Survival skills! No discharge without them

Hospitals decide what every diabetic needs to know

About 10 years ago, nurses at York (PA) Health System would contact diabetes educators when a patient needed teaching. Today educators have moved to the outpatient area and set up formal classes. This trend is common in health care today, says Donette Lasher, MAT, patient education coordinator for the health care system.

When the educators left, the inpatient floor nurses were supposed to teach patients survival skills if they were admitted to the hospital for diabetes and refer them to the outpatient program. A formal policy was written and pamphlets stocked on each unit, yet many of the nurses felt they lacked expertise or they just didn’t have the time.

"It takes about an hour to go over some of the information," explains Lasher. As a result, patients on the inpatient side weren’t being referred to the outpatient area. All the referrals were coming from the endocrinologists at clinics.

A committee was formed last summer to examine the problem. The committee decided someone needed to be accountable for inpatient diabetes education. The committee of physicians, dietitians, diabetes educators, and nurses considered training nurses or hiring an inpatient diabetes educator.

Lasher called other hospitals to inquire about their inpatient education for diabetes, tracked the teaching history at York Health System, and had the nurses ask their clinical directors for suggestions. The consensus was that an inpatient diabetes educator would be the best solution, and money was allocated to fill the position.

Many health care facilities today are reviewing their policy for inpatient diabetes education to correct problems. "The major problem is letting people fall through the cracks," says Nancy Moline, RN, MEd, CDE, regional diabetes care management program coordinator for Kaiser Northern California Region in Oakland. "The connection between inpatient and outpatient is really difficult sometimes. You don’t necessarily catch everyone."

A second problem is providing consistent information. Different health care workers sometimes give patients contradictory information, says Moline.

Educational solutions vary

Various health care institutions are implementing solutions to these problems in a number of ways. At Kaiser, a tool kit for diabetes teaching is stocked on each floor. "I started by inservicing the nurses about diabetes and then decided they needed some kind of a tool kit so they would have everything they need at their fingertips," says Moline.

The tool kit contains all the information needed to teach patients about Type I or Type II diabetes. The kit is built around a starter kit produced by a drug company with the basic tools a newly diagnosed diabetic needs, such as a syringe for insulin.

Additional materials, such as pamphlets and videos, were inserted to tailor the kit to the teaching policies outlined by Kaiser. A teaching sheet explains what the nurses are supposed to teach and the order in which it should be taught. For example, it lists which videos for newly diagnosed diabetics should be shown first, second, or third. The tool kit and teaching checklist provide a guideline of what survival skills are needed by newly diagnosed patients.

There is also a quick assessment tool nurses give patients. It’s a simple quiz in which patients check "yes" or "no" answers for several questions. "The assessment tool gives nurses an idea of how to target the patient’s education," says Moline.

Teaching is slightly different at Baptist Health System in Miami. Anyone with diabetes who is admitted to the hospital is given an identification bracelet to wear that reads "diabetes precaution." Diabetes patients wear the bracelet regardless of the diagnosis for which they are admitted to the hospital, explains Lois Exelbert, RN, MS, CDE, administrative director for the Diabetes Care Center at Baptist Hospital.

In addition to the bracelet, special posters are hung in the patient’s room reminding nurses what information is important to teach the patient. A reminder for the physician to order diabetes education is placed in the chart.

"As soon as we get an order from the physician for diabetes education, our team goes out," says Exelbert. The team consists of a nurse and dietitian from the outpatient area who are both certified in diabetes education. Because many of the patients are so sick during their hospital stay, they are simply taught survival skills that consist of giving insulin when appropriate, testing for blood glucose levels, and following a basic meal plan. The teaching is ordered for newly diagnosed diabetes patients or those struggling to control their disease.

Although the program at York Health System is not yet complete, an assessment tool is in the process of being created. This tool is a combination of a tool found at another hospital and one produced by the American Diabetes Association.

Focus groups consisting of patients who have been discharged from York also are being used to help design the curriculum and review materials such as videos and pamphlets. The patients are asked what their priorities were as inpatients and what they needed to know when they were discharged. A way to evaluate the effectiveness of the teaching also is being built into the program.

While an inpatient teaching plan is important to ensure that patients are taught survival skills and referred to the outpatient program, nurses must be continually reminded during inservices to make sure the teaching gets done, says Moline.