Endoscopy or colonoscopy guidelines

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1 Endoscopy or colonoscopy guidelines for patients with diabetes The development and audit of local pilot guidelines for patients with diabetes undergoing an endoscopy or colonoscopy as an out-patient D Wamae, A McHoy* Introduction Undergoing an endoscopy or colonoscopy can be an anxiety inducing experience for anyone, yet having diabetes and managing an insulin regimen during bowel preparation and nil-by-mouth magnifies patient concern. In addition, poor compliance and control pre- can lead to complications such as hypo- and hyperglycaemia before and during the appointment, and in some cases lead to the being cancelled. In the light of contemporary developments in the management of diabetes, such as the use of basal insulins, it was recognised by the Diabetes and Endoscopy Units in which the authors work that there was a need to review and re-write the guidelines for patients undergoing an endoscopy or colonoscopy as an out-patient. This article aims to explore the process in which new local guidelines for patients with diabetes were developed, and how audit has been used as a tool to evaluate the guidelines and improve clinical practice. Method Following a literature search, no nationally recognised professional guidelines or standards were found for patients with diabetes undergoing an endoscopy/colonoscopy. Therefore, our Trust pre- information leaflets for patients, and the manufacturers product prescribing information guidance for oral ABSTRACT Local pilot guidelines for patients with diabetes undergoing an endoscopy or colonoscopy as an out-patient were developed to reduce patient anxiety and the risk of hyperglycaemia and hypoglycaemia prior to and during their. Audit was used as a tool to evaluate the guidelines. The audit highlighted that very few patients treated with insulin are prioritised to have their early on the morning list. The results demonstrated that, of the patients who normally experienced at least one hypoglycaemic episode (blood glucose <mmol/l) a week, none reported an increase in hypoglycaemia experienced, and five patients had improved control. Of the 8 patients who did not normally experience at least one hypoglycaemic episode a week, all patients continued to be free from hypos. Of the six patients who normally experienced at least one hyperglycaemic episode ( mmol/l) a week, none reported an increase in the frequency of their hyperglycaemia, and two patients had improved control. Of the patients who did not normally experience at least one hyperglycaemic episode a week, patients reported no increase in the frequency of hyperglycaemia. However, two patients reported transient asymptomatic hyperglycaemia. The guidelines have assured standardisation of advice now given to patients, and enabled elective patients treated with insulin to be scheduled first on the morning list. Contact with a diabetes specialist nurse has enabled patients to access specialist advice regarding their general diabetes management that they would otherwise have not received. Copyright 006 John Wiley & Sons, Ltd. Practical Diabetes Int 006; (): 0 0 KEY WORDS endoscopy/colonoscopy guidelines; audit; protocols agents and insulins, were used to develop the pilot guidelines. It must be noted that if future changes are made to these patient information leaflets for example, as research into the length of time a patient fasts influences protocols then the diabetes guidelines will need adjusting to reflect the changes. Sixteen variations of the guidelines were developed to reflect the most common treatments, the type of, and time of day for which the patient was booked. For example, Pilot Guideline 6 (Figure ) reflects advice for someone on a basal-bolus regimen having an endoscopy in the afternoon, whereas Pilot Guideline 9 (Figure ) is for someone on oral agents having a morning colonoscopy. The guidelines are in the format of flow charts with prompts to ensure blood glucose monitoring and treatment of hypoglycaemia are discussed. Standards As there were no baseline standards available, the objective of the project was to maintain the safety of patients Dionne Wamae, Dip PP, RGN, Diabetes Specialist Nurse Alison McHoy, BSc(Hons) PP, Dip PP, RGN, Diabetes Specialist Nurse Diabetes Centre, Worthing Hospital, Lyndhurst Road, Worthing, UK *Correspondence to: Alison McHoy, Diabetes Centre, Worthing Hospital, Lyndhurst Road, Worthing, West Sussex, BN DH, UK; alison.mchoy@wash.nhs.uk Received: 6 October 00 Accepted in revised form: March 006 Pract Diab Int April 006 Vol. No. Copyright 006 John Wiley & Sons, Ltd. 0

2 Figure. Guidelines for diabetic patients undergoing an afternoon endoscopy: qds/basal bolus regimen taken before midday NPH nocte, Levemir or Lantus taken after midday Day before the afternoon Take normal am dose of Take short/rapid-acting insulin as normal; eat and drink as normal Take short/rapid-acting insulin as normal; eat and drink as normal Take normal pm dose of. If due NPH take half normal dose Day of the afternoon Take normal am dose of Take a morning dose of with a, then nothing to eat and drink until after the Monitor BG at least hourly. May need to suck on dextrose tablets to keep capillary blood glucose above mmol/l Omit lunch-time dose of After the take short/rapid-acting dose Take a morning dose of with a, then nothing to eat and drink until after the Monitor BG at least hourly. May need to suck on dextrose tablets to keep capillary blood glucose above mmol/l Omit lunch-time dose of After the take short/rapid-acting dose following the new guidelines through preventing an increase in episodes of hypoglycaemia and hyperglycaemia. Three proposed standards were established with the assistance of the Audit Department and approved through the Audit Committee. Proposed standard. All patients treated with insulin should be first on the morning list. It has been recommended that patients with diabetes should be placed near the start of the morning list. The National Service Framework for Diabetes Standard 8 also states that protocols need to encompass the appropriate timing of investigations, hence it was reasoned that patients treated with insulin should be first on a list. Proposed standard. Patients undergoing an endoscopy or colonoscopy as an out-patient, who were following the local pilot guidelines, should not experience an increase in the frequency of hypoglycaemia (capillary blood glucose <mmol/l). Blood glucose of less than mmol/l is a frequently referenced figure to denote hypoglycaemia although patients may report clinical signs at higher or lower levels than this. Proposed standard. Patients undergoing an endoscopy or colonoscopy as an out-patient, who were following the local pilot guidelines, should not experience an increase in the frequency of hyperglycaemia (capillary blood glucose mmol/l). A consistent numerical definition of hyperglycaemia proved difficult to attain, although any premeal blood glucose level above 7mmol/L could be classified as hyperglycaemia. The authors recognise that capillary blood glucose levels above normoglycaemia are detrimental to the individual; however, as many of our patients have suboptimal control an arbitrary figure of mmol/l was used for audit purposes only. Sample The audit sample included the first 0 patients treated with oral agents and/or insulin, due for an endoscopy or colonoscopy as an outpatient, who were referred to the diabetes specialist nurse (DSN) helpline for advice. The audit period was between 6 November 00 and March 00. Patients were advised by the Endoscopy Unit to contact the Diabetes Centre not 0 Pract Diab Int April 006 Vol. No. Copyright 006 John Wiley & Sons, Ltd.

3 Figure. Guidelines for diabetic patients undergoing a morning colonoscopy: oral agents Gliclazide Glipizide Glimepiride Gliclazide MR Glibenclamide /tolbutamide Metformin Repaglinide Novonorm Nateglinide Starlix Acarbose Glucobay Rosiglitazone Avandia Pioglitazone Actos Day before the am Monitor BG at least hourly. May need to sip at clear sugary drinks to keep capillary blood glucose above mmol/l, i.e. Lucozade Take half morning dose of. doses of. due that day At 9.00 take Fleet as instructed Take morning dose of metformin doses of metformin due that day At 9.00 take Fleet as instructed Take morning dose of. doses of. due that day At 9.00 take Fleet as instructed Take glitazone as usual with a light breakfast before At 9.00 take Fleet as instructed Day of the am twice a day then omit am dose and just take normal pm dose three times a day then omit am dose. Once able to eat and drink after, take lunch dose. Take pm dose as normal once a day then omit dose until after the. Then take normal dose once able to eat and drink Take glitazone as usual If only takes. once a day, then omit dose but take it once eating and drinking. If it is after.00 then omit dose for that day am and pm then omit am dose and take pm dose as usual Pract Diab Int April 006 Vol. No. Copyright 006 John Wiley & Sons, Ltd. 0

4 more than two weeks prior to their. Patients who were treated with diet and exercise alone, not home blood glucose monitoring, or on treatment regimens not covered by any of the local pilot guidelines, were excluded from the audit. The DSN advised the patients over the telephone regarding their diabetes treatment for the period before their up until their first meal post-. The advice given to patients followed one of the 6 guidelines relevant to their treatment, type and time of their. A proforma of two parts was used to prompt questions and collect data, the first part being started on this initial contact. Patients were informed that an audit was being undertaken and permission to telephone them again after their was sought. A follow-up phone call was then made to the patient approximately five to seven days from when the preparation for the began. During this contact the DSN discussed with the patient how their blood glucose levels had been during this time and if any problems had occurred. The hospital record systems were also used to gather information, and data were analysed using Excel. Results Results against standards Standard (Figure ). The audit established that only 9% of patients using insulin were scheduled to have their within the first hour of the morning list, yet 9% of patients solely on oral agents were also booked in for the early morning slots. This highlighted that there was no distinction between methods of treatment in prioritising appointment allocations. It was also identified that certain consultants only undertook particular s in the afternoon and therefore some patients could not be given the option of a morning. Once again, only 9% of patients treated with insulin had their within the first hour of the afternoon list, with two patients with type diabetes not booked until.0pm. Figure. Time of day the patients were due their (n=0) Number of patients Not to to to to to to to to to known Time of day Type Type insulin-treated Oral agents Of all patients in the audit sample, only % had their within the first hour of the morning list. From the telephone discussions with patients, many expressed concern about not being able to eat/drink for long periods of time, and those taking insulin appeared to experience high levels of anxiety, especially if they were booked later in the day. Standard. Of the patients who normally experienced at least one hypoglycaemic episode a week, 6 Figure. Advice given in addition to information contained in the pilot guidelines Insulin transfer HbAc Diet & exercise Blood glucose monitoring To contact GP/ practice nurse Dose adjustment tablets Dose adjustment insulin Aims of control Hypoglycaemia 0 6 Number of patients none reported an increase in hypoglycaemia experienced, and five patients had improved control. Of the 8 patients who did not normally experience at least one hypoglycaemic episode a week, all patients continued to be free from hypoglycaemia. Standard. Of the six patients who normally experienced at least one hyperglycaemic episode a week, none reported an increase in the frequency of their hyperglycaemia and two patients reported improved 0 Pract Diab Int April 006 Vol. No. Copyright 006 John Wiley & Sons, Ltd.

5 control. Of the patients who did not normally experience at least one hyperglycaemic episode a week, patients did not report an increase in the frequency of hyperglycaemia. The two patients who reported temporary asymptomatic raised blood glucose levels had an HbAc of 8.6% and 0.%, and it is likely they were testing more frequently during this time, as advised by the guidelines. Key points Guidelines for the management of patients with diabetes having an endoscopy or colonoscopy improve patient care The use of guidelines standardises advice given to patients which is evidence based Involving diabetes specialist nurses in pre- care can improve patient outcomes and relieve patient anxiety Collaboration between the Diabetes and Endoscopy Units has enabled many more patients to have access to specialist advice Additional findings A 9% compliance rate identified that the local pilot guidelines were user friendly and not too complicated for the patients to follow. The remaining % did not follow the specific guidelines and were not questioned as to why; therefore conclusions here would be speculative. From the records available at the Diabetes Centre, many patients (6%) had not had access to the DSNs within the last year, whilst others were unaware the service existed. On discussing the forthcoming plans with patients it became apparent that a significant number of patients (68%) required advice on additional issues regarding their general diabetes control such as dealing with hypoglycaemia. This was advice that the patient would not have received if they had not contacted the Diabetes Department prior to their, and contributed to optimising control preinvestigation (Figure ). Discussion Audit limitations Much of the collected data was based on the patient s perception of their control i.e. not all patients perceived a blood glucose of less than mmol/l as hypoglycaemia because they were asymptomatic and therefore information collection relied heavily on the in-depth assessment and questioning by the person collecting the data. In addition, patients may not normally test their blood glucose so frequently and therefore only increased the number of tests once they were being asked to monitor closely and were expecting a follow-up. Increased testing following first contact with the DSN may have contributed to variances in control post- compared to pre-. It was felt that patients were unlikely to say that they did not follow the advice, or if they did anything different from the recommended guidelines, for fear of being penalised by the health professional asking the question. No adverse effects were identified when using the local pilot guidelines, although it must be noted that due to the fact that some regimens are more commonly used than others, not all the guidelines developed were utilised, and some were used only a few times. It is therefore unfair to comment on the guidelines that were not used. The most commonly used guidelines related to oral agents. Implications for practice The pilot guidelines have been well received by the DSNs, as they enable standardisation of advice and succinct exchange of information, while increasing patient access to the DSN service. Non-urgent patients, treated with insulin, are now prioritised and scheduled first on the lists, preferably in the morning. However, it was acknowledged that patients requiring an urgent endoscopy/colonoscopy needed to be investigated as soon as possible irrespective of time of day. The provision of specialist advice via our helpline, to patients who would otherwise have missed out, is regarded as a valuable part of the service provided by the DSN team. The Endoscopy Unit has now set up a process to ensure all patients treated with insulin or oral agents are referred to the DSNs for advice two weeks before their. The local pilot guidelines have been used for over nine months and have been a successful project for both departments. The guidelines are currently in the process of being ratified to become Trust policy and to extend the scope of their use for inpatients undergoing an endoscopy/ colonoscopy. The work has also led to interest from our Day Surgical Unit and Eye Surgery Department. Conclusion This project was initially resource intensive and took far longer than anticipated to get to this stage. Yet, through development and audit of locally driven guidelines, and by working collaboratively with the Endoscopy Unit, patient care has been positively influenced and advice given to patients with diabetes having an endoscopy or colonoscopy as an out-patient is now evidence based, standardised, and evaluated through audit. For further information on these guidelines please contact the authors. Acknowledgements With thanks to the Endoscopy Unit for their help and collaboration and for the support of the Audit Department. Conflict of interest statement None. References. Krentz A, Baily C. Type Diabetes in Practice. UK: Royal Society of Medicine Press Ltd. 00; 7.. DoH. The NSF for Diabetes Standards. London: Department of Health, 00.. Defronzo R, Ferrannini E, Keen H, et al. International Textbook of Diabetes Mellitus, rd edn. Volume. Chichester: Wiley & Sons, 00;. Pract Diab Int April 006 Vol. No. Copyright 006 John Wiley & Sons, Ltd. 0