I recently started a position as an inpatient diabetes clinical specialist/educator and am horrified by some of the glucose control we see while patient with diabetes are hospitalized, many times for things other than their poor diabetes control.   I'm also the only persone here in this role and ours is a 580 bed hospital, and on any given day we could have 150+ patients in house with diabetes.

What is being done in your institutions to get better diabetes control during hospitalizations?  Do any of you have functioning 'diabetes nurse advocate" programs that help decrease the number of patients to be seen on a daily basis? Do you also follow out patients?  Who has hired you?   What inpatient glycemic goals do you use?  Is your hospital still using sliding scale insulin?  Does your institution take people off oral agents at admission?

I really feel like I could keep 3 of me busy full-time without any difficulty.  So, I'm happy for any help and answers you can give me.

Thanks.

Donna Jornsay

Hi Donna,  I can only speak for myself but I think many of us see the same horrors on a daily basis.  My institution does not even have a full time CDE.  I am primarily the manager of the wound care team but because I am the only CDE in the house I am called upon frequently to help out.  I am in the process of developing "Diabetes Champions" for each unit.  We will take 2 RNs from each unit, each shift and give them an intense training program over a 2 day period so that they can learn the different types of insulin, mechanisms of action, teaching strategies, ect.  We also are revising our diabetes curriculum for our new RN orientees, giving them an abbreviated version of the Champion class.  We hope to have our champions up and running by early summer.  We are a 650 bed acute care facility.  We still use sliding scales, but we have been able to reduce the amount of pts taken off orals and managed only on sliding scale as this becomes a problem upon discharge.  We were able to institute a hypoglycemia protocol which has saved tons of time and energy, thus treating patients faster and providing better outcomes. Its all a work in progress and we dont even have a full time CDE.  I am still looking for feedback as to what should be the protocol when a patient is admitted with a pump.  My institution does not see many pump patients and when we have one as an inpatient it is always challenging. Thanks for asking the questions many of us are wondering as well.

Thanks, Judy, for giving me some of your thoughts.  Where is your hospital located? 

I'm designing my champion program similar to yours.  I've outlined 8 topics, including meal planning, target glucose values, insulin action, oral agents, hypo/hyper.  I'm planning to do 8 weekly sessions for both days and evenings, each one lasting about 90 minutes, so the RNs won't have to be off the floor for the entire day.  Our hospital will give a salary increase to any RNs with a certification, so my goal is to mentor these RNs and ultimately have them sit to take the CDE exam, after they document their 1,000 hrs of pt education.

We're in the process of developing an insulin pump protocol, which I can't share just yet, but it involves the pt self managing their pump.  If they are not able to do that, then they have to be taken off the pump and started on basal/bolus therapy.  We have an attestation form for the pt to sign.  I've gotten support from the pump companies to have additional supplies in my office for pta who may need them.  Our policy states that I will assess the pump pt's knowledge base, within 24 hours.  Since I don't work weekends, it's already a problem, because they're no one else to cover for me for weekends, or God forbid, vacation.

As the pump population grows, this is a major concern.  Another hospital in our area is looking to have their IV team become knowledgable in pumps, but I truly think I'll do better with my RN champions.

Donna

Hi Donna
I have been in a similar position in a large hospital in Manhattan. 1/2 my position was for the Endocrine Department in the Faculty Practice and the other 1/2 of my position was Diabetes Clinical Nurse Specialist for all the Adult patient areas. Neither Nursing or Endocrine had any idea how comprehensive my position was and I often worked 12 hour days, five days a week just to get everything done. I developed an Inpatient Teaching Manual for the Inpatient Nurses to use to teach the patients with Diabetes. In giving Inservice to all the nurses about using the manual to teach and care for patients, the nurses also were updated themselves. The manual provided a means of standardizing what was taught . A similar manual was prepared for nurses to use in outpatient areas. I also was given time in the Orientation Program for new nurses to explain the program and instruct them in Diabetes care, education and management.  In addition, the nurses were able to call me for a consultation if they were having a diabetes related problem.  I the helped the nurses problem solve so that the next time they encountered a similar situation, they would know what to do. I also worked with the Chief of the Diabetes Program (an MD) for quality assurance related to diabetes. Through this collaborative process, we developed protocols for insulin drips, diabetes medication management, DKA and HHS.
Good luck, Donna.  I hope this helps

Thanks, Pat.  It definitely helps.  The manual you developed:  was it all things you put together or did you use company prepared educational materials?  Can you give me some examples of what you included in this manual and what topics you covered?

I certainly understand the 12 hour days as I feel there'as simply never enough time to get everything done.  I try to spend my mornings doing systems work to change the things that need to be changes, and afternoon seeing in-patients.

Hi Donna. I did not include pharmaceutical company booklets. We did, however, use specific pages from literature supplied by a specific meter company or drug company when it conveyed the desired message simply. The manual was also translated into spanish.These are the topics that were covered:
What is Diabetes?
Benefits of good control
Insulin administration
Insulin action
Disposal of insulin syringes & lancets
Diabetes pills
Monitoring your blood sugar
Blood sugar test record (which included a space indicatinf that the test strips & meter were quality controlled)
Hypoglycemia (Novo Nordisk pictures used)
Hyperglycemia(Novo Nordisk pictures used)
 

DKA, HNKS (HHS)
Urine or blood ketone testing
Sick Day guidelines
diet guidelines
preventing diabetes complications (presented in a very positive way)
foot care
Pregnancy & diabetes (brief...stressing pre-conception control )
Instructions for diabetes management at home (with room for individualization as well as standards of care)
Information on Outpatient Classes for follow up education

Wow, Pat.  That was VERY comprehensive.  Thanks for ther extensive list.  LIJ doesn't want us to use branded materials either, so I was curious.

Did you have the hospital print these for you?  or how were they produced?   How much time did you spend teaching all of this?  Is there any way I could get a copy of one of these?  Thanks so much, Pat.

Hi again, Donna
The manuals were printed by the hospital and given to each inpatient unit initially and as they needed the supply replenished. Rgearding how much time I spent teaching...I never was a clock watcher.  I often had to come in early or late to inservice the night shift . Day & evening shifts inservice was scheduled with the supervisor or head nurse (before they deleted the head nurse position) at the time most convenient for the staff.  In between, I was always on call for consultation with the nurses when they had a problem realting to diabetes assessment, care or self management education. The outpatient department used a similar manual to reinforce the same content. I also inserviced the Home Care nurses regarding this teaching initiative.  It was very time consuming, but the end result was worth it. I will try to find an extra copy of the manual for you to look at, Donna. In addition to nursing support, the best help in all of this is an MD who is an advocate for what you are trying to achieve.  You cannot be in every spot in the hospital every moment. Don't hesitate to make it known if you feel you could use at least a part time RN,CDE to assist you if the patient load is too great.

Thanks Pat for all your helpful insight.  I keep telling everyone in administration, that I could literally keep 3 full time certified diabetes educators busy.  But I think this problem exists nationwide, and is not really being addressed.

Currently diabetes is present in 25% of all patients admitted to the hospital.  And 29% of all patients going for surgery have diabetes.  Also previously undiagnosed diabetes, or just transient hyperglycemia, contribute the greatest to poor outcomes.  There's an increase in surgical site infections, an increase in nosocomial infections, an increased mortality post MI, increase in pneumonia, congestive heart failure, and stroke, and definitely an increase in length of stay.  Can you tell I'm doing nursing grand rounds today on Inpatient glycemic control?

Despite all this data that exists, and the fact that diabetes impacts on all of our hospital's "Core Measures", diabetes seems to continue to just not quite be a priority.  I wonder, is it that the problem is too big or too pervasive for anyone to want to tackle?   When I presented some of our hospital's data re inpatient glycemic control to a large Performance Improvement group, the leaders of the institution seemed genuinely surprised by how pervasive the problem is.  I must admit that I'm baffled by this.  I guess as a person living weith diabetes, who has been admitted to several different area hospitals, I KNEW it was bad.

So, I guess I'll just keep plugging away one problem at a time, but I certainly do appreciate your help.  If you can find that booklet, please forward to me at LIJ, 270-05 76th Ave, New Hyde Park, NY 11040.  Thanks again, Pat.  I so appreciate yout insights.

Hi Donna
After many years of working very hard to develop and present very successful diabetes programs to improve quality of care or to prevent problems through self management diabetes education for patients, I too could not understand why preventing diabetes-related problems was not more supported in a sustainedway.  Initially, there is great support when these programs and initiatives are thought to be lucrative financially for the institution. As soon as the administrators who watch the bottom line find that prevention of problems and close observation to achieve glycemic control in hospitalized patients was not a big money maker it is taken off the "must do" list.  Even more shocking was the realization that hospitals make money on admissions for all the comorbidities related to poor glycemic control. It seems that good intentions lose out many times.  I am convinced that the only real way for changes to take place in hospitals is for a reward or penalty to prompt behavior change.
Keep up the good work, Donna. We are all motivated by the real differences we make in the lives of patients who need our care. That is our reward and what keep us fighting uphill battles.

Pat,

very well said.  I think the current push towards no reimbursement for admissions in which a pt suffered an adverse event such as severe hypo, or diabetis ketoacidosis, or hyperosmolar state will hopefully, help drive the efforts towards inproved patient outcomes, and frankly safety.

All of our hospitals core measures have one thing in common--glycemic control, or the lack thereof, and hyperglycemia.  It's also that hospital systems change so slowly, that by the time you do everything needed to create a systems change, the administrators have developed other priorities.  It certasinly can be frustrating.  

Well said Donna!  How many times have you embarked on a new aspect of diabetes care (and were so happy that someone besides you gave you some level of support) only to find that it floundered and needed life support towards the end because it took so long to get into the pipeline and then, when everything was finally "in place" it wasnt the flavor of the week anymore so no one really cared if it got off the ground or not!  I see it happen with adverse events.  An adverse event happens, we have 200 meetings about the adverse event and how to prevent it from ever happening again, and by the time everything is put into place no one cares about the implementation and cares even less about it's sustainability.  I am glad I am not the only one out there with the same frustrations!

Judy,

you are certainly not the only one out there with these frustrations.  Systems change slowly!!!  We all know that, and have to figure creative ways to keep the process moving forward.  Sometimes I find it helps to recruit a new warm body into the project, and sometimes, we may just have to let those things that are truly NOT the higherst priority, go.   Sadly, the wheels of progress turn slower than even the health care systems for which we work.

This is a very interesting conversation and I would like to add another facet and strategy. Utilize the Risk Management Department of your hospital. We called a conference with Risk  Management and our hospital's liability Insurance company. They are certainly experts in the field and then we set up policies and protocols for cutting down law suits and paitent  readmissions as well as complaints. We did this as part of our quality improvement program. Perhaps having the entire nursing department address this as a Quality Improvement process will make the wheels run faster and cleaner. You can then monitor the progress and do outcome studies to present to your medical staff, nursing executive committee and accrediating agencies. Good Luck

Good suggestion, Ginger
I was personally involved in a Quality Improvement Project in my hospital. WE identified many problems related  to :
physician behavior:med errprs, not understanding diabetes meds,not changing diabetes meds in response to fingerstick blood glucose,not understanding how to treat and follow up hypoglycemia, not understanding management of NPO patients
Procedure scheduling Issues: delayed or missed meals,length of NPO status, emergency priorities,ambulatory priorities,same day surgery priorities
Nursing behavior:Medication error, poor documentation of fingersticks,not responding appropriately to low blood glucose,not following up after treating low blood glucose, not informing MD about the low bg, fingerstick technique error,and probably the biggest problem...giving insulin at the right time in relation to actual mealtime and what the patient actually eats
Patient related:NPO procedures, poor po intake, changing clinical status, drug interactions, refusal of fingersticks
As a result of this study, the Quality Assurance Committee that I was part of developed a capillary blood glucose monitoring form as a process control chart. Under the direction of the Chief of Diabetes, Dr Sheila Roman, this chart was used hospital wide along with the medical algorithms and critical path guide which improved diabetes management and education

Hi Pat, It sounds like you did a terrific program and that the patient care benefited greatly. One of the things that came out of our Quality Improvement program was adding glucose monitoring to the list of our mandatory competencies every year. Each RN and Cerified Patient Care Assistant had to demonstrate to Staff Developement their technique on the Accucheck meter we used hospital wide. We got the lab to assist us in the monitoring and everyone had to pass the evaluation each year. It build everyone's committment to making monitoring accurate and valuable and led up to us teaching each RN the fine points of pattern managment. It really helped us improve care. The next step was getting the staff and Laboratory Managment to allow us to let the patients do their own testing first so they knew what they were doing when the went home. With patients having shortened stays in hospitals there is so many survival skills to teach and so little time. That a whole other issue.

I totally agree, Ginger

Ginger and Pat, thank you both for that discussion.  Ginger, the involvement of the Risk Management team is a great idea, and one that I definitely plan to follow up with.   I don't think the hospital for which I am working have seen diabetes yet as a risk managment issue, and yet glycemic control so clearly relates to all the hsopitals core measure that it would like to improve.  I have the feeling that the baseline hyperglycemia with which many members of the staff have become complacent, is just like background noise, nothing that anyone is really listening to.   So, I continue to be the squeekly wheel.

Thank you both though for thiese suggestions.  If only I had a few more bodies here to help with this project.  It's overwhelming sometimes.

Donna

You are welcome Donna, Keep up the good fight. We need to remember that our first job is patient advocacy and that is what Diabetes Educators have been doing since day one. We are all on your side and if we can help feel free to call on us. That is why the network here is so important. Take care

Hi Donna
It seems to me that one of the biggest problems with achieving glycemic control in hospitalized patients is being able to time the insulin injection with actual arrival of the meal tray.  I have just heard about a solution some hospitals were able to adopt. The food trays for patients with diabetes are delivered to to the nursing station. The nurse then brings the tray to the patient as well as the insulin. That way the nurse can assess the patient's status in terms of what will actually be eaten and the insulin can be given appropriately.  Hopefully, of course, there is a pre-meal insulin dose ordered that includes an Insulin to carbohydrate ratio to cover carbohydrates to be eaten as well as insulin sensitivity factor to address pre meal hyperglycemia.