Diabetes care ward rounds issues and measures

At present, the three most prominent common problems in diabetes care ward rounds in domestic medical institutions at all levels are the implementation of individualized care plans, inflated self-management compliance verification of patients, and lagging early warning of acute and chronic complication risks. The core solution directions can be summarized as the effect of hierarchical responsibility binding, scenario-based verification of patients' true compliance, and multidisciplinary linkage pre-control port for complications.

To be honest, these problems cannot be solved by changing a few nursing records. Last week, I came across a typical example during bedside rounds in the Endocrinology Ward No. 3: 72-year-old Aunt Zhang had sequelae of cerebral infarction and her right limb muscle strength was only level 3. The nursing record clearly stated that "the patient has mastered the insulin pen injection operation." However, she was asked to demonstrate on the spot. She could not use half of her hands and could not pinch the skin. When she pushed out the medicine and pulled out the needle, she took out half a drop of the medicine, which was equivalent to a third less injection. Corey had held a special discussion meeting on this kind of issue before, and the two groups of people argued quite fiercely: the head nurse in the management post felt that the nurses were not trained well enough, so the frequency of operational assessments should be increased, and the patients must get full marks in each training to be considered successful. ； An old nurse who has been working on the front line for more than ten years feels that the problem is not in the assessment. "In the hospital, there are nurses holding her hands to practice, so of course she can pass. When she goes home, she lives alone with no one to help her, so no matter how familiar she is, it is useless." In the end, we compromised on a plan. During the ward rounds, in addition to checking the operation, we also asked, "Is there anything that didn't go well when you went home to do it yourself?" For Aunt Zhang, we equipped her with an injection auxiliary stand with a fixed buckle, which can be operated with one hand. After half a month, her fasting blood sugar dropped directly from 9.2 to 6.7 during the follow-up, which was much more effective than adding medication.

Speaking of this, I think of the 30-year-old type 1 diabetes patient I met last month. He is an Internet programmer. Every time we asked him during ward rounds whether he had measured his blood sugar on time, he took out the records on his mobile phone and showed us. They were all within the standard value of 4.8-7.0. When he was sent to the emergency room for ketoacidosis, and after adjusting the cloud data of his dynamic blood glucose meter, we discovered that he often stayed up late eating takeout, and didn't care when his blood sugar rose above 16. All the records on his mobile phone were copied from the normal ones, for fear that we would say he didn't follow the doctor's instructions. In the past, many hospitals relied on verbal questions + reading paper records to check compliance during nursing rounds, which led to many pitfalls. Now each hospital's approach is different: some tertiary hospitals have directly opened data ports with equipment manufacturers. With the patient's consent, raw data of dynamic blood glucose can be directly synchronized without manual reporting. ； Some community hospitals also take a "soft line" and sign a "self-management contract" with patients, making it clear that they will not criticize even if their blood sugar is high, but will only help adjust the plan, which in turn makes patients more willing to tell the truth. ； Some scholars have suggested that forced synchronization of data will infringe on patient privacy and reduce patient cooperation. Currently, there is no unified conclusion in the industry. Basically, each hospital chooses the appropriate method based on its own service population. Our department is now a combination of the two. If young patients are willing to use the device, they will synchronize their data. If the older patients cannot use smart devices, they will ask their accompanying family members to ask questions. It is much more reliable than just listening to the patients themselves before.

Another problem that is most easily overlooked is the lag in early warning of complications. Last year, an old uncle who had been suffering from diabetes for 21 years said he was not feeling well every time he was asked during ward rounds. It was not until he said that his feet were so numb that he could not walk that he discovered that there were early signs of diabetic foot, and he might face the risk of amputation in half a month. In the past, routine diabetes ward rounds basically only checked fasting/postprandial blood sugar. Now we have added 10g nylon wire to detect peripheral neuropathy and dorsalis pedis artery palpation as required items in daily ward rounds. This is done for inpatients every two weeks. Patients who are discharged will also have community nurses check at home for follow-up. Currently, it is still in the trial operation stage, but 3 patients with early peripheral neuropathy have been discovered in advance. Interestingly, some hospitals feel that there is no need to include these items in daily ward rounds, which will lengthen the ward round time and increase the workload of nurses. It is better to conduct complication screening once a month. Both models have their own advantages and disadvantages, and it also depends on the department's staffing configuration and the patient's severity of illness.

Speaking of diabetes care rounds, it's really like doing product testing for users. You can't just look at how good the questionnaire the other person fills out is, but you have to squat down and see where he gets stuck during actual operation. Otherwise, no matter how scientific the recipe is and how standardized the injection process is, it will be in vain if the patient cannot use it. We have stepped into many pitfalls before. We sent out identical printed recipes to all patients, but half of them turned around and threw them away. Later, we changed it to asking patients to report their favorite dishes. We helped change cooking methods and calculate consumption, and the acceptance rate tripled. In fact, after working in this field for a long time, you know that there is no one-size-fits-all measure. If you leave an extra two minutes during ward rounds and ask "Are there any difficulties?", many problems can be solved in advance, patients will suffer less, and our work will take less detours.