GLASGOW, SCOTLAND — Specific guidelines for patients with diabetes who have a scheduled endoscopy can help avoid an overnight hospital stay and also reduce complications, according to research presented at the Diabetes U.K. Annual Professional Conference.
The usual requirements for patients undergoing endoscopy include preprocedure fasting and bowel preparation, which can make it difficult for diabetic patients to maintain good glucose control, putting them at risk of dysglycemia during or after the procedure. However, developments in the management of diabetes, including use of basal insulins, mean that there are now opportunities to help diabetic patients manage these difficult situations.
Recognizing the inadequacy of current endoscopy guidelines at her hospital, Dionne Wamae, a diabetes specialist nurse (DSN) at Worthing and Southlands Hospitals NHS Trust, Worthing, England, along with fellow DSN Alison McHoy, developed new recommendations to help diabetes patients prepare for endoscopies.
“Before we started our study, patients on insulin were being admitted overnight and the guidelines didn't take account of the many different types of insulin available,” said Ms. Wamae. Furthermore, non-health professionals were frequently giving advice to patients before their procedures, and DSNs were giving varied, non-evidence-based advice, Ms. Wamae added.
Ms. Wamae and Ms. McHoy used literature searches, prescribing information for oral agents and insulins, and existing endoscopy guidelines to put together a set of 16 scenarios for management of patients with diabetes who are going to undergo endoscopy.
“Variations of the guidelines were developed to reflect the most common treatments, the type of procedure, and the time of day for which the patient was booked,” said Ms. Wamae.
For example, one guideline gives advice for someone on a basal-bolus regimen who is scheduled to have an endoscopy in the afternoon. Depending on the specific formulation of treatment they are taking, patients should adhere to normal treatments on the day before the procedure and the following morning, eating and drinking as normal, but omit their lunchtime dose of rapid-acting insulin and take an additional rapid-acting insulin dose with the evening meal after the procedure is complete. Another guideline describes what someone on oral agents for diabetes should do to prepare for a morning procedure. There are also additional recommendations included within the guidelines for monitoring of blood glucose.
There were no baseline standards available to see how diabetes patients fared on standard endoscopy guidelines. However, Ms. Wamae and Ms. McHoy did an audit to assess whether patients following the new guidelines successfully completed their planned procedures without an increase in the frequency of hypoglycemia or hyperglycemia.
The audit was undertaken for 16 weeks between November 2004 and March 2005, and included any adult with diabetes who was being treated with insulin or oral medication and who also was scheduled for an endoscopy or colonoscopy as an outpatient. The study sample included 40 patients.
During the course of the audit, the endoscopy department advised patients to call a DSN for advice 2 weeks prior to their procedure. The nurse instructed patients on how best to modulate their insulin or oral agent treatment in accordance with the new guidelines. Patients were then telephoned 5 days after they should have started their preprocedure preparation and asked about blood glucose control. In all, 68% of patients required preprocedure advice and 40% required advice on follow-up, but 32% asked for no advice at all.
According to Ms. Wamae, the audit showed that the guidelines worked well and improved the safety of patients. “Out of the 40 patients, none had an increase in number of hypoglycemic episodes, and some of the 12 patients who normally experience frequent hypoglycemia had fewer, possibly because of the benefits of having advice,” she said. Two patients experienced an increase in hyperglycemic episodes from the day they began preparation for their endoscopy.
An important finding from the study was that patients were more anxious if their procedure was later in the day, especially if they were on insulin. “All patients treated with insulin should be first on the procedure list in the morning,” said Ms. Wamae.
The guidelines are now hospital policy for both inpatient and outpatient endoscopies, and Ms. Wamae's colleagues at the hospital also have adapted them for day surgery procedures that normally take less than 11/2 hours. “Feedback has been very positive,” she said.