Introduction
In 2020, it was estimated that 5.2% of total Hong Kong population suffered from Diabetes Mellitus (DM). The majority of DM patients who required Community Nursing Services (CNS) for empowerment of DM self- management were frail elderly. Hypoglycaemic incidents in this patient group were at greater risk of causing severe adverse events, including functional decline, repeated admission and even death if problems unaddressed.
Continuous glucose monitoring (CGM) system refers to a sensor continuously measuring glucose levels in the interstitial fluid for a long period of time. Patients’ glucose profile can be shown in the reader instantly. Corporate CNS teams have implemented a pilot project of using this painless smart device to enhance support for these high-risk DM elderly from June 2022 to February 2023. The aim of this study was to examine the feasibility of picking up asymptomatic hypoglycemic episodes followed by timely interventions by using the CGM system. Individualized nursing care plan would be formulated according to patients’ glucose profile for empowering their DM self-management skills.
Objectives
1. To improve patients’ glycemic control
2. To detect asymptomatic hypoglycemia (Hypo G)
3. To empower patient’s DM self-management skills
4. To prevent avoidable emergency admission due to poor DM control by early medical-nursing intervention
Methodology
A prospective study was conducted to review the variations of recruited patients’ glucose profiles and DM self- care abilities after eight weeks DM empowerment program. DM patients aged 60 or above without care by DM specialist clinic would be recruited. Patients’ self-monitoring blood glucose (SMBG) profile and the 14-item Summary of Diabetes Self-Care Activities Assessment (SDSCA) were assessed in pre-intervention phase as baseline information. Two sets of CGM were applied at the first week and the 7th week with a duration of 14 days each time. Community nurses provided personalized lifestyle modification and/or seeking consultation from specialists according to CGM results. The primary outcome was the change of patients’ glucose profile in terms of time in range (TIR: 4-10mmol/L). Secondary outcomes included (1) hypoglycaemia (hypo G) events (self-reported reading < 4 mmol/L from CGM/SMBG data); (2) time below range (TBR: hypo G occurrence consisting of 2 levels. 1. Low level: 3.9-3 mmol/L. 2. Very low level: 13.9 mmol/L). At the end of 6th week, post intervention SDSCA was conducted to compare the differences in patients’ DM self-care abilities. Pre-post intervention HbA1C comparison was conducted. Furthermore, patients’ accident & emergency attendance and unplanned admission related to DM complication would be monitored during the program.
Result
Demographic data
Program completed at the end of February 2023, a total of 68 patients (33 females and 35 males; mean age: 77.4 years, range: 60-99 years) completed eight weeks’ DM empowerment program. Their duration of DM ranged from 1 to 37 years. Blood glucose of 44 patients (64.7%) were controlled by insulin +/- oral antidiabetic medication.
Outcomes
The mean TIR was improved by 1.8%, from 62.3% to 64.1% (n=37) (p=0.464). 27 out of 37 TIR increased patients (73%) were improved by more than 5%, which was indicating clinically beneficial results with each 5% increase in TIR according to ADA recommendation.
Pre and post HbA1C results were available in 44 patients (64.7%). Mean of HbA1C was reduced by 0.4%, from 8.3% to 7.9% (p=0.017) after intervention.
19 patients (27.9%) reported a total of 33 hypo G episodes detected by SMBG in pre-intervention phase. On the contrary, CGM system detected 54 patients (79.4%) experienced hypo G with total 425 episodes during the 1st application; in which 60% (n= 255) of asymptomatic hypo G occurred at midnight and during fasting.
In evaluating the effect on time below and above target glucose range, mean TBR was reduced by 1.1%, from 6.9% to 5.8% while mean TBR very low level was reduced by 1.6%, from 2.7% to 1% (p = 0.036). The mean TAR was reduced by 0.7%, from 30.8% to 30.1% while mean TAR very high level was reduced by 2.7%, from 12.7% to 9.7% (p=0.111).
By comparing pre and post SDSCA items to assess patient’s crucial DM self-care activities, including general and special diet, exercise, glucose monitoring, foot care, medication and hypo G management, the program showed that patients reported significant improvement in all of the self-care activities (p< 0.005) except medication since high scores were observed in both phases.
35 early follow up and adhoc consultation were initiated by CN for suboptimal glycemic control. All these interventions were timely taken during CGM application. None of these patients had accident & emergency attendance or unplanned admission due to DM condition during the 8 weeks program.
Conclusion
This CQI project demonstrated effectiveness of smart devices to detect asymptomatic hypoglycemic conditions compared to the conventional practice. Furthermore, CGM result provided a precise and clear information, in which increased community nurses’ alertness for initiating consultation and conducting individualized patient care plan timely. Also, patients were markedly motivated by community nurses showing improvement in DM self-management with device assistance. Moreover, their blood glucose controls were improved as evident by narrowed down the glucose fluctuation and the post intervention HbA1c were reduced significantly.
No patient attended AED or required hospitalization for poor diabetic condition during program period.
The overall results might not be statistically significant due to the small sample size. However, the project achieved a milestone in delivering safer patient care with smart technology for high-risk elderly in community care.
