CDE Debra Dudley: Evolution of the Nurse in Diabetes Care (World Diabetes Day)

Part one of our series is a conversation with Debra Dudley, RN, CDE, BS. Debra’s nursing career has spanned 50 years and she has spent the past 25 specializing in diabetes education and glycemic management. She is currently the Clinical Diabetes Educator for AdventHealth Waterman in Tavares, Florida, and has extensive experience in Pediatrics, NICU and Maternal Child Health. Debra is an industry leader in providing support for those with a diagnosis of diabetes or pre-diabetes and improving their self-management through informative discussions, classes and support groups.

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Betsy Kubacka: Over the course of your career, how has the role of the nurse evolved in treating people with diabetes?

Debra Dudley: Over the past 50 years, I've seen the role of the nurse evolve from basic bedside care to teaching the patient to be responsible for their own care and their own health.

Diabetes is probably the only chronic disease where the patient is in charge of their own health care. With other chronic diseases such as congestive heart failure, cardiovascular disease, arthritis and even cancer, the provider is mostly the one in charge. But with diabetes, it becomes the responsibility of the patient. Every time they eat or exercise, they have to make decisions on how it will impact their blood glucose. Each time they measure their blood sugar, they have to make a decision about if and what they need to do about it.

In the mid-1990s, healthcare providers began to realize the importance of teaching patients with diabetes the skills they would need for their own healthcare. They needed to teach the patient about the disease and how to treat it. This was the only way to improve long-term health, decrease hospital admissions (which are much more frequent with diabetes patients) and reduce the chronic complications that come from poor control of glucose.

My career as an educator is actually because of that change in focus – shifting from disease management by healthcare providers to self-management by the patient. Now, I've been a diabetes educator for 30 years and each day I realize the importance in educating people with diabetes and how it can change the outcome, both of their disease and the quality of their life.

BK: What are some of the greatest challenges you and your staff face when treating people with diabetes?

DD: One of the greatest challenges I face is the limitation of my time; another big one is the current cost of insulin. As an inpatient educator, I would love the opportunity to visit each patient each day and give them guidance. You don't always have a teachable moment with a patient, but if you could just give them a few minutes every day, it would be wonderful.

But there's not enough time or available resources for inpatient education. It has to be paid for by insurance, and that is very limiting because it's not reimbursable.

I think what makes it most difficult in the long run is when we see so many of our patients with diabetes become what we call frequent flyers. They keep coming in with the same issues because we aren’t able to spend the time that's needed to provide them with adequate guidance on proper self-care.

I also find the astronomical cost of insulin to be very challenging. A tiny vial of insulin is over $300. There are instances where we send patients home on two different kinds and they’re using four-to-six vials per month. When you add that up, it’s more than most of us make in a month’s time. If they don't have enough for insulin and living expenses, they have to make decisions. Is it going to be rent? Is it going to be food? Is it going to be medication? This is why people turn to rationing their medication.

I have patients who are taking 650 units of insulin a day – that’s half a vial. Can you imagine the cost of taking care of themselves? Thankfully, this specific issue is being addressed and as of January 1, the cost of insulin will be just $35 per month.

When you look at the impact that diabetes has on the individual, the community, the healthcare system, and our nation as whole, it’s alarming. Each year, we see 80,000 amputations, 60,000 people who lose kidney function and have to go on dialysis and 5,000 people every year, blinded by diabetes.

It has to stop. We have to confront this, because in the long run, it's going to save time, money and reduce the number of hospitalizations. Above all else, it's going to improve the health of the person and their quality of life.

BK: How has technology enabled nurses to overcome some of their most significant challenges in treating people with diabetes and what are some of the tangible benefits you’ve been able to identify?

DD: There have been a lot of developments in technology over the past 50 years that have impacted treatment both in the inpatient and outpatient settings. I remember early in my career, as a nurse, putting tablets in tubes of urine as our only means of measuring sugars. That's how we would dose insulin, which as we know now is completely backwards of what we really needed to do. So, we've come a long way.

The most important to me from an outpatient perspective is actually the evolution of the continuous glucose monitor. When blood glucose monitors first came out, (and I remember when patients didn't have access to them), we sent them home and told them how to take readings. The problem was, there was minimal information on what to do with that data, and so they were of little value. The continuous glucose monitor allows the person to check their blood sugar every five minutes, it tells them whether they're trending up or trending down and it allows the user to see if they need to make an adjustment based on the trend. I think that's fascinating.

As far as in the inpatient capacity, the eGMS insulin dosing software system has been amazing for us. We're very blessed to have a progressive leadership group in our hospital, and we implemented Glucommander on December 5, 2017. We transitioned about 50 patients in one day from IV and SubQ insulin, or on multiple injections where doctors were providing those orders, to using Glucommander to determine the doses.

Before we began using Glucommander, if a nurse believed a patient was not in good control of their blood glucose, the nurse would have to call the patient’s provider to make a dose change. When you’re checking blood sugar five times a day per patient, it led our staff to make a minimum of 3,000 calls a month to providers just to adjust insulin doses. That’s just the first call!

By the time doctors would call back, approve the order, and the nurses would administer the insulin, the amount of time wasted was both staggering and frustrating. The use of Glucommander has reduced our amount of monthly calls by 95% - from over 3,000 to 150.  

But the benefits go way beyond workflow improvements and efficiencies. Glucommander has the ability to adjust each dose according to the everchanging needs of the patient. It takes into consideration what their blood glucose is at the moment, their food intake and what their reactions were to previous doses. This has helped our staff improve glycemic control and provided our nursing staff and medical personnel with more time. Time is more essential than ever because the nursing shortage has left many overworked.

BK: As you know, the theme of World Diabetes Day 2020 is “The Nurse and Diabetes.” As someone who’s been involved in the profession for 50 years, what are your thoughts on illuminating the role of nursing professionals in the treatment and education of people living with diabetes?

DD: I love that World Diabetes Day is focusing on the job of the nurse with diabetes, because for me, it all reverts back to education. It’s the only way we can achieve prevention.

There's that old cliché that knowledge is power – and it’s a cliché – but like most clichés it has truth. The only way that we can prevent and manage diabetes is with the education of our patients, our community, and to be honest, our country as a whole.

In this country, we have 30 million people with diabetes. That means almost one out of every three patients a nurse will see in her entire career is impacted with diabetes. We must educate to empower not only our healthcare workers, but also our community members. We have to empower them to make changes in their decision making and behavior, and empower them to adequately administer self-care. Then, and only then, can we change that individual's health and positively impact healthcare as a whole.

Diabetes is a chronic disease that affects 30 million people in the U.S. alone. It presents a tremendous burden on the overall cost of healthcare when you consider the number of days people are out sick from work or school, the amount of time they are hospitalized, and the increased workload on nurses and providers. I'm glad WDD chose to focus on nursing and education because to me that's the beginning of a healthy nation and a healthy patient.