practice.

  4. 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).

  5. 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.

  6. 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.

  7. Cohort study n = 112Age 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%).

  8. 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

  9. 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.

  10. 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).

  11. 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).

  12. 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.

  13. 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

  14. May – June 2013 – Glucose screening On Admission • 43 adults admitted to SWAH stroke unit with a confirmed diagnosis of stroke • 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

  15. Glucose Derangement Glucose >7.8mmol Glucose >11mmol No patient with glucose results <4mmol

  16. HbA1c 7mmol or above

  17. How were they monitored?

  18. 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%.

  19. 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.

  20. 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 • 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 • 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. • 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. • 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. • Royal College of Physicians. National Clinical Guidelines for Stroke 4th edn. London: RCP 2012.

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