Diabetes Care Practices Research Articles

Diabetic Retinopathy Screening by General Practitioners Using Non- Mydriatic Retinography

Diabetic retinopathy (DR) is the leading cause of visual loss in people aged 30 to 69 years. Most authorities recommend screening of the ocular fundus to prevent severe visual loss. The increasing incidence of diabetes mellitus and fewer ophthalmologists in many countries is leading to inadequate screening. Establishing an adequate system for DR screening is a complex issue and represents a challenge for most health authorities. To alleviate the burden of DR screening for most health systems, some investigators have suggested that general practitioners (GPs) perform the initial screenings. The aim of this article was to review the current status of DR screening performed by GPs using non-mydriatic retinography. The five studies analyzed in this review indicated that after adequate training GPs can be effective and reliable screeners of DR using non-mydriatic retinography. Including GPs in the screening model would be a useful way to alleviate the increasing demands of ophthalmic care resulting from the increased prevalence of diabetes mellitus. In addition, GPs would have full control of the diabetic process, which could bolster their motivation and confidence in other areas of diabetes care and medical practice. Keywords: Diabetic retinopathy screening, General practitioners, Non-mydriatic retinography

Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: A randomized controlled trial

BackgroundType 2 diabetes is a serious and growing problem in Taiwan where it is the fifth leading cause of death, and health care costs are 4.3 times higher than for people without diabetes. ObjectivesThe purpose of this study was to determine whether participation in a motivational interview for people with type 2 diabetes would improve their self-management, psychological and glycemic outcomes. DesignA randomized controlled trial to assess the effects of the motivational interviewing intervention. SettingsParticipants were drawn from the diabetes outpatient clinic of a large teaching hospital in South Taiwan. ParticipantsA sample of 250 type 2 diabetes people. MethodsType 2 diabetes people were randomly allocated into either the motivational interview group or the usual care group from baseline to 3months follow-up. The intervention was based on motivational interviewing which encompassed a variety of interviewing techniques, and reflected each person's readiness stage to change. The control group was provided with usual care by nursing staff. ResultsA total of 250 type 2 diabetic participants were randomized. The retention rate in the intervention group was 83% (n=104). The motivational interview did improve participants significantly in self-management, self-efficacy, quality of life, and HbA1c among diabetes people with appropriate baseline value (<121.24, <174.57, <107.18, and >7.62, respectively) but not in depression, anxiety and stress (F=0.13, p=0.72) compared to the control group at 3months follow-up. ConclusionThe findings provided important evidence concerning the positive effect of motivational interventions in self-management, psychological and glycemic outcomes. This research provided evidence for future clinical practices in diabetes care.

Diabetes care in India: Assessing the need for Evidence-Based education

The top 3 countries with the highest number of people living with diabetes are China, India and USA. Diabetes not only reduces the quality of life and life expectancy, but also imposes huge economic burden on the health system and families. For improved diabetes care and patient outcomes continuing medical education of the existing health work force in evidence based diabetes care is essential. Patient’s education in diabetes self-management is also essential. This article reviews the existing literature on evidence based practice in diabetes care and barriers at physician-patient level to suggest that there is legitimate need of competency based training in diabetes management. The article also attempts to identify some of these existing educational programmes in diabetes management in India and their key strengths.

Surveillance of an Online Social Network to Assess Population-level Diabetes Health Status and Healthcare Quality.

Objective:Test a novel health monitoring approach by engaging an international online diabetes social network (SN) in consented health surveillance.Methods:Collection of structured self-reports about preventive and self-care practices and health status using a software application (“app”) that supports SN-mediated health research. Comparison of SN measures by diabetes type; and, SN with Behavioral Risk Factor Surveillance System (BRFSS) data, for US-residing insulin dependent respondents, using logistic regression.Results:Of 2,414 SN app users, 82% (n=1979) provided an A1c and 41% (n=996) completed a care survey of which 931 have diabetes. Of these: 65% and 41% were immunized against influenza and pneumonia respectively, 90% had their cholesterol checked, 82% and 66%, had their eyes and feet checked, respectively. Type 1/LADA respondents were more likely than Type 2/pre-diabetic respondents to report all five recommended practices (Adjusted OR (95% CI) 2.2 (1.5, 3.2)). Past year self-care measures were: 58% self-monitored their blood glucose (SMBG) ≥ 5 times daily, 37% saw their diabetes nutritionist, 56% saw a diabetes nurse educator, 53% saw a doctor for their diabetes ≥ 4 times. Reports of health status did not differ by diabetes type in the SN sample. The SN group was more likely than the BRFSS comparator group to use all five preventive care practices (Adjusted OR (95% CI) 1.8 (1.4, 2.1) and SMBG ≥ 5 times daily (Adjusted OR (95% CI) 10.1 (6.8, 14.9).Conclusions:Rapid assessment of diabetes care practices using a novel, SN-mediated approach can extend the capability of standard health surveillance systems.

Using Electronic Health Record Systems in Diabetes Care: Emerging Practices.

While there has been considerable attention devoted to the deployment of electronic health record (EHR) systems, there has been far less attention given to their appropriation for use in clinical encounters - particularly in the context of complex, chronic illness. The Department of Veterans' Affairs (VA) has been at the forefront of EHR adoption and, as such, provides a unique opportunity to examine a mature EHR system in widespread use. Moreover, with a high prevalence of diabetes in its patient population, the VA provides a useful platform for examining EHR use in the context of chronic disease care. We conducted a sequential, exploratory qualitative study at two VA Medical Centers in the Midwest. First, we conducted observations of 64 clinical consultations with diabetes patients. These observations involved 31 different health care providers. Second, using insights from these observations, we conducted in-depth, semi-structured interviews with 39 health care providers focusing on their use of information in diabetes patient care. Field notes and interview transcripts were analyzed using a grounded theory approach. Our analysis generated several categories of EHR use in clinical encounters: priming, structuring, assessing, informing, and continuing. We also outline some mismatches between EHR system design and VA diabetes care practices. We conclude by discussing implications of these emergent system uses for improving the software design of EHRs to better support chronic disease care, as well as for our understanding of the integration of technologies in health care.

2010 Consensus statement on the worldwide standardization of the hemoglobin A1c measurement

This article is being simultaneously published in 2010 in Annals of Clinical Biochemistry, Clinical Chemistry, Clinical Chemistry and Laboratory Medicine, Diabetes Care, Diabetes Research and Clinical Practice, Diabetologia, Diabetic Medicine and Pediatric Diabetes. Copyright 2010 by The American Diabetes Association (ADA), the European Association for the Study of Diabetes (EASD), the International Diabetes Federation (IDF), the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and the International Society for Pediatric and Adolescent Diabetes (ISPAD). Copying with attribution allowed for any noncommercial use of the work.

Evaluation of the Potential for Bloodborne Pathogen Transmission Associated with Diabetes Care Practices in Nursing Homes and Assisted Living Facilities, Pinellas County

To evaluate and characterize routine blood glucose monitoring practices in nursing homes and assisted living facilities (ALFs). Cross-sectional, self administered survey and facility site visit. Two hundred eighty-nine licensed long-term care facilities in Pinellas County, Florida. Stratified random sample of 48 long-term care facilities (17% overall sample). Data on facility characteristics, infection control policies, staff practices, and equipment used for blood glucose monitoring. Differences between facilities in each stratum were compared and evaluated using the Pearson chi-square or Fisher exact test. Fifteen nursing homes and 17 small and 16 large ALFs participated; 53 declined (48% participation rate). Bloodborne pathogen training (P=.02), hepatitis B vaccination (P=.003), and blood glucose monitoring (P<.001) policies were reported less often at ALFs. Staff glove use during blood glucose monitoring was lowest (50%) at small ALFs (P=.02). Reusable fingerstick devices intended for personal use were most often in use at ALFs (P<.001); four of 18 facilities (including 1 nursing home) were inappropriately using them for multiple residents. At 22 facilities (including all nursing homes), multiple residents shared blood glucose meters; only six (27%) reported cleaning them after each use. Despite existing recommendations, practices that facilitate bloodborne pathogen transmission during blood glucose monitoring were identified at nursing homes and ALFs. Infection control practices and policies were most often lacking at ALFs. Better training and oversight of blood glucose monitoring in long-term care is needed to prevent transmission of bloodborne pathogens.

Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study

In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n=4198) in 10 US health plans across the country and their physicians (n=1217). We characterized physicians' diabetes care PDM preferences and practices as 'no patient involvement,' 'physician-dominant,' 'shared,' or 'patient-dominant' and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients'satisfaction with physician communication; and (3) whether patients' A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. Most physicians preferred 'shared' PDM (58%) rather than 'no patient involvement' (9%), 'physician-dominant' (28%) or 'patient dominant' PDM (5%). However, most reported practicing 'physician-dominant' PDM (43%) with most of their patients, rather than 'no patient involvement' (13%), 'shared' (37%) or 'patient-dominant' PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred 'shared' PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred 'patient-dominant' treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred 'no patient involvement' in treatment decision-making. There were no differences in patients' satisfaction with their doctor's communication or control of A1c, SBP or LDL depending on their physicians' PDM preferences. Physicians' self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses. Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes.

Evaluation of an online Diabetes Needs Assessment Tool (DNAT) for health professionals: a randomised controlled trial

BackgroundContinuous medical education is traditionally reliant to a large extent on self-directed learning based on individuals' perceived learning priorities. Evidence suggests that this ability to self-assess is limited, and more so in the least competent. Therefore, it may be of benefit to utilise some form of external assessment for this purpose. Many diabetes educational programmes have been introduced, but few have been assessed for their benefit in a systematic manner. As diabetes is an increasingly prevalent disease, methods for the dissemination and understanding of clinical guidelines need to be explored for their effectiveness. This paper describes the study design of a randomised controlled trial to evaluate the effectiveness of using an interactive online Diabetes Needs Assessment Tool (DNAT), that builds a learning curriculum based on identified knowledge gaps, compared with conventional self-directed learning. The study assesses the effect of these interventions on health professionals' knowledge of diabetes management, evaluates the acceptability of this process of learning and self-reported changes in clinical practice as a result of this novel educational process.MethodsFollowing a baseline assessment, participants will be randomised to undergo a 4-month learning period where they will either be given access to the diabetes learning modules alone (control group) or a Diabetes Needs Assessment Tool (DNAT) plus the diabetes learning modules (intervention group). On completion of the DNAT, a personalised learning report will be created for each participant identifying needs alongside individualised recommendations of the most appropriate learning modules to meet those requirements. All participants will complete a Diabetes Knowledge Test before and immediately after the allocated learning and the primary outcome will be the state of knowledge at 4 months. Learners will also be surveyed immediately after the learning period to assess the acceptability of the learning formats and the perceived usefulness and usability of the materials. After a further month, all learners will receive a series of questions to evaluate self-reported changes in clinical practice as a result of this educational experience and asked to include specific examples of any changes in their diabetes care practice.Trial registrationCurrent Controlled Trials ISRCTN67215088

HbA1c — new unit of measurement necessitates a new educational exercise

For those of a certain generation there was a time before routine HbA1c measurement, when the adequacy of diabetes control was assessed simply from serial urine tests supplemented by the occasional random blood glucose estimation. Seemingly sufficient at the time, we now know this means of monitoring was clearly inadequate, and the consequence of such inevitable poor control was associated with a prevalence of serious long-term diabetic complications substantially higher than those seen today. Along with blood glucose self-monitoring, the introduction of HbA1c measurement in the early 1980s heralded an exceptional milestone in diabetes care, coincident with developing awareness that good diabetes control was important if risk of complications was to be minimised. The principle of having an extended time-linked indicator of diabetes control was an entirely new concept in clinical care and its implications were immediately apparent to both patient and doctor alike (no specialist nurses on the scene at this stage!). Initially restricted to specialist hospital-based diabetic clinics, where in fact the majority of people with diabetes were then seen, HbA1c testing gradually became an established part of good clinical practice in diabetes care and an essential component of the annual review process. Indeed, its importance is recognised by priority inclusion within current ‘Quality Framework’ targets. All now involved in delivering diabetes care will be fully familiar with the fundamental knowledge gained from HbA1c measurement as an indicator of overall glycaemic control and that, derived from studies such as DCCT and UKPDS, the results can be extrapolated to provide an evidenced-based signal of long-term risk for the development of diabetic complications. Health care professionals now depend on the ready availability of quality-assured, reliable HbA1c measurement and the latest result will always be a main focus of discussion in a clinical consultation. Much will pivot on that outcome. However, its interpretation has not always been that straightforward. The similarity of unit expression between blood glucose concentration and HbA1c as a percentage of total haemoglobin often gives rise to the impression that both are one and the same. Yet, they are clearly not so and with the HbA1c% tracking significantly below the average glucose, a false interpretation of control may be made. In addition, despite laboratory efforts to reference to the DCCT specific standard, a need for a better global standardisation has been identified. For these and other reasons from 1 June 2009 the unit of measurement of HbA1c will change to mmol/mol and the figures will look very different. For example, present HbA1c levels of 6.5% and 7.5% will be reported as 48 mmol/mol and 59 mmol/mol, respectively (Table 1). For two years the old units will still be provided in parallel. The principle of measurement remains the same and some limitations as previously in respect of certain confounding haematological disorders remain. Yet it will require a focused educational exercise to ensure that the new reporting of HbA1c is understood and implemented safely into routine clinical diabetes care. With this purpose in mind two information sheets, one for clinical health care professionals and one for people with diabetes, have been produced from the Association for Clinical Biochemistry, NHS Diabetes and Diabetes UK. Copies can be downloaded from the latter's website: www.diabetes.nhs.uk. The changeover is imminent but it will be an interesting transitional time.

New measures of diabetes self‐care agency, diabetes self‐efficacy, and diabetes self‐management for insulin‐treated individuals with type 2 diabetes

To develop and refine three new scales that measure diabetes self-care agency, diabetes self-efficacy and diabetes self-management to reflect the American Diabetes Association current standards of diabetes care and the American Association of Diabetes Educators self-care behaviours. And, to establish the clarity, consistency and content validity of the scales. There is a need to have valid and reliable instruments or scales to assess an individual's diabetes self-care agency, self-efficacy and self-management to plan appropriate interventions that can be effective in improving glycaemic control and delaying or preventing diabetes-related complications. A methodological design was used to conduct this study. Ten clinicians and 10 insulin-treated individuals with type 2 diabetes (T2DM) from a diabetes care center in the southern USA participated in this study. Analysis consisted of inter-rater agreement to determine clarity and consistency with standards of diabetes care and content validity of individual items on the scales (I-CVI) and the overall scales (S-CVI/Ave) to determine relevance for current diabetes care practice. All I-CVI and S-CVI/Ave of the DSES exceeded the minimum acceptable criteria. All I-CVI and the S-CVI of the DSMS also exceeded the minimum accepted criteria, except for one item that had I-CVI = 0.70. Evaluation of the items and the directions of the scales by the sample of insulin-treated individuals with T2DM exceeded the minimum criteria of 80% inter-rater agreement. RELEVANCE TO RESEARCH AND CLINICAL PRACTICE: Further psychometric testing of the scales with samples of insulin-treated individuals with diabetes is warranted and will lay the groundwork for further research and clinical practice to enhance the capability, confidence and actual performance of diabetes self-management activities among insulin-treated individuals with T2DM. The scales can be used by diabetes care providers to assess and follow-up individuals with diabetes who need intense case management. They also can be the measures of choice to conduct future research to test the effects of interventions among insulin-treated individuals with T2DM.

Educating Families on Real Time Continuous Glucose Monitoring

The purpose of this article is to describe the process of educating families and children with type 1 diabetes on real time continuous glucose monitoring (RT-CGM) and to note the similarities and differences of training patients using continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI). A total of 30 CSII participants and 27 MDI participants were educated using the Navigator RT-CGM in a clinical trial. Time spent with families for visits and calls was tracked and compared between patient groups. The Diabetes Research in Children Network (DirecNet) educators were surveyed to assess the most crucial, time intensive, and difficult educational concepts related to CGM. Of the 27 MDI families, an average of 9.6 hours was spent on protocol-prescribed visits and calls (not measured in CSII) and 2 hours on participant-initiated contacts over 3 months. MDI families required an average of 5.4 more phone contacts over 3 months than CSII families. According to the DirecNet educators, lag time and calibrations were the most crucial teaching concepts for successful RT-CGM use. The most time was spent on teaching technical aspects, troubleshooting, and insulin dosing. The most unanticipated difficulties were skin problems including irritation and the sensor not adhering well. Educators who teach RT-CGM should emphasize lag time and calibration techniques, technical device training, and sensor insertion. Follow-up focus should include insulin dosing adjustments and skin issues. The time and effort required to introduce RT-CGM provided an opportunity for the diabetes educators to reemphasize good diabetes care practices and promote self-awareness and autonomy to patients and families.

Are family factors universally related to metabolic outcomes in adolescents with Type 1 diabetes?

To assess the importance of family factors in determining metabolic outcomes in adolescents with Type 1 diabetes in 19 countries. Adolescents with Type 1 diabetes aged 11-18 years, from 21 paediatric diabetes care centres, in 19 countries, and their parents were invited to participate. Questionnaires were administered recording demographic data, details of insulin regimens, severe hypoglycaemic events and number of episodes of diabetic ketoacidosis. Adolescents completed the parental involvement scale from the Diabetes Quality of Life for Youth--Short Form (DQOLY-SF) and the Diabetes Family Responsibility Questionnaire (DFRQ). Parents completed the DFRQ and a Parental Burden of Diabetes score. Glycated haemoglobin (HbA(1c)) was analysed centrally on capillary blood. A total of 2062 adolescents completed a questionnaire, with 2036 providing a blood sample; 1994 parents also completed a questionnaire. Family demographic factors that were associated with metabolic outcomes included: parents living together (t = 4.1; P < 0.001), paternal employment status (F = 7.2; d.f. = 3; P < 0.001), parents perceived to be over-involved in diabetes care (r = 0.11; P < 0.001) and adolescent-parent disagreement on responsibility for diabetes care practices (F = 8.46; d.f. = 2; P < 0.001). Although these factors differed between centres, they did not account for centre differences in metabolic outcomes, but were stronger predictors of metabolic control than age, gender or insulin treatment regimen. Family factors, particularly dynamic and communication factors such as parental over-involvement and adolescent-parent concordance on responsibility for diabetes care appear be important determinants of metabolic outcomes in adolescents with diabetes. However, family dynamic factors do not account for the substantial differences in metabolic outcomes between centres.

Editorial [Hot Topic:Translating Clinical Evidence into the Practice of Diabetes Care (Guest Editor: Richard W. Grant Contents)

Editorial [Hot Topic:Translating Clinical Evidence into the Practice of Diabetes Care (Guest Editor: Richard W. Grant Contents)

Comparison of the Prevalence of the Metabolic Syndrome by WHO, AHA/NHLBI, and IDF Definitions in a German Population with Type 2 Diabetes: The Diabetes in Germany (DIG) Study

This study investigated the prevalence of the metabolic syndrome (MetS) in a German population with type 2 diabetes (T2DM) using the three definitions for MetS according to WHO 1999, AHA/NHLBI 2005, and IDF 2005 criteria. Four-thousand and twenty participants as a cross section of daily practice of diabetes care in Germany (238 unselected sites) were included in the Diabetes in Germany (DIG) study. T2DM and age between 35-80 years. major cardiovascular event < 3 months before entry, NYHA-IV, macroproteinuria, and cancer < 5 years before entry. The components of MetS were measured following a standard protocol for anthropometric and laboratory control. The average diabetes duration was 8.4 years and HbA (1C) 7.0%. The prevalence of MetS by WHO criteria was 26.1%, by AHA/NHLBI 79.3%, and by IDF 82.6%. The degree of agreement (kappa statistic) was kappa = 0.69 between AHA/NHLBI and IDF definitions, but only 0.12 for WHO VS. IDF, and 0.17 for WHO vs. AHA/NHLBI. The frequency of central obesity by WHO was 50.9%, by AHA/NHLBI 72.9%, and by IDF 92.0% and for hypertension 29.3%, 92.6%, and 92.6%, respectively. However, the frequencies of lipid components by the three definitions were in the same range (57.8%, 59.5%, 59.5%). In this representative German sample of patients with type 2 diabetes, the prevalence of MetS was very highly independent of using the IDF or AHA/NHLBI definition. Females were significantly more affected than males. The distinctly lower prevalence delineated from WHO criteria is due to low frequency of central obesity and hypertension as consequence of higher cutoff limits for these components used in the WHO definition.

Evidence-based decision-making

Clinical decisions in diabetes care are complex, because they cover a wide range of unrelated issues which are affected by varied contexts of healthcare providers from multiple disciplines. The purpose of this paper is to reflect on the extent to which evidence is used to underpin clinical decisions within the area of diabetes care. In order to do this, it is necessary to capture information on the application of principles of evidence-based practice in diabetes care. Publications debating the nature of evidence-based practice and diabetes care were identified through searching the MEDLINE and CINAHL databases and located through the search engine Google. Additional publications were identified from references cited in relevant papers. These publications viewed evidence-based decisions as a balanced integration of different aspects of the clinical situation such as patient preference and clinician experience, in addition to the best available evidence. Simultaneously, each aspect of clinical care needs different forms of evidence. This is the argument for evidence-based diabetes care, where heterogeneous variables interact in different milieus. In conclusion, evidence-based diabetes care is a loose structure and set of ideas which needs to be adjusted according to each specific clinical situation.

The management of lipohypertrophy in diabetes care

Lipohypertrophy has been a recognized complication of insulin therapy for many years, yet research shows that its prevalence in insulin-injecting patients with diabetes remains high. The problem for the patient is that the injection of insulin into a site of lipohypertrophy, although painless, may lead to erratic absorption of the insulin, with the potential for poor glycaemic control and unpredictable hypoglycaemia. Despite the important implications of this for diabetes control in insulin-injecting patients, there is a dearth of information and completed research into the condition. This article raises awareness of lipohypertrophy by reviewing the available literature on the prevention, identification and management of the condition from a nursing perspective. Recommendations for medical and nursing practice in diabetes care to improve prevention and management of lipohypertrophy are made.

Evidence-based decision-making: the case for diabetes care

Clinical decisions in diabetes care are complex, because they cover a wide range of unrelated issues which are affected by varied contexts of healthcare providers from multiple disciplines. The purpose of this paper is to reflect on the extent to which evidence is used to underpin clinical decisions within the area of diabetes care. In order to do this, it is necessary to capture information on the application of principles of evidence-based practice in diabetes care. Publications debating the nature of evidence-based practice and diabetes care were identified through searching the MEDLINE and CINAHL databases and located through the search engine Google. Additional publications were identified from references cited in relevant papers. These publications viewed evidence-based decisions as a balanced integration of different aspects of the clinical situation such as patient preference and clinician experience, in addition to the best available evidence. Simultaneously, each aspect of clinical care needs different forms of evidence. This is the argument for evidence-based diabetes care, where heterogeneous variables interact in different milieus. In conclusion, evidence-based diabetes care is a loose structure and set of ideas which needs to be adjusted according to each specific clinical situation.

Should annual measurement of the ankle–brachial index be routine practice in diabetes care?

Should annual measurement of the ankle–brachial index be routine practice in diabetes care?

Perioperative Blood Glucose Control

Progress in improving care processes for hospitalized patients with diabetes has been very slow. The prevalence of diabetes is increasing steadily, making it a diagnosis that is present more often in patients who are hospitalized to have surgery. Evidence demonstrating the benefits of blood sugar control in hospitalized patients has been accumulating, which has resulted in clinical practice recommendations that provide direction for changing practice. Multidisciplinary development of institution-specific standards for the care of patients with diabetes is essential for improvement in processes and outcomes. The safety implications of diabetes care practice changes require close monitoring and timely reporting. There are increased costs associated with diabetes care practices that are needed to improve blood glucose control in hospitalized patients, and these are offset, at least in part, by cost savings that occur because of improved outcomes. Perioperative nurses are integral to making practice changes that will improve outcomes for patients with diabetes. Their participation in multidisciplinary teams who are working toward improving outcomes for patients with diabetes will ensure that the unique needs of patients having surgery are represented and that plans include care processes that prevent complications related to the surgery itself as well as uncontrolled blood glucose levels. Perioperative nurses can collaborate with other health professionals in developing standards, including policies, procedures, and protocols, that are necessary for making changes in diabetes care practices. In addition, perioperative nurses are providing diabetes care by monitoring blood glucose levels, assuring timely treatments for elevated blood glucose levels, obtaining equipment needed for implementation of intravenous insulin protocols, documenting blood glucose levels and treatments for hyperglycemia, collecting data to evaluate care processes and outcomes, and providing feedback regarding effectiveness of diabetes care practices to individuals and groups who have responsibility for process improvement activities.