World Diabetes Day (WDD) was created in 1991 by the International Diabetes Federation (IDF) and the World Health Organization in response to growing concerns about the escalating health threat posed by diabetes. It is marked every year on November 14, the birthday of Sir Frederick Banting, who co-discovered insulin along with Charles Best in 1921.
The theme for World Diabetes Day 2020 is The Nurse and Diabetes, and it aims to raise awareness around the crucial role that nurses play in supporting people living with diabetes. As the number of people with diabetes continues to rise across the world, the role of nurses and other health professional support staff becomes increasingly important in managing the impact of the condition.
In recognition of WDD 2020 – and its specific focus on the role nurses play – Glytec’s Director of Clinical Practice, Betsy Kubacka, MSN, AGPCNP-BC, RDN, CDCES, is conducting a three-part interview series with nursing professionals that have clinical expertise in treating patients with diabetes and glycemic management issues. Click here for part one of the series entitled, “Diabetes and the Nurse,” with Debra Dudley. For part three, “Lori Weiss on the Role of the CDCES in Nurse Education and Patient Safety,” click here.
Part two of our series is a conversation with Barbara McLean, MN, RN, CCRN, CCNS-BC, NP-BC, FCCM. Barbara has been in clinical care practice for 40 years and has first-hand experience treating people with glycemic management issues in the ICU. She is the advancing evidence-based practice clinical specialist at the Grady Health System in Atlanta, Georgia, and has made more than 3,000 presentations nationally and internationally. Barbara has written 24 chapters, 16 articles, and is a regular reviewer for Critical Care Medicine, Intensive Care Medicine and NEJM.
Betsy Kubacka: How does your role as a consultation expert with the critical care team in the ICU, overseeing a patient’s glycemic management, differ from a Clinical Diabetes Educator guiding nurses and people living with diabetes?
Barbara McLean: My perspective might be quite different than a CDE because the majority of my patients are intubated, on ventilators and often with multiple comorbidities. I am not educating them about what's going to be their long term affects from diabetes. I am so grateful for the role of the Clinical Diabetes Educator whose purpose is to educate about the long-term impact of living with diabetes and provide pathways for management. My role is to assist bedside nurses, providers and physicians focus on a pathway for intensive glycemic management which ultimately improves outcomes for patients.
The role of the critical care nurse is continuously changing and often mutates in the moment. For a bedside nurse, workflow is typically broken down into three columns:
Excellence in glycemic management in the critical patient is every bit as important as managing hypotension, but in the ICU, it may not have reached the level of importance that it deserves. Evolving the knowledge about and commitment for intensive glycemic management requires a basic understanding of cellular signaling, hormonal response and how that response is seen in the serum.
One of my major goals is to assist all providers with the recognition that when their patient is hyperglycemic, the patient’s cells are in fact hypoglycemic creating a significant negative impact, as measured by elevated blood glucose in the serum. This understanding requires both an educational and cultural change requiring a collaborative effort to promote a normal metabolic situation and the ensuing cardio-cerebral-hemopoetic protection that glycemic management affords.
During COVID, promoting that type of change within critical care practice requires a dependency on measuring blood glucose accurately, on time and right now. In intensive care, despite evidenced-based initiatives, measuring blood glucose has not always achieved the notoriety it deserves.
What we see today (and since Van De Berghe’s first study) is a slow evolution towards importance and understanding regarding tight glycemic control in critical care. This is not the traditional DKA model, which has always been so important. In critical and acute states, we are reflecting on pituitary, pancreatic, hormonal alterations that are profoundly altered. Sepsis, COVID-19, trauma, CT surgery, stroke and in fact almost every diagnosis presents with some glycemic challenges. The end effect is sinister and subtle because hyperglycemia does not present with the immediate and drama of a profound acute hypotensive event or a cardiac arrest. All the same, it is life threatening and dangerous.
My personal and professional commitment is to elevate the understanding and knowledge of the critical care nurse to advocate for all patients and not accept sustained hyperglycemia, promoting active management and protection from hypoglycemia as well. But increased knowledge is not enough. That knowledge and advocacy must be correlated and paired with a method that enables nurses to measure, manage and control their patient’s blood glucose with ease. Historically the method of managing the patient’s blood glucose with a direct correlation to insulin adjustment has been difficult and inaccurate.
BK: You work across the entire platform in critical care, which includes nurses, pharmacists, respiratory therapists and physicians. From your perspective, what are the most significant challenges you see in regard to glycemic management?
BM: Critical care is primarily based on emergent and rescue therapy. How can I save this person’s life? Oftentimes critical care focuses so much on life saving that the impact of hyperglycemia, and what that reflects, is not considered part of the life saving package – it's often a delayed reaction and embedded with fear of consequential hypoglycemia.
When most clinicians discuss hyperglycemic management, they’re thinking about short-term fears of hypoglycemia and long-term outcomes – macrovascular or microvascular. The consideration of gross cellular hypometabolism, and organ specific hypermetabolism, ketosis, metabolic acidosis may not be the first concern.
Ultimately, there are two issues in terms of glycemic management in the ICU. I believe the first is most critical care clinicians don't fully consider the profound effect of hyperglycemia in the critically ill patient (because it is not emergent), and the second is they are limited by the fear of incidental or profound hypoglycemia. The latter, of course, is life threatening
As a result, the tendency of providers has been to allow for hyperglycemia and long-term effects rather than the possibility of life-threatening hypoglycemia.
But we do need to appreciate that excess glucose in the serum is typically accompanied by low glucose in the cell. Serum Hyperglycemia is often caused by cells communicating a demand for carbohydrate source. If insulin isn’t available as a transporter, or if there isn’t insulin receptivity, this may lead to that end effect we so commonly see: hyperglycemia in the serum and hypoglycemia in the cell.
It is our responsibility to educate providers about what serum hyperglycemia actually means to cellular function and cellular integrity. Most believe they understand hyperglycemia and that the glucose-insulin-glucagon relationship appears to be pretty straightforward. The missing piece is what the role of hyperglycemia and cellular function is, and why it's so essential to treat hyperglycemia. And again, the major fear that the aggressive and appropriate treatment of hyperglycemia and lead to life-threatening hypoglycemia.
BK: How has the implementation of technology benefited critical care clinicians in improving glycemic management in the ICU and what are some of the tangible benefits you’ve been able to identify?
BM: It's important to recognize that the most significant technological advancements as far as glycemic control is concerned are not yet at an artificial intelligence or closed-loop technology, which would replicate our endogenous health glycemic control. Glycemic control still requires a high degree of nurse interface and nurse intervention. But no technology has yet to replace the importance of precision insulin adjustment in a real time, right now mode without the nurse interface. However, eGMS insulin dosing software system has facilitated a precision, algorithmic, mathematical approach to glycemic control. The partnership between providers and technology are based on three basic principles.
Number one, elimination of the human calculation requirements directing the basic adjustment of insulin in appropriate relationship to the patient's glucose. Human error has led to massive miscalculations in insulin adjustment leading to precipitous and dangerous drops in the patient’s glucose levels. That is a significant patient safety issue.
Secondly, eGMS has significantly impacted the measurement intervention gap. Nurses no longer have to manually calculate insulin adjustments because when blood glucose is measured and the measure is recorded into Glucommander, there is an immediate request for adjustment, using a multiplier factor to the fifth decimal, for precision adjustment. For nurses, this is essentially a physician's order. An order that is instantaneous, and mathematically calculated. Glucommander has narrowed the measurement intervention gap to roughly five seconds between BG measure and insulin adjustment. Amazing!
It’s difficult to quantify the value of reducing that gap. If we look at the nursing sensitivity of management of glucose, the amount of time it requires to phone a physician or pharmacist, receive a response and administer the dose can be unbelievably dangerous for a patient. If a nurse happens to tend to another critically ill patient while waiting for a response, the patient in need of a dose adjustment has gone even longer without the proper amount of insulin. Narrowing the measurement to intervention gap not only increases patient safety, but it also significantly decreases nursing time and improves nurse workflow.
The third benefit the eGMS provides nurses is to keep them on a time track for each blood glucose measure via an alert system that can only be silenced by performing the BG. Even the best nurses with the greatest intentions in world-class hospitals struggle to consistently measure blood glucose on time. In general, this happens because they're involved with multiple critical patients and the standard BG check is not a top priority. Providers and bedside nurses desire to do the right thing, but traditionally, strict glycemic control has proved dangerous and difficult. eGMS has narrowed the gap and offers significant protection, still requiring the engagement and commitment of the bedside caregiver.
BK: As you know, the theme of World Diabetes Day 2020 is “The Nurse and Diabetes.” As someone with a deep understanding of the impact glycemic management has on the overall patient experience, what are your thoughts on highlighting the role of nursing professionals in preventing adverse health effects associated with poor blood glucose?
BM: Nurses rise to any challenge offered, as long as they have the reason why and the resources to do so. Glycemic management is no different than any task that might seem insurmountable, but becomes achievable when we blend science, evidence and technology and nursing commitment. Nowhere is that more obvious that in the time of COVID. We all have to appreciate the nurses we work with and their daily herculean efforts. The nurses at my hospital care for some of the most critical patients with five or six vasoactive drips, on a ventilator and Continuous Renal Replacement Therapy. In addition to that, they’ve made glycemic management a priority improving outcomes for some of our most critically ill patients.
My colleagues always rise to the challenge, raising the bar of excellence and we see that when reflecting on our glycemic data. We continue to exceed benchmarks for glycemic management, almost obliterating hypoglycemia and we continue, everyday, to exceed expectations and adapt to a brave new world of technology and improved outcomes.