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Leveling with Safety

Date: May 31, 2013

Certified diabetes educators Holly Bashura, Erica Hall and Terri Kemmerer (left to right) apply their expertise to one of the many nurse-led projects designed to advance patient care across The Johns Hopkins Hospital.
Certified diabetes educators Holly Bashura, Erica Hall and Terri Kemmerer (left to right) apply their expertise to one of the many nurse-led projects designed to advance patient care across The Johns Hopkins Hospital.

A nurse practitioner by training, Terri Kemmerer once envisioned a career in women’s health care. When her son was diagnosed with type 1 diabetes in 2005, though, Kemmerer changed course to concentrate on the management of the disease that afflicted her son and 26 million others in the United States living with type 1 and type 2 diabetes. 

“I never turned back,” says Kemmerer of the decision that led her to The Johns Hopkins Hospital, where, as a staff member in the Division of Endocrinology and Metabolism, she coordinates education programs and provides clinical care for the inpatient diabetes management service.

Kemmerer’s talents are instrumental to one of dozens of nurse-led projects designed to boost patient safety and care at the hospital.

Under the wing of Kemmerer and nurse practitioners Holly Bashura and Erica Hall, all certified diabetes educators, hundreds of nurses across the hospital have mastered the skill of blood sugar management, a complex process that is essential to patient safety, but easily misunderstood by untrained caregivers. 

Formalizing Glucose Management

Nurses versed in the fine points of insulin therapy and glucose management form the bedrock of a program established in 2006 by Johns Hopkins endocrinologist Sherita Golden to improve glucose management for patients with diabetes as well as those with hypoglycemia, a potentially fatal condition triggered by plummeting blood sugar levels. 

 Now well equipped to monitor blood sugar levels and use glucose management protocols, nurses have helped the hospital to achieve a steady decline in patients experiencing hypoglycemia. 

Nurses continue to work side by side with Golden and an array of faculty, hospital leadership and safety experts. Together, they’ve created a uniform and effective set of practices for preventing hypoglycemia and for managing excessive glucose levels associated with hyperglycemia, commonly caused by diabetes.

Because they are on the front line, nurses are the “eyes and ears” of the glucose management project, Golden says. “It’s easy for providers to suggest a policy, but nurses help put that policy in perspective because they can tell us whether it fits into their workflow and actually benefits patients.” 

The adjusted glucose management policies have increased nurses’ authority to make decisions at the bedside. Should a patient’s blood sugar drop to an unsafe level, for example, the revised hypoglycemia policy allows a nurse to take prompt actions, such as giving orange juice, rather than wait to call a doctor. 

Enter Super-Users

Nurses are also at the center of the program’s strategy for supporting staff compliance with glucose management policies. Kemmerer and her team have trained 150 nursing “super-users” to serve as unit-based authorities on glucose management. They meet patients’ needs, educate staff and troubleshoot when problems arise. “For nurses to come forward to understand the particulars of the diabetes disease process and gain even more critical thinking skills is pretty profound,” Kemmerer says. 

 Glucose management factors into the process of caring for patients whether or not they have diabetes. Stress caused by a heart or lung transplant, for instance, can prompt a patient’s blood sugar to rise, slowing recovery, says super-user Felix Guzman, a nurse on the cardiovascular progressive care unit.

An informed staff can enhance the healing process, Guzman says. “The more knowledge the staff has, the more they can think critically. They’re also better able to articulate to patients why they are taking certain steps to manage glucose levels. That way, the patients are also better able to understand the process.”  

Rounds, Workshops and Vigilance

When not on the hospital floors caring for patients, observing glucose management practices and responding to questions, Kemmerer and her team are developing monthly rounds centered on thorny treatment issues such as how to reconcile medications for patients with diabetes who bring prescriptions from home to the hospital. Twice-annual super-user training workshops require advance planning as well.

Diabetes educators continue to develop tools to strengthen nurses’ ability to make treatment decisions at the bedside. Bashura is putting the finishing touches on a nursing pocket card that places hypoglycemia protocols at their fingertips. “They’ll have a lot of information to back up what they’re saying in terms of getting a recommendation from a physician,” she says. 

Additionally, Veronica Sanchez, a quality improvement nurse, is reviewing patient safety records related to insulin, hyperglycemia and hypoglycemia. Sanchez’s findings will allow diabetes education team members and faculty researchers to uncover clues as to why certain patients are more at risk for unsafe blood sugar levels. 

“The goal,” Bashura says, “is to identify what factors most commonly contribute to insulin therapy complications and come up with a plan to prevent them.”  

—Stephanie Shapiro