guest post by Amy Tenderich of diabetesmine

Tony wrote to me recently asking for some insights on what hospitals can possibly do to better treat/ encourage /help patients with diabetes. Thank you for the opportunity to air this issue, as hospital care for diabetics is (believe it or not) notoriously bad!

The core problem is terrible glucose control while hospitalized, whether the patient is conscious or not. The conscious ones are often miffed because they’re forced to follow some set protocol rather than being allowed to manage their diabetes themselves, which generally they do best. The unconscious patients often either go unmonitored, or are allowed to run unacceptably high.

At a recent seminar on diabetes patient gripes, one woman told me: “When I was hospitalized for surgery, the doctors insisted that I remove my insulin pump! Then they gave an order that I should receive 2 units of insulin for every 40pts blood glucose over 180 – but I’m extremely insulin-sensitive. One nurse was ready to inject me right after dinner! Why can’t they let me manage my diabetes? I know what I'm doing!”

Meanwhile, a nurse who comments on my blog regularly reports that the surgeons she works with like to say, “You can never have too much sex or blood glucose.” I guess keeping the patients extra-high avoids any possible risk of hypoglycemia.

Yikes!

“A blood glucose >200 mg/dL in the hospital patient causes increased morbidity and mortality,“ Dr. Bruce Bode told DCU editors last year. “In the 21st century, blood glucose >200 mg/dL in the hospital will be considered malpractice.”

What exactly can be done to remedy this? I queried a few of my expert contacts, including Kelly Close of Close Concerns and Dr. Steven Edelman of TCOYD, to compile some points that should offer a good springboard for improvement:

* Check the BG (blood glucose) of everyone who checks in, not just those who are already diagnosed, as many people are diagnosed with diabetes while in the hospital being treated for something else

* Institute a policy to allowing patients with both type 1 and type 2 on insulin to remain in control of their own insulin adjustments. Hospital rules will call for some type of protocol, but it should be one where a doctor approves the suggestions made by the patients themselves (they obviously know their diabetes better than anyone else)

* If the patient is on an insulin pump, speak to them about it if they are able to speak. Let them help decide whether removing the pump for certain treatments is necessary and/or beneficial

* Be respectful of, but not terrified of, hypoglycemia. Again, there are numerous horror stories about the very high blood glucose rates that hospital patients run. Up until a couple of years ago, the guidelines of the American Stroke Association actually recommended treating only blood glucose over 200 mg/dL (implying that any level up to that is OK!)

* Promote tight glycemic control standards. Tools like new continuous glucose monitors and software programs for intravenous insulin dosing should help. (See also the ADA’s Call to Action hammered out by the experts last year)

* Obtain the special certification for quality inpatient diabetes treatment established last year by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Diabetes Association (ADA)

* Pay the nurses more so that they stay in their jobs! These individuals provide the real hands-on care and advocacy, and are thus the real leaders on the tight glycemic control front

* Take advantage of that “teachable moment” during hospitalization in which patients who’ve undergone a life-altering experience may be more open and willing to consider learning how to use insulin or otherwise intensify their care.

The way I understand it, there is a boatload of research indicating the importance of tight glycemic control in the ER and the ICU (thought leader here is Dr. Greet van den Berghe) – but less evidence is gathered on the hospital "floors," where the risks seem less treacherous.

One hospital that I’m told gets high marks on tight glycemic control across the board is Providence St. Vincent Medical Center in Oregon, led by Dr. Tony Furnary, who’s referred to as “the father of tight glycemic control.”

Thank you, Father Anthony, for your efforts – ‘cause the hospital can be a terrifying enough place for us patients without having to worry that our glucose control will go haywire. Bottom line is, if the patient is conscious and willing, please let them take diabetes monitoring into their own hands!

* Amy Tenderich is co-author of the new book, Know Your Numbers, Outlive Your Diabetes.