Nursing Education on Diabetes in the Hospital Setting

Jane Threlfall, RN ,BA, CDE

                “I held the insulin....the blood sugar was normal"..."But we’re using sliding scale"..."I don’t understand the harm if the blood glucose is a little high."

                At Piedmont Hospital, the single most common diagnosis across the board is diabetes mellitus. It is usually not the primary admission diagnosis, but often a secondary diagnosis. The patient is admitted for a renal transplant, CABG, lower extremity cellulitis, MI, CVA, or COPD. Diabetes is often in the background, and its management in the hospital has profound effects on mortality, morbidity, and yes, cost.  

                As diabetes educators, we are familiar with all the studies regarding the importance of blood glucose (BG) being within target in the hospital. For example, the DIGAMI study: Acute MI and admission BG > 198 mg/dl. These intervention patients treated with IV insulin and discharged on MDI for three months yielded at one year a 30% reduction in mortality! The greatest benefit being seen in those without a previous diagnosis of diabetes: 58% reduction in hospital mortality and a 52% reduction in mortality at one year. The Van der Berghe study had the medical community looking at the profound benefit of using IV insulin to obtain BGs of 80-110 mg/dl in the ICU setting: (This is the standard in our ICUs.) bacteremia reduced by 46%; use of antibiotics for longer than 10 days reduced by 35%; needs for mechanical ventilation for longer than 14 days was 42% less; and 43% relative risk reduction in mortality. Median ICU costs were 20% lower for patients in the intensive insulin arm. Study after study has shown the absolute and true benefit of maintaining normoglycemia in the hospital. 

                One blood glucose value over 220 mg/dl, even for a few hours, impairs the body*s ability to heal and fight infection for three weeks. With hyperglycemia, we see electrolyte abnormalities, immune suppression, volume depletion, and impaired wound healing.  “Hyperglycemia in the hospital is a mortal sin” is a quote from endocrinologist, Dr. Paul Davidson. 

                We’re the experts. We know all this stuff. How do we pass this vital information on to the nursing staff who are doing the actual patient care? How do we, as educators, help our colleagues understand the rationale for checking BGs every hour when someone is on an IV insulin drip? How do we empower nurses to feel free to initiate the “Steroid-Induced Hyperglycemia Protocol?”  Or understand why you don’t give a whole amp of D50 for a BG of 68?  As a youngster, “Because I said so” was a guaranteed pout-producing flag for misbehavior. We all need to know why something is being done, and more importantly, the benefit of any action.

                I still pick up shifts on the Transplant Unit here at Piedmont Hospital. As any floor/ICU/ER nurse knows, the amount and frequency of new rules, meds, protocols, and computer system changes can be absolutely overwhelming. What are the ways that we can impart diabetes research and information to hospital nursing staff?

                What I hope to share in this article are the ways that we try to keep the nursing staff in the loop, interested, and involved as they care for their patients with diabetes.

  • On our hospital intranet site, through an e-learning platform known as “NetLearning,” our system has two mandatory diabetes modules that are part of yearly review sets.
  • As part of orientation for new nurses, an educator speaks for 30 minutes to all new RNs about diabetes updates, protocols, treatment options, etc. A consolidated “cheat sheet” is given with needed info on oral agents, insulins, CSII, CHO/Insulin ratios, and IV insulin.
  • Trying to get information out hospital-wide regarding new orders, policy changes, or any educational information can be extremely challenging (translation: hit or miss at best). We have now divided up all the nursing units among the 5 RN diabetes educators, so that every nurses’ station will have its “own” diabetes expert, and information can be shared simultaneously and effectively.
  • As part of orientation, nurses view a video with step by step instructions on the use of the Glucommander, an algorithm-based computer program to calculate IV insulin drip rates.
  • One venue we’ve found to be effective to pass on information such as “How to Translate the A1C” has been “Bathroom Tips.”  We simply print the information on some bright colored 8"x11" paper, get a roll of scotch tape, and ‘hit the road,” posting the tips in the nurses' bathrooms on each unit.
  • A diabetes educator is also part of our Nursing Assistant orientation. Explanations of what effect that beautiful fruit basket and those extra juices have on Ms. Murph’s blood glucose help all.  Nursing assistants also have yearly diabetes modules to complete on the “NetLearning” system.
  • Every nurses' station has an insulin pump notebook including site change information, how to give a bolus, etc.
  • Several times a year we have all day diabetes seminars for nursing staff where we cover carbohydrate counting, meds, A and P, insulin pump certification, etc.

         Many of the traditional ways of sharing information such as quarterly education forums, storyboards, and in-services somehow don*t result in effective, remembered information and educational sharing. I hope that some of these ideas will help translate our knowledge to a nursing audience that has huge responsibilities, an ever-changing knowledge base, and little time to learn all that is expected. Like we tell our patients, knowledge is power. The same is true for informed nurses caring for hospitalized patients with diabetes.

Jane Threlfall is a diabetes nurse educator at the Diabetes Resource Center at Piedmont Hospital.

 

 

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