Diabetes care safety management courseware

The core of diabetes care safety management is centered on the four core dimensions of prevention and control of abnormal blood sugar fluctuations, error prevention throughout the entire medication process, early screening and early control of complications, and patient self-management empowerment. The three goals of "error prevention, loss stopping, and efficiency improvement" are implemented in every practical detail of clinical diagnosis and treatment and home care. There is no absolutely unified standard. All plans must be dynamically adjusted to match the patient's age, disease course, cognitive ability, and living habits.

I came across a typical negative example while working the night shift in the endocrinology department last week: Aunt Zhang, who lives in bed 72, ate her granddaughter’s wedding candy the day before. She was afraid that the doctor would tell her that her blood sugar was high the next day, so she secretly took half an extra tablet of glimepiride without telling her family. As a result, she fell off when she turned over in bed at three in the morning.

When it comes to patients dispensing their own medicines, the nursing community has actually been arguing for many years. One group is firmly opposed, believing that patients are not professionals, and poor dosage control can lead to hypoglycemia and coma. All medication adjustments must be made by the doctor, and they cannot make changes by themselves even if they wait for an extra half day for the outpatient clinic. ； The other group was brought up by colleagues in community nursing. They said that many elderly people with diabetes who have stable long-term conditions will inevitably encounter special situations such as fever, overeating, and missed medicines. It is too late to go to the hospital. As long as systematic training is done in advance and the assessment is passed, fine-tuning of up to 1 unit of basal insulin or half a tablet of metformin/gliclazide can actually reduce the risk of large fluctuations in blood sugar. Among the patients I take care of is an old man who has been suffering from type 2 diabetes for 12 years. Last year, he had COVID-19 and his fever reached 39 degrees. I added 2 units of basal insulin according to the method I taught him before. His blood sugar remained stable at 8-10mmol/L throughout the disease and he did not go into ketosis. Of course, the premise was that I tested him and his family three times for the indications for adjusting the dose, and confirmed that they understood what conditions could be adjusted. After the adjustment, I needed to test the blood sugar and call him immediately if anything was wrong. Otherwise, I would not dare to let go.

Not only medication, but also the rotation of insulin injection sites now has two completely different guidelines. The requirements of European and American ADA guidelines are relatively loose. As long as each injection avoids induration and scars, and does not inject the same position twice in a row, there is no need to remember the grid. This is mainly because elderly patients are afraid that they will not be able to remember and will be burdened. ； Our country's 2022 version of diabetes care guidelines recommends the grid positioning method. Divide the abdomen into small grids with 2cm intervals, one at a time, and do it in order, which can minimize the probability of fat hyperplasia. I usually don’t stick to standards when educating patients. For young people with type 1 diabetes who get injections 4 times a day, I will give them stickable grid patches and they just need to take the injections in order. ； For those who are older and have poor memory and only take basal insulin once a day, ask them to memorize the four areas of "upper left, upper right, lower right, and lower left" and change one area every week. As long as they don't insert the same needle hole repeatedly, it doesn't matter even if the difference is 1cm occasionally. Don't put so much pressure on yourself.

Many people think that safe care means not getting the wrong injection or taking the wrong medicine. In fact, early screening for complications is also a major part of safety management. Last month, we jointly conducted a community free clinic with the ophthalmology department, and met a 68-year-old Uncle Wang. He said that his vision has been a bit blurry recently, and he thought it was due to increased presbyopia. A fundus check revealed that he had stage 3 diabetic retinopathy. If he had been checked six months earlier, an injection of anti-VEGF would have been able to control it. Now he needs three laser treatments to maintain his current vision. There are also different opinions on the frequency of screening. Some guidelines say that as long as glycation is below 6.5% for six consecutive months, fundus and urine microalbumin can be checked every two years. ； Some experts also say that regardless of whether blood sugar is stable or not, as long as the disease lasts for more than 5 years, it must be checked once a year. I am more inclined to the latter. I have managed a diabetic patient before, and his glycation has been below 6% for three consecutive years. The physical examination showed that the urinary microalbumin has increased. He didn't feel anything at all. After adjusting the medication, it was quickly reversed. If he waits for lower limb edema to be checked again, he may have reached stage 3 of kidney disease.

There are also many home care safety pitfalls that are easily overlooked, and many people would not believe them if they were told. A patient came for follow-up last week. The blood glucose meter has never been calibrated after 5 years of use. The measured blood sugar was 2.3mmol/L lower than the venous blood. He always thought that his blood sugar was controlled very well, but the result was that the glycation level was 7.9%. Some patients use an insulin needle seven or eight times in order to save money. Last time, an old man used a needle for almost a month and developed a large abscess in his abdomen. He had to stay in the hospital for a week before it recovered. The hospitalization fee was enough to buy several years of needles, so the gain outweighed the loss.

In fact, after more than ten years of working in diabetes care, my biggest feeling is that safety management has never been about holding a set of standard cards for everyone. Some people are more precise, injecting insulin according to the grid and measuring blood sugar 4 times a day, so that their blood sugar can be stabilized and their mood can be stabilized. ； Some people are more strict and cannot remember so many rules. As long as they don't mix medicine randomly, do screenings on time every year, and throw away needles after using them once, they can control it very well. The core is not to provide perfect care, but to avoid stepping into big pitfalls that can kill or cause disability, and to do the rest as comfortable as possible. After all, if your blood sugar is stable, your mentality will be more stable.