Date of Award

Spring 5-23-2020

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Karen Macauley, PhD, DNP, FNP-BC, GNP-BC

Abstract

Abstract

Purpose:The purpose of this evidence-based practice project is to decrease glycated hemoglobin (HgbA1C) levelsby initiating use of a manual insulin pump in patients with Type II Diabetes Mellitus (T2DM) with poor glycemic control who are on multiple daily insulin injections (MDII).

Background: Uncontrolled hyperglycemia is associated with a myriad of complications and co-morbidities that are generally associated with vascular changes that include nephropathy, neuropathy, blindness, stroke, and heart disease (Winter et al., 2015). Coronary artery disease and cerebrovascular disease alone accounts for approximately 65% of the deaths in diabetic patients (Molinaro & Dauscher, 2017). Achieving and maintaining therapeutic glycemic levels, blood pressure, and lipid control is essential in the prevention of these complications (Molinaro & Dauscher, 2017). A randomized clinical trial showed that initiation of a manual insulin pump in patients with T2DM with poor glycemic control reduced HgbA1C levels by ≥1% in 73% of patients (Lajara, Nikkel, et al., 2016). A meta-analysis study showed that at 6 months, HgbA1C levels decreased 1.1% with use of an insulin pump compared to a 0.4% reduction with MDII (Reznik et al., 2014).

Medical expenditures are approximately 2.3 times higher for people with diabetes than those without diabetes (American Association of Diabetes, 2018). Diabetic medications account for 43% of the medical burden with almost $15 billion spent on insulin alone, putting the total estimated cost of diabetes in the U.S. at $327 billion (ADA, 2018).

Outcomes:The goal for this project is ≥1% reduction in HgbA1c.

Process: Patients with T2DM ina southern California underserved community health center were assessed and identified for eligibility for placement of a manual insulin pump device. Data collection included HgbA1C levels prior to initiation of the pump and post-initiation per clinic protocols and provider orders. Patients were followed up for ongoing education and assessment as needed by the clinical pharmacist and clinic providers.

Results: Use of the insulin pump showed a mean significant decrease of -1.26% in HgbA1C levels.

Implications for Clinical Practice:The implementation of a simple insulin delivery system that improves glycemic controls in patients with T2DM is an evidence-based strategy providers can use to help patients manage uncontrolled diabetes, improve national diabetes score outcomes, lessen complications, increase treatment persistency and decrease harmful sequelae resulting from poorly controlled glycemic indexes.

Conclusions: Delivery via a basal-bolus regimen is still the gold standard for insulin therapy, and innovations in insulin delivery systems have helped patients achieve therapeutic glycemic levels. Initiating simple insulin delivery systems into eligible diabetic patient populations who have failed other pharmacological therapy may decrease financial expenditures, complications, and comorbidities associated with this disease.

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