The management of deranged blood glucose levels in neurosurgical

Patients Taking Dexamethasone

Introduction

Corticosteroids cause hyperglycaemia in patients with and without pre-existing diabetes, and evidence suggests most patients receiving high dose corticosteroids will experience hyperglycaemia. The majority of patients with brain tumours receive dexamethasone perioperatively to reduce oedema and the associated neurological deficits. Alongside the obvious potential complications of hyperglycaemia, in neurosurgical patients it can also trigger a cascade of systemic and local cerebral effects that are associated with: poorer surgical outcomes, increased complications, prolonged admissions and increased mortality. In the Wessex Neurological Centre, we anecdotally observed that a proportion of neurosurgical patients’ taking dexamethasone that had delayed discharges due to deranged blood glucose l evels (BGL), and there was an overreliance on the input of the hospital’s Inpatient Diabetes Outreach Team (IDOT) in the management of these patients.

Aims

• To identify the number of delayed discharges due to deranged BGL in neurosurgical patients taking dexamethasone, and the proportion of which were known to have preexisting diabetes

• To improve the neurosurgical team’s ward-based management of post-operative patients with deranged BGL by developing a tailored protocol with with the aim of reducing the number of IDOT referrals and delayed discharges

Primary outcome measures

• To define the proportion of patients with deranged BGL that are referred to IDOT, and/or have delayed discharge solely due to high BGL.

• The development of a safe and effective protocol approved by IDOT and neurosurgical teams using an evidence based approach

Methodology

We conducted multi-faceted PDSA cycles to delineate the impact of high BGL and how and where we could optimise BGL management in neurosurgical patients taking dexamethasone.

• PDSA 1 - A questionnaire to explore the perceived confidence of the neurosurgical senior house officers/advanced nurse practitioners in managing hyperglycaemia in neurosurgical patients taking dexamethasone. This enabled us to tailor our intervention of developing concise clinical guidance, and subjectively gauge the future impact or improvement with the planned intervention.

• PDSA 2 - Patient Pre-op/BGL/Discharge data: We undertook retrospective data collection of patients undergoing resection of brain tumour (excluding biopsies, and meningiomas) between January–February 2021 in a single UK based neurosurgical centre. Data collected included pre-operative HbA1c (Yes/No), Known diabetes (Yes/No), Deranged BGL (>2 readings of >12mmol/L in 24 hours) (Yes/No), IDOT referral (Yes/No), Delayed discharge (Yes/No).

• PDSA 3-Flow charts for the management of hyperglycaemia, were co-developed by the UHS Neurosurgical and Adult Diabetes teams based on Joint British Diabetes Societies –‘Management of Hyperglycaemia and Steroid Therapy, May 2021’.

Patient identification

We retrospectively identified 57 patients under the neuro-oncology team in a 2-month period. Exclusions were 4 meningioma resections, and 11 biopsies. Of the 42 patients undergoing resection of a brain tumour, 38 received post-operative dexamethasone and were included in analyses.

PDSA 2 - Patient BGL, diabetes

Status

and the effect on discharge (Bar chart Right)

7/38 (18.42%) patients receiving postoperative dexamethasone had high BGL. 3/7 were new diagnoses of diabetes according to pre-operative HbA1c levels. 3/7 were previously known to have diabetes and 1/7 did not have diabetes. 3/38 (7.89%) patients had delayed discharges as result of high BGL.

PDSA 3- Managing hyperglycaemia in neurosurgical patients: ward-based management flow chart

Acknowledging our findings from PDSA 1 and 2, we initially developed written guidance to facilitate the neurosurgical team managing hyperglycaemia. However after discussion, the utility of a flow chart was preferred. Managing diabetes can be daunting for healthcare professionals. However, the desired impact of this guidance will allow the neurosurgical team to independently and safely manage hyperglycaemia in patients taking dexamethasone. This will reduce the clinical burden on the IDOT team, and empower the neurosurgical team. The aim is that this will directly result in reduced delays in treatment time for patients, by mitigating having to wait for IDOT review. The outcomes from our changes and the implementation of this guidance will be measured by evaluating future IDOT referrals and delayed discharges for this patient group.

Conclusions

Our preliminary findings elucidated a rationale for the development of further guidance in managing high BGL in neurosurgical patients taking dexamethasone. It is a common and predictable sequelae of the treatment, with potential to increase admission time.

Lessons learnt and reflections

We took a multifaceted approach which enabled us to identify multiple areas in which improvements could be made. It has helped me recognise the importance of a functioning MDT in the continuity of care of patients through from pre-assessment to discharge. The involvement of all stakeholders facilitated the sharing of ideas and the construction of an intervention that would benefit all. Pertaining to our unexpected finding that significant HbA1c results were going unactioned, I think that accountability as an individual and as a clinical team needs to be emphasised to maintain patient safety.

PDSA 1 - Questionnaire Results

12 healthcare professionals in neurosurgery responded to the questionnaire. Results indicated a scope for further education and guidance in order to increase confidence in managing hyperglycaemia and reduce reliance on IDOT.

Results of 3 (of 12) questions from the questionnaire for neurosciences SHO/ANP team regarding management of hyperglycaemia in neurosurgical patients. 1–Notatallconfident;5–Veryconfident

An unexpected finding -Pre-operative HbA1c measurement results 21/38 had HbA1c checked a pre-assessment or a recent HbA1c. 2/4 patients with known diabetes had there HbA1c checked. 4/21 patients who did have their HbA1c checked, were new diagnoses of diabetes but were not acted upon prior to admission.

Local standards: HbA1c should be requested for all patients with diabetes. However routine testing for patients not known to have diabetes is variable, and there is no current standard.

Verbal discussion with pre-assessment team elicited that in patients not known to have diabetes there is no formal escalation plan for high HbA1c

Guidance flow charts developed for the neurosurgical team in managing patients with hyperglycaemia taking dexamethasone. (Left)Patients known to have diabetes. (Right) Patients not known to have diabetes.

What next?

• Implementation and raised clinical awareness of the guidance and flow charts., after which repeat cycles of PDSA 1 –to gauge improvement in perceived knowledge and confidence of staff. PDSA 2 -To objectively measure the impact of the new guidance on IDOT referrals and delayed discharges. PDSA 3–Any further changes to the guidance or troubleshooting will be undertaken if required.

• The next aim will be to address the issue of ensuring elevated pre-operative HbA1c are escalated appropriately, in order to medically optimise patients before surgery and mitigate inpatient high BGL, and thus complications and prolonged admissions.

By Ibukun Osuntoki, Aiknaath Jain, GbemiAjao and Issa Beegun

Are patients receiving their medications within an appropriate timeframe following their admission under ENT?