Evidence informed glucose monitoring practice after stroke

Liz Laird, Lecturer of NursingAlison Beattie, Stroke Service Coordinator, WHSCT

BackgroundEach 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 mellitusUndiagnosed 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 SWAHWard 5 Stroke Unit19 bedded unit – Single roomsProvides direct admission for all hyper-acute and acute stroke patientsProvides acute rehabilitation

Consultants: Dr Kelly, Dr Keegan, Dr Bhaumick

Nursing StaffSr McIIveen Senior Nurse Mary Robinson Stroke Specialist Nurse Sheila Grimes

May – June 2013 – Glucose screening

On Admission43 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 DM1 patient (2%) newly diagnosed - type II DM

Glucose >7.8mmol Glucose >11mmol

Glucose Derangement

No patient with glucose results <4mmol

HbA1c 7mmol or above

How were they monitored?

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.

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Laird EA, Coates VE, Chaney D. Systematic review of descriptive cohort studies on the dynamic of glycaemia among adults with

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Laird EA, Coates, VE. Systematic review of randomized controlled trials to regulate glycaemia after stroke. Journal of Advanced Nursing

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