Conquering the diabetes education dilemma
Consistent lessons for safe discharge
By Sue Lesser, MSN, RN, BC, LCCE, Nurse educator, Cooley Dickinson Hospital Northampton, MA
Diabetes education for the patient in the hospital has become an impossible task for nurses who find it difficult to teach along with all their other duties. The consequence is frequently a poor outcome for the patient.
Yet patients can decrease diabetes-related complications if they are taught how to keep themselves in tight glycemic control. Patient education can reduce the morbidity and mortality of diabetes.
To improve inpatient diabetes education, a committee at Cooley Dickinson Hospital in Northampton, MA, developed a diabetes education pathway to provide guidance to all disciplines on survival skills that need to be taught to patients diagnosed with diabetes. The implementation of this pathway helps ensure health care providers will properly teach hospitalized patients so they can be safely discharged.
The curriculum includes topics based on "need to know" vs. "nice to know" information. The result is that everyone teaches by a consistent diabetes education plan. Nurses, dietitians, and case managers all participate in the education pathway. Each discipline has an educational obligation to the patient.
All disciplines teach American Diabetes Association (ADA)-endorsed patient self-management skills. Self-management skills require that people with diabetes know how to take medications appropriately, control blood sugar levels, and manage diet with regular exercise. We know that teaching self-management skills is vital because the tighter glycemic control a diabetic maintains, the fewer complications and the higher quality of life they will experience.
Nurses' responsibility in the education pathway is to teach patients about their medications (either oral or insulin injections) and the signs of and solutions for hypoglycemia. They also reinforce education on carbohydrate counting and blood glucose testing taught by other disciplines.
The dietitian initiates the diet/exercise and carbohydrate counting instruction. The case manager is responsible for contacting a meter distribution company to see the patient when education is needed on the use of blood glucose-testing meters.
The meter company will come to the hospital and see the patients before discharge to provide them with a blood glucose testing meter and education on how to test their blood sugar. If the company representative is unable to see the patient in the hospital before discharge, a visit to the patient's home will be arranged within 24 hours after discharge.
We stock the two most commonly reimbursed meters in the hospital so that, if they have to, nurses can teach the patients how to use a meter before discharge. Initially we were reluctant to have an outside vendor teach our patients; however, we found they were much more knowledgeable than we were on reimbursement for blood testing meters and they had more time flexibility to teach the patient.
Insurance companies and programs such as Medicare and Medicaid reimburse for blood glucose meters, but the type of meter they cover is not consistent. Therefore, we encourage patients to get their meters in the hospital before they go home. It is unfortunate when a patient pays out-of-pocket for a meter and then later finds they cannot get recompensed. Ultimately, we want to ensure that our patients have a meter and are confident in how to use it. Patients without means of payment are absorbed by the system and receive free meters.
A continuing education process
Hospitalization also provides an opportunity to re-educate established diabetics on new techniques and technology. We use the hospitalization to update patients who might be using antiquated meters or who have developed bad habits. Often we can use this incident to enhance their knowledge and improve their lifestyle.
To promote the continuum of care, the case manager makes an appointment for ongoing diabetes education before the patient is discharged. A diabetes nurse educator (CDE) and a diabetes nutritional specialist (RD) will see a patient newly diagnosed with diabetes or a patient in crisis one-on-one in their office within a few days of discharge. Group classes are also offered, based on an ADA evidence-based curriculum, in four weekly, two-hour sessions. Insurance is receptive to paying for outpatient diabetes education, but no one is turned away for lack of payment.
We are continuing to measure the success of our diabetes education pathway by continuously measuring the outcomes of this new program. We believe we are now teaching self-management skills to 95% of our new diabetes patients and 90% of those inpatients with established diabetes. Furthermore, 75% of our hospital patients are being seen after discharge for further diabetes education with our community diabetes educator.
We can't ensure lifestyle changes will occur, but we can ensure that our patients are educated enough to make informed decisions about their disease. Staff nurse satisfaction has improved because patients are now receiving consistent, planned diabetes education, and consequently their patients are going home better prepared to deal with a chronic illness.
Also, many nurses are uncomfortable with their ability and knowledge base to provide diabetes education. Nurses' perceptions of the patient with diabetes in a study done in 1990 were that previously diagnosed patients were more knowledgeable than they were; so the nurses tended to teach patients newly diagnosed with diabetes more often.
Therefore, in addition to the pathway we provide formal education, workshops, and in-services within the hospital to increase the nurses' ability and confidence to teach patients and families.
Marcum J., Ridenour M., Shaff G., et al. A study of professional nurses' perceptions of patient education. J Contin Educ Nurse 2002; 33(3): 112-118.
Moriarty D.R., Stephens L.C. Factors that influence diabetes patient teaching performed by hospital staff nurses. Diabetes Educ 1990; 16(1): 31-35.
For more information on the diabetes education pathway for inpatients at Cooley Dickinson Hospital, contact:
- Sue Lesser, MSN, RN, BC, LCCE, nurse educator, Cooley Dickinson Hospital, 30 Locust Street, Northampton, MA 01061. Phone: (413) 582-2849. E-mail: Sue_Lesser@cooley-dickinson.org.