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Service to manage patients with diabetes by Michael Baker Public Relations In July, the Medical University Hospital introduced the Diabetes Management Service (DMS) as part of a hospital initiative to offer specialized care to patients with diabetes or problems with high blood sugar. Kathie Hermayer, M.D., the service’s director, watched the program grow from its infant stages. In August 2003, she joined a group of colleagues in the Department of Medicine and Medical University Hospital Authority on a trip to the University of Wisconsin, which already had a diabetic management service in place. “We came back from Wisconsin with a lot of good ideas about launching our own service at MUSC,” she said, noting that John Feussner, M.D., chairman of the Department of Medicine, provided strong support from the service’s outset. “The following October, we began monthly meetings with a Hospital Diabetes Task Force to develop different diabetes templates to serve the hospital. “The task force represents a collaborative effort between the Department of Medicine and the Medical University Hospital,” she added, “and Dr. John Heffner (Medical University Hospital director) has been supportive of the program under the Center for Clinical Effectiveness and Patient Safety.”  After the October meeting of the service and the task force, the two groups spent the next year developing numerous tools for improved diabetes care, including an adult hypoglycemia protocol and clinical pathway guidelines to aid nurses in caring for patients with diabetes. “The nursing pathway was important because, historically, nurses had to refer to three different sources to access the information it provides,” Hermayer said. “Now, they’ll have all of the patient’s information in one place.” Similarly, the adult hypoglycemia protocol promotes efficiency and autonomy with the development of a standing order for nurses to administer treatment under emergency conditions. “If a diabetic patient has an emergency at 3 a.m.—such as dangerously low blood sugar levels—is the nurse supposed to withhold treatment until he or she receives confirmation from the doctor? Of course not,” Hermayer asserted. “The standing order allows nurses to initiate the hypoglycemia protocol immediately under a set of clearly defined conditions.” The task force and the service are developing a hyperglycemia protocol to manage patients with dangerously high blood sugar as well. Another, fledgling improvement involves the development of an updated insulin order form. The old order form provided a comparatively simplistic, less thorough method of determining doses of insulin for patients. According to Hermayer, the use of sliding scale insulin as the only replacement in an insulin-deficient patient offers treatment that is “ineffective at best and dangerous at worst.”  The new insulin order form provides a more detailed option for physicians and nurses. It addresses the patient’s needs for basal insulin, which covers every-day needs for patients who don’t meet the natural daily requirement; prandial (bolus) insulin, which provides coverage for meals; and correction insulin, which treats unexpected high blood sugars. The hospital will pilot the new order form in October and expects to launch it throughout the hospital in the winter. The improvements to diabetes care, both proven and pending, will address what Hermayer considers a notable patient demographic in the Medical University Hospital. “The hospital houses approximately 500 beds, and at any given time, 120 to 130 contain a patient diagnosed with diabetes,” she explained.  The high percentage of hospital patients with diabetes isn’t terribly surprising, as South Carolina ranks second in the nation in the disease’s prevalence. Still, it underscores the importance of effective diabetes care. Furthermore, Hermayer stated, numerous published studies show that patients with diabetes who underwent vascular surgical procedures and suffered acute heart attacks experienced improved outcomes under tight glycemic control. “Better glycemic control has been proven to improve outcomes in various areas,” Hermayer said. “It cuts down on infections, improves wound healing, decrease the cost of hospital care, helps the brain recover after a stroke, and reduces mortality by 28 to 50 percent.”  Despite the benefits of increased glycemic attention, the management service exercises a great deal of diplomacy, working with other departments in the hospital rather than commandeering patient care. “We try to be very respectful of the differing needs of services throughout the hospital,” Hermayer asserted. “Not all doctors need or want us to assume concurrent diabetic care for their patients, so we consult and make recommendations as needed. However, we’re willing to provide concurrent care for diabetes management on any adult patient when we are requested to do so by the primary team managing the patient.”  One department already took advantage of the service’s expertise. The Department of Vascular Surgery, directed by Bruce Elliott, M.D., instituted an automatic referral order to the service for any patients admitted with diabetes.  “Our goal is to cut down on the morbidity and mortality associated with diabetes and to reduce the incidence of hypo- and hyperglycemia,” Hermayer concluded. “We want to improve the delivery of diabetes care in the hospital.” Friday, Oct. 1, 2004 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.