Three Heads Are Better Than One: The Effect of New CMS Measures on Nurses, Dietitians, and Certified Diabetes Care and Education Specialist Clinicians

With the Center for Medicare and Medicaid Services (CMS) releasing its quality measures on glycemic management, hospitals will soon track and publicly report rates of:

• Severe hyperglycemia (NQF #3533e) – defined as the percentage of hospital days with one blood glucose reading greater than 300 mg/dL (excluding the first 24-hour period after admission).
• Severe hypoglycemia (NQF #3503e) – defined as the percentage of patients having one blood glucose reading less than 40 mg/dl during their stay, within 24 hours of administration of insulin (or other antihyperglycemic agents).

The first rule measures prolonged, untreated rates of hyperglycemia in the hospital, and the second aims to prevent medication-induced hypoglycemia during a hospital stay by capturing data on patients with severe hypoglycemia.

With such measures, CMS is choosing to acknowledge the serious problem of severe hypo- and hyperglycemia among hospitalized patients. With nearly 40% of all patients requiring insulin therapy during their hospital stay, this is a complex problem that also affects nurses, dietitians, and certified diabetes care and education specialist clinicians, and therefore requires a complex solution. In order to provide the best patient care and ensure proper insulin dosing for patients, there needs to be cooperation between the entire care team.

Three Heads Are Better Than One

As a registered nurse and certified diabetes care and education specialist, I know firsthand that proper insulin dosing and patient education are foundational to patient safety and predictably good outcomes. Expert knowledge and coordination are required to accurately monitor blood glucose levels, nutritional intake, patient status, insulin titration and other treatments that affect blood sugar for patients in need of insulin therapy. Dietitians provide expert advice on how to meet nutritional and metabolic needs while minimizing variability in blood glucose fluctuations. In addition to physicians and pharmacists, a well-rounded expert care team for patients requiring insulin consists of three heads: patient care nurses, dietitians, and certified diabetes care and education specialists. Each discipline provides the care team with a unique perspective and expert knowledge that benefits the patient, reduces adverse events, and improves the overall quality of care.

It is important for nurses and this entire care team to be educated on the goals of the new glycemic CMS measures in order to provide the best patient care. Here’s what you need to know:

1. Severe hypoglycemia should be a “never event” even for seriously ill patients in the hospital. CMS is sending strong signals that severe hypoglycemia (blood sugar less than 40 mg/dL) as a result of insulin dosing errors should be virtually eliminated and that letting patients experience persistent hyperglycemia to avoid hypoglycemia is unacceptable.
2. Balancing hypo- and hyperglycemia should be the goal. The new CMS measures are counterbalanced so that the intended outcome is to achieve reasonable blood sugar control in the hospital. This will drive improvements in inpatient processes and encourage hospitals to reevaluate their use of suboptimal protocols like sliding scale insulin alone to manage hyperglycemia. Technology-driven decision support tools for customized insulin dosing will be key as we begin to report on these measures.
3. Collaboration can drive improvement in workflows. Tapping into the expertise of each specialist on the patient care team – nurses, dietitians, certified diabetes care and education specialists, and other providers – can lead to better workflows, improved patient care, and higher quality standards.

Nurses cannot improve patient outcomes solely on their own. By uniting the entire care team of nurses, dietitians and certified diabetes care and education specialists, hospitals can work towards the goal of making preventable incidences of hyper- and hypoglycemia as a result of medication errors a never event.

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