Chloe Johnson has type 1 diabetes. Since 2004, the retired middle-school English teacher and grandmother of five has had an insulin pump. Generally, she no more needs help using it to control her blood sugar than she would need help diagramming this sentence.
“I can take care of myself a whole lot better than anybody else,” she said, “as long as I’m conscious.”
That caveat is among the many reasons that Dr. Michael McDermott launched the inpatient Diabetes Management Program at UCHealth University of Colorado Hospital (UCH) in 2004 and, in 2008, formed the program’s Glucose Management Team, one of the few such inpatient services in the country.
Johnson, 65, has had health problems that have led to hospital stays, including a 2013 kidney transplant. During those stays, she hasn’t always been fully conscious. That’s when the hospital’s Glucose Management Team steps in.
“It’s really helpful because a lot of times, you can’t think straight because you’re just whacked out with what’s going on,” Johnson said. “They take the pump out of your hands and I feel totally safe.”
Proper diabetes management is painstaking for an individual such as Johnson even during the normal course of her life. She has to take into account what she eats, physical activity, how she feels, and the readings from finger-poke blood tests throughout the day, among other factors. An inpatient hospital environment introduces even more complexity.
Being sick can increase the production of growth hormone, cortisol and adrenaline, which can boost blood sugar – it’s called stress hyperglycemia, and it can make non-diabetics temporarily diabetic and thrust diabetics out of control. Medications can also affect blood-sugar levels, as can skipped meals in advance of scans or surgical procedures or the changes in diet and exercise parcel to hospital stays. It’s not uncommon, either, for patients to find out they have diabetes after being admitted for entirely different reasons. The Glucose Management Team steps in then, too.
Underlying all this is that the consequences of diabetes can be grave for hospital inpatients. High blood sugar increases a patient’s risk for hospital-acquired pneumonia, heart failure and infection as well as complications following surgery (orthopedic surgeons, for example, will often insist that patients coming in for non-emergency procedures such as knee replacements have their blood glucose under control).
“Diabetes just causes bad outcomes,” summed up McDermott.
One in four
McDermott launched the inpatient Diabetes Management Program to establish best-practice standards of care and to teach nurses and doctors on how to manage diabetes patients. Before long, though, it was clear that it would take much more.
More than one quarter of patients admitted to UCH have diabetes. As noted, managing it can be tricky, requiring not only knowledge and expertise, but also enough experience with diabetes care (as well as an evolving bevy of technologies including closed-loop systems, continuous pumps and different types and concentrations of insulin) to recognize and adjust to nuances that can, without action, turn into a diabetic crisis. Ten years ago this September, the Glucose Management Team took shape with a physician, a clinical nurse specialist and a physician assistant. Ten years hence, the team has grown to eight clinical nurse specialists, physician assistants and nurse practitioners led by UCHealth endocrinologist and diabetes specialist Dr. Cecilia Low Wang. They see about 40 patients a day, focusing on the trickiest cases. Team members see patients seven days a week and are on call 24/7.
Nurse Practitioner Stacy Seggelke has been with the Glucose Management Team since the beginning. She’s kept an eye on Chloe Johnson during inpatient stays since just after the 2013 kidney transplant, when Johnson wasn’t entirely conscious. Given the medications and the various other factors affecting Johnson’s blood sugar, Seggelke took care of Johnson’s pump.
“She came in and explained to me how she was changing the settings. She was just fabulous,” Johnson said.
Seggelke looks beyond blood sugar, Johnson added. One example: Seggelke suggested grief counseling after the death of Johnson’s son, the father of three of Johnson’s grandchildren, which turned out to be an enormous help. Another example: Johnson had taken a fall the day before a diabetes check and landed hard on her wrist. Seggelke didn’t like the look of it and sent her down to the UCH Emergency Department, where indeed it was diagnosed as broken.
“She just seems to really want to help the whole person, and she totally understands that your diabetes affects the whole person,” Johnson said.
The team’s work extends into patient and provider education, adds Low Wang. “There’s diabetes-related stress among those who have a known diagnosis and are feeling out of control,” she said. “And if you’ve never had diabetes and you come in and become hyperglycemic, there are tons of questions on what the implications are.”
The Diabetes Management Program has a similarly expansive view of its duties. Its standards are now codified into UCHealth’s Epic electronic health record, and many have become the baseline for inpatient diabetes care across all UCHealth hospitals, said Elaina Thompson, the program’s nurse manager.
The program has continued to evolve, Thompson said, in part by harnessing the electronic health record. The technology enables remote tracking patients’ blood glucose and, if something seems off, reaching out to physicians and nurses to offer advice or assistance to help get the patient back on track. They’ve also created a formal knowledge assessment – a sort of quiz – to establish a patient’s sophistication with respect to managing their diabetes before approaching them with additional education. You don’t want to belabor the basics with the likes of Chloe Johnson, after all.
“The motto is ‘teach to their needs,’” Thompson said. “If I’m a patient and you’re telling me stuff I already know, chances are you’ve tuned me out by the time we get to the stuff I don’t know.”
The work has paid off not just for patients, but also in terms of national recognition. The Society of Hospital Medicine has ranked UCH among the country’s top performers in controlling its inpatients’ blood sugar, and the Diabetes Management Program has become one of the fewer than 2 percent of U.S. hospitals to receive Joint Commission certification for advanced inpatient diabetes care. It’s the only such hospital in Colorado.
It’s about much more than bragging rights, though.
“No matter what you’re in the hospital for, if you’re diabetic, it’s going to play a part in your treatment and can have an impact on how they treat you, how they should teat you, and what they need to be aware of and take care of,” Johnson said.