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Long-Term Care Survey Alert

CLINICAL CARE:

Keep Your Diabetes Care in the Best-Practice Zone

Published on Sat Jun 20, 2009

Get tips for managing insulin, lab testing, preventive care, and more.

Diabetes mellitus can set residents up for problems that spill over into your quality reporting and survey results. A few key strategies can, however, help your team sidestep common stumbling blocks to managing this common disease as effectively as possible.

Start by tackling inappropriate use of sliding scale insulin, which can put a resident and your facility on a slippery slope toward negative outcomes."Sliding scale insulin regimens leave too much room for error," and it's a reactive rather than proactive approach to treating hyperglycemia, says Naushira Pandya, MD, CMD, who chaired the American Medical Directors Association diabetes clinical practice guidelines.

Instead: Use sliding scale insulin as an adjunct for supplementing insulin in patients taking oral medications who are still achieving glucose control, Pandya suggests. Other candidates for sliding scale insulin include "patients new to insulin or medically unstable." The latter includes patients who aren't eating regularly or are too sick to eat -- or those on high dose steroids or just readmitted from the hospital, Pandya adds.

Also make sure to analyze the glucose logs. Pandya sees practitioners rely on the patient's A1c values rather than looking at the glucose log to see what's going on -- for example, is the person having a problem with glucose levels in the morning or evening? Looking at glucose log trends allows clinicians to adjust insulin therapy -- and even oral therapy in some cases  -- in a more logical way, she says.

As for achieving glucose control,guidelines recommend shooting for an A1c between 7 and 8 percent unless the person is terminally ill or has a very poor prognosis, says Pandya. "If the person is prone to hypoglycemia, then relax the glucose control. A reading in the 70s or 80s or even 90 in some people before breakfast may be too low. Before meals, a reading between 110 to 130 would be OK."

Tip: Consider moving to insulin for people with type 2 diabetes who have maxed out on two types of oral medication, advises Pandya. In that case, generally speaking, adding a third one does not help, she notes. If the person's diabetes remained uncontrolled, "then add a long-acting insulin."

Follow the Guidelines for Doing Lab Testing

The American Diabetes Association recommends A1c testing every three months, advises Pandya. But AMDA would tailor that to three to six months in long-term care depending on the patient's prognosis, she adds. What about lipid monitoring? Do the testing on patients with an expected lifespan of five or more years, advises Pandya. If the person has a life expectancy less than that, individualize the testing. "If the person has low lipid levels, you wouldn't monitor their lipids." If the person is on an antipsychotic, then he should receive lipid monitoring.

Liberalize the Diet

"All the major professional organizations ... believe residents should have a normal diet and not worry about excessive carbohydrate intake if they are getting fairly consistent carbs at each meal"-- and not eating a lot of food from outside sources, advises Pandya. (Post-acute residents in the SNF for a short time who are on a carb-controlled diet should continue to receive that diet, she adds.)

Maintaining consistent carbohydrate intake provides the key to diabetic control, agrees Brenda Richardson, MA, RD, LD, CD, a nutritional consultant in Pekin, Ind."The American Diabetes Association says there is no evidence to support that a diet with no concentrated sweets or added sugar makes a difference in blood glucose levels," Richardson notes.

Keep the resident's family in the education and care plan loop. The family can help by encouraging the resident to eat a healthy diet that limits excess snacking, Richardson notes. Family members "may help keep the resident content by providing his favorite foods in small amounts, especially if the resident requests them." Ask family members to notify nursing staff if their resident consumes a large amount of sweets or sweetened beverages as the resident may need close monitoring and/or medication adjustments, Richardson advises.

Provide Preventive Care

"People with diabetes should have a foot exam frequently, and be seen regularly by a physician," advises Evonne Fillinger, RN, BSN,WCC, RAC-CT, clinical operations consultant with Boyer & Associates in Brookfield, Wis.

"The foot exam should include a yearly neuropathy screen," adds Pandya. If the resident has peripheral neuropathy, he should have protective footwear, daily foot inspections,and diabetic shoes. And "step up diabetic control through use of oral medication or insulin."

More foot care tips: Make sure the person wears cotton socks, as synthetic materials tend to hold the moisture in and make the person more prone to fungal infections of the feet, advises Fillinger. The nursing staff can cut the diabetic person's toenails unless he has an infection or the nails are hypertrophic with a fungal infection, advises Pandya. "In that case, the patient may need a podiatrist," she adds.

Other preventive services include an annual eye and cognitive exam,adds Pandya. Also screen for depression. "People with diabetes are more prone to having depression," which could be due to their increased rate of cerebral atherosclerosis.

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