Center for Diabetes: Nurses Lead Successful Patient Education Efforts
“We’re facing a diabetes epidemic that shows no signs of abating, judging from the number of individuals with pre-diabetes,” said Catherine Cowie, PhD, of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), lead author of a study by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) completed in 2005-2006. The study, which was published in the February 2009 issue of Diabetes Care, showed that the prevalence of diagnosed diabetes in individuals age 20 and older increased by more than 50 percent between the 1988-1994 study period and 2005-2006. (Find complete study findings online.)
Education is key to reversing this ominous trend, and that is the core mission of Crozer-Keystone’s Center for Diabetes under the leadership of endocrinologist Ruth Ann Fitzpatrick, M.D. Located at Springfield Hospital since 1997, the system’s diabetes education program originally began in 1987at Crozer-Chester Medical Center with the support of nursing staff. Nurses remain the primary engine behind diabetes education.
Expanding Education Efforts
The Center’s team of nurse educators includes Mary Jane McDevitt, RN, BSN, CDE, program coordinator, Kathleen Plecenik, RN, BSN, CDE, and Mary Weldon, RN, CDE. Together, they conduct classes for patients with diabetes, pre-diabetes and gestational diabetes at Springfield. During the past two years, they have expanded their efforts to Crozer Medical Plaza at Brinton Lake and, most recently, to Community Hospital.
“We began offering classes at Community Hospital in May 2009 because we realized that many patients were finding it difficult to get to Springfield,” explains McDevitt. “We wanted to make our services more easily accessible to the community in Chester, and the response has been great. Most patients are walking to Community for the classes, which we offer twice a month. We also held an open house there in September that was very well attended.”
During the 10-hour diabetic education program offered several times weekly among the three sites, patients learn how to take care of themselves through good nutrition, exercise, medication and monitoring. In teaching these classes, the Center for Diabetes nurses collaborate with nutritionist Lynn Diven, RD, LD, CDE, as well as a pharmacist and an exercise physiologist.
A monthly pre-diabetes class is also offered to help patients with high blood sugar to avoid developing diabetes. Gestational diabetes classes are held weekly to teach pregnant women how to care for themselves, how to check blood sugar and urine ketones and, if necessary, administer insulin.
Avoiding Complications of Diabetes
Patients also learn about the complications that can arise when diabetes goes untreated or patients are not compliant with treatment. “Patients usually don’t realize the serious complications that can result from diabetes,” says McDevitt. “These include heart disease, stroke, hypertension, kidney disease, neuropathy and lower-limb amputations, among others.”
According to the ADA, the risk for death among people with diabetes is about twice that of people without diabetes of similar age. Adults with diabetes have heart disease death rates that are two to four times higher than adults without diabetes, and the risk for stroke is two to four times higher among people with diabetes. Diabetes is also the leading cause of kidney failure and the leading cause of new cases of blindness among adults age 20 to 74 years.
“We emphasize the importance of preventing these complications by controlling blood glucose, blood pressure and blood lipids, and by taking proper care of eyes, feet and kidneys,” notes McDevitt.
Six months after a patient has completed the diabetic education program, the Center for Diabetes sends a post-education survey to measure compliance with meal plans, weight loss and exercise. “Survey results show that our program is very successful,” McDevitt relates. “Our patients understand what they need to do and why it is important, and the vast majority are compliant.”
New Diagnostic Tool: A1c
New diagnostic tools have enhanced the Center’s efforts to help patients control diabetes and prevent complications. The hemoglobin A1c test was developed just a few years ago to measure the percentage of glucose that is attached to the hemoglobin of the red blood cell.
“Once the sugar is attached, it stays there for the life of the red blood cell, which is about three months,” McDevitt explains. “If the A1c test shows that your percentage of glucose is high, that means that your average blood sugar for the last three months has been high. Our goal is an A1c of 6.5 which equates to an average blood sugar of 145. Research evidence shows that staying within that parameter enables patients to avoid all the complications of diabetes.”
All people with diabetes should have the A1c test done twice a year. “Before the A1c, we could only get blood sugar readings at one point in time,” notes McDevitt. “This test gives us a lot more information about the patient’s condition over time.”
Glucose Monitoring Technology Advances
The Center for Diabetes provides continuous glucose monitoring for diabetic patients who require insulin. A sensor is placed under the skin and a transmitter is attached, which the patient wears for five days. The monitoring system takes 288 blood glucose readings daily. At the end of the five-day period, the patient returns to the Center where the transmitter is downloaded onto a computer and a readout shows how the insulin injections have been affecting the patient’s blood sugar. This system, which has been available for about two years, provides a wealth of information to the patient’s physician who uses it to adjust the insulin dosage for the patient. “The technology is becoming more user friendly all the time,” says Weldon.
Another more advanced continuous glucose monitoring sensor enables the patients to download information to the computer themselves. “This sensor brings blood sugar readings up onto the pump every five minutes,” explains McDevitt who, along with Plecenik, teaches patients how to operate it. “Patients wear it all the time and it can be used for many years.”
Intensive Glucose Management
Research has shown that intensive glucose control reduces the incidence of complications of diabetes. For patients who need insulin, McDevitt and Plecenik teach a self-management program in which patients complete a worksheet with records of everything they eat, blood glucose readings before and after each meal, and the amount of insulin they take every day for two weeks. Then patients return to the Center, where the nurses review the worksheet, using the information to fine tune their insulin dosage, determine where they can adjust their insulin to carbohydrate ratios and insulin sensitivity factors, and make recommendations to the physician.
“In many cases, the physician decides to place these patients on an insulin pump,” notes Plecenik. “We teach them how to use it and continue to monitor them until we feel their blood sugar is well controlled with the pump.”
Patient Referrals to the Center
Most patients are referred to the Center by their physicians. All HAN physicians have referral forms which they complete and fax to the Center. Patients can also initiate a referral by calling the CKHS Call Center or the Center for Diabetes directly to register for diabetes education classes. The Center will then contact the patient’s physician for an order.
Center for Diabetes nurses often go out into the community to provide education at health fairs and other events. They also organize the annual “CKHS Healthy Living with Diabetes” event. Nearly 100 people attended this year’s program, which was held on Nov. 14 at Springfield Hospital.
The Center’s nurses also run support groups for diabetic patients on the second Thursday of the month, from 6:30 p.m. to 8:15 p.m., with a variety of guest speakers and group discussions.
Keeping Up with Advances
McDevitt, Plecenik and Weldon regularly attend professional seminars to stay abreast of the latest advances in technology and treatment for diabetes. The three are active members of the American Association of Diabetic Educators