By Robert Rushakoff, M.D.
Improving inpatient diabetes management remains a daunting task. If you ask health care providers what “inpatient diabetes management” means to them, the response would be somewhat like that of the blind man and the elephant—each person has a different view, skewed by their unique perspective. Physicians may be concerned about glucose, with some more concerned about hypoglycemia and others about hyperglycemia. Nurses have to interpret orders, assess the patient’s diet, administer the appropriate dose of insulin, and educate patients who are acutely ill. Others are concerned about medication safety and insulin errors, or length of stay, or transitions of care. And yet others are worried about patient satisfaction or making meals available at any time (without regard to how insulin will be administered for those ad hoc meals).
THE INSULIN EXAMPLE
In the past, we have seen insulin order sets (both paper-based and computer-based) that fail miserably. The physicians did not really know how to use the new orders, and unless the orders were mandatory, would revert to old sliding scale orders, or just write “sliding scale insulin” on the new orders. Regardless of outpatient insulin doses or glucose control, once in the hospital the patient would invariably be put on the same small dose of insulin. Was it any wonder why the glucoses were never controlled? Pharmacy and nursing staff would lack input or training on the new orders, and mistakes would occur at every possible point—the orders, order interpretation, pharmacy interpretation, documentation, etc.
It was with this background that we undertook a project to help change inpatient glycemic control utilizing a mentoring approach. Our team consisted of physicians with strong backgrounds in setting up inpatient diabetes programs, and importantly, three advanced practice diabetes specialty nurses, among the country’s most experienced in inpatient diabetes management. We felt that institutions had to commit to a top-down commitment to change, laying the basic infrastructure for diabetes management. This would require buy-in and commitment from physicians, nurses, pharmacists, dietitians and administrators. From our collective experience, we knew that this was critical for success.
In a paper about this intervention, we describe the mentoring process we used to assist ten hospitals in implementing changes in infrastructure, education and clinical practice. One of our physician-nurse teams visited each hospital and helped them determine what changes were needed, and the methods and timeline to achieve these changes. We found it was imperative to have both a physician and a nurse on the team, to bring a balance of perspectives on the priority of different issues.
With the assistance of our mentoring program, while short term, the participating institutions are well on their way to successfully reaching their goals.