Kidney Transplant Patients with Diabetes Get the Help They Need

Kidney Transplant Patients with Diabetes Get the Help They Need

Linda Cohen, RN, MSN, MPH, CDE; Nelcia Trim, RN, BSN; Jocelyn Alleyne, RN, MSN; and Stephen R. Marrone, RN-BC, EdD, CCRN, CNOR
Monday December 17, 2007

The science of transplantation has grown enormously over the past decade. As a result of these advances, a patient's age is no longer a criterion for transplant eligibility at most U.S. transplant centers. Along with increased age,however, comes a greater risk for developing diabetes. Diabetes is the leading cause of end-stage renal disease, accounting for about 45% of new cases, according to the American Society of Nephrology (www.ASN.org).

Contrary to popular belief, hospitalized patients are faced with daily challenges that can significantly affect their diabetes management and control — timing of meals; insulin therapy; timing of blood glucose monitoring; and a multitude of diagnostic and therapeutic procedures routinely required that take the patient off the unit for long periods of time. Compounding these routine factors are other stressors that can also have an effect, such as infection, fever, glucocorticoid therapy, surgical trauma, and general medical stress.

Kidney transplant recipients must also face taking immunosuppressive agents such as steroids, calcineurin inhibitors (cyclosporine), and tacrolimus. These agents are well known to cause havoc with glucose control. It is therefore no surprise that glycemic control can pose additional problems and an enormous challenge for these high-risk patients.

At SUNY Downstate Medical Center, Brooklyn, N.Y., a recent pattern in insulin-reported errors in our large kidney transplant population (3,000 transplants to date), along with a lack of standardized diabetic management protocols (each physician on the Transplant Unit wrote his or her own diabetic management orders, which can result in a wide range of orders being given), prompted Nelcia Trim, RN, BSN, assistant director of Nursing, (Transplant Unit) and Linda Cohen, RN, MSN, MPH, CDE, assistant director of Nursing, to come up with a plan for improvement. Cohen had completed a research study on diabetes management for her graduate nursing research class and was the perfect choice to collaborate on this project. (See sidebar).

A Great Start

Cohen and colleagues found that the risk of pre-lunch hyperglycemia was more than 5 times greater in those who started breakfast more than 45 minutes after receiving insulin. Based on those findings, a pilot program was conducted using pre-printed orders that were developed with input from the Transplant Nursing and Surgical Staff, the Nursing Performance Improvement Council's Diabetes Subcommittee and the multidisciplinary Glycemic Control Committee. These orders included critical components for inpatient management —

• time of pre-prandial bedside capillary glucose testing;

• insulin administration times (with different lead times prior to eating based on type of insulin);

• diet orders;

• correction dose and schedule; and,

• hypoglycemia treatment.

To make patient information readily available for the various healthcare providers, the pre-printed form included two parts — the actual order was listed on the front and a list of the daily blood glucose values, the medication administration record, and daily food intake record on the reverse side. Having all components of diabetes management on one form and in one area enhanced the clinicians' ability to make a comprehensive plan with all the critical information at hand. For physicians who had limited exposure to and experience with diabetes, it was a superb learning opportunity. We also found that the nurses often used it as a teaching tool during patient and family education sessions.

Positive Results

Prior to the study, insulin was administered by the night nurses before breakfast was served on the day shift, and breakfast was served two to three hours after the patients received insulin. This delay resulted in patients experiencing episodes of hypoglycemia. Post-study, insulin is given just before the patient eats breakfast. Since this protocol was initiated, there has been a marked decrease in hypoglycemic episodes and nursing care time is no longer spent contacting physicians for orders to treat hypoglycemic episodes.

There has been a steady increase in the awareness and activity regarding improving inpatient glycemic control throughout the hospital since completing the study. Some of the initiatives include developing and implementing a hypoglycemia protocol that gives the nurses the authority to administer intravenous dextrose, intramuscular glucagon, glucose tablets, or apple juice for various clinical situations. We have also added a diabetes component in the nursing orientation schedule that focuses on the importance of glycemic control and new hypoglycemic agents in the hospital.

Linda Cohen, MSN, MPH, RN, CDE, is assistant director of nursing, Nelcia Trim, RN, BSN, is a ssistant director of Nursing, Jocelyn Alleyne, RN, MSN, is director of nursing, Oncology and Transplant Services, and Stephen R. Marrone, RN-BC, EdD, CCRN, CNOR, is director of Nursing Education and Research at SUNY Downstate Medical Center, Brooklyn, N.Y.

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