Authors: (including presenting author): :
Chan WS(1) Lin LH(1) Ozaki Risa(1) Yi YY(2) Lam CP(1) Kan PL(1) Fong PK(1) Yeung HM(1) Choy WY(1) Law KK(1) Lee SK(1)
Affiliation: :
(1) Diabetes Metabolic and Endocrine Centre, Prince of Wales Hospital (2) Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong
Keyword 1: :
Nurse-led intervention
Keyword 2: :
Improve Glycemic Control
Keyword 3: :
Insulin resistance
Introduction: :
Patients requiring daily insulin doses greater than 1 unit/kg/day are considered as insulin resistant. Yet, not all cases possess genuine insulin resistance; as many are pseudo-resistant resulting from poor injection technique, lipohypertrophy, improper insulin storage, or insulin non-adherence. Nurse-led interventions that identify and address these modifiable factors can significantly reduce insulin requirements and improve patient outcomes. In our program, nurse intervention extended beyond patient education and rectification of injection technique, to include nurse-led insulin titration using a multidisciplinary team approach. Case discussions with endocrinologists were followed by intensive titration protocols, ensuring individualized adjustments and close monitoring to optimize glycemic control.
Objectives: :
To evaluate the impact of structured nursing intervention, including nurse-led insulin titration and multidisciplinary case management, on insulin dose requirement, glycemic control, blood pressure, lipid profile, and hospitalization rates in patients with high insulin requirements (>1 unit/kg/day).
Methodology: :
A retrospective review was conducted on 85 patients with type 1 or type 2 diabetes who had been using insulin for more than one year, between June and September 2024 . Individuals were excluded from the study if they had type 1 diabetes, under 18 years of age, had psychiatric illness, or were receiving steroid therapy. Baseline demographic and clinical data were collected, including presence of lipohypertrophy and injection practices. Nursing interventions comprised correction of injection technique, site rotation, injection timing, storage practices, nurse-led insulin titration, and multidisciplinary case discussions with endocrinologists. Pre- and post-intervention comparisons were made for total daily insulin dose (TDD), HbA1c, blood pressure, lipid parameters, and hospital admissions rates. Statistical analyses included paired t-tests and McNemar’s tests, with significance set at p< 0.05.
Result & Outcome: :
Before intervention, lipohypertrophy was identified in 83.5% of patients, and 47.1% injected more than 40 units insulin in a single dose, both contributing to poor insulin absorption. After intervention, among the 87 patients with an insulin requirement exceeding 1 unit/kg/day, 67 individuals (77%) achieved a reduction to a requirement of less than 1 unit/kg/day. Furthermore, among the 47.1% of patients who were receiving a single insulin dose exceeding 40 units, 86% ultimately attained a single-dose insulin regimen below 40 units. The mean TDD significantly reduced from 87.0 ± 28.4 units to 58.0 ± 21.8 units (p< 0.001), which is a 31.21% reduction. with insulin requirement per kilogram falling from 1.27 ± 0.31 to 0.85 ± 0.29 units/kg (p< 0.001). HbA1c improved from 9.3 ± 1.7% to 7.9 ± 1.2% (p< 0.001). Blood pressure showed modest improvement, with a favorable reduction in diastolic values. Lipid parameters demonstrated selective benefit, with LDL cholesterol decreasing significantly, while HDL cholesterol and triglycerides remained unchanged. Hospital admission rates were also lower, with acute emergency visits reduced from 3.5% to 1.2% and hospitalizations from 18.8% to 1.2%. Overall, the intervention demonstrated meaningful improvements in patient outcomes, including better glycemic control, reduced insulin requirement, and fewer hospital admissions. These outcomes enhance quality of care and contribute to both immediate and long-term cost savings by reducing hospitalizations and medication costs from unnecessary high-dose insulin. But most importantly, to promote the key aim of reducing future diabetic complications.
