Paper
Friday, July 15, 2005
Nurse Case Management of Diabetic Clinic Patients
Abigail E. Marter, RNC, BSN, Pulmonary Medicine Clinic, Naval Medical Center, San Diego, CA, USA and Cynthia J. Gantt, RN, FNP, PhD, Head, Population Health Department, Naval Medical Center San Diego, San Diego, CA, USA.
Background: An evidence based nursing (EBN) research committee was established using the Iowa Model of Evidence-Based Practice to Promote Quality Care in a large military medical treatment facility (MTF). This pilot study resulted from the identification of a “problem focused trigger” related to the care of outpatients with diabetes mellitus (DM). Previously, case management (CM) of DM patients was reactionary and dependent upon primary care managers (PCM) submitting a formal consult to one designated RN. Previous studies have demonstrated improvements in clinical indicators such as A1c and process measures such as rates of eye exams and attendance at self-management programs with RN CM. Objective: This pilot study evaluated the effects of proactive RN contacts using office visits and telephone calls on selected clinical outcomes and process measures for DM patients. Research Design and Methods: A total of 93 patients with newly diagnosed diabetes and those in poor glycemic control (A1c >7.5%) were targeted for proactive clinic-based RN CM services. Baseline and follow-up levels of A1c, microalbumin, LDL; rates of dental, foot, and retinal exams; and attendance at DM self-management and nutrition classes were examined. PCM and time since diagnosis were also addressed. Results: RN contacts were associated with improved A1c levels, increased rates of foot, dental and retinal screening examinations, and attendance at DM self-management and nutrition classes. Neither RN office visits nor telephone contacts alone demonstrated significant results. No associations were found between length of time since diagnosis and RN contacts or primary care manager and A1c results. Conclusions: An organization-wide EBN initiative resulted in this pilot study that demonstrated the positive outcomes associated with proactive CM using existing RN staff. This study has resulted in the diffusion of proactive RN contacts for DM patients by all clinic nurses, and has expanded to patients without an annual A1c test.