The following is a guest article by Barbara McLean, MN, RN, CCRN, CCNS-BC, NP-BC, FCCM the advancing evidence-based practice clinical specialist at the Grady Health System.
Over the past year, discussions surrounding health disparities, inequities and the social determinants of health have been amplified as COVID-19 exposed how severely they increase risk and impact the overall health of a person or population. These critical shortcomings affect all races and ages and are proven to drive up to 80% of all medical outcomes. The pandemic illuminated that – despite decades of meaningful work – we are still no closer to reducing the economic challenges, cultural differences and environmental disadvantages that exacerbate the symptoms of illness and disease.
I see this with both acute and chronic disease states, in particular with diabetes, in my daily work at a large urban hospital in downtown Atlanta. Our health system opens its doors to all persons regardless of race, ability to pay, immigration status and other considerations that often drive disparity and inequity. I personally witness that members of our community come in sicker because they struggle with inadequate nutrition, increased environmental stress, undiagnosed and untreated conditions, and the inability to adhere to treatment regimens, primarily as a result of cost and support. It’s no surprise that decades of research have shown diabetes disproportionately impacts racial and ethnic minorities, as well as low-income adult populations, when improvements in management require medications, diet and lifestyle changes that may be unavailable or prohibitively difficult for that community to achieve.
The same communities that experience worse symptoms with their disease are those with the least amount of access to a specialist. This results in trips to the emergency room to regain control of their blood glucose and reduce the risk of mortality. There are approximately 130 million total emergency department visits each year in the United States and 12.3% of those are diabetes related. Furthermore, 35% of the ED visits associated with diabetes ended with patients being admitted to the hospital for additional monitoring and treatment.
Technology can serve as the great equalizer for patients with diabetes and other chronic diseases. I see it every day. Health systems just need to recognize the opportunity they have to mitigate the social determinants of health for their patients by investing in innovative solutions.
In outpatient settings, continuous glucose monitors (CGMs) and other technologies are extremely effective at helping people manage their diabetes. But it is incumbent on the individual to acquire this technology through insurance or a hefty out of pocket expense, again creating an inequity in practice for those who need the most attention. This access barrier for the most vulnerable populations creates significantly worsening conditions, driving critical levels of unattended hyper- or hypoglycemia and life-threatening consequences. As clinicians, we struggle to bring these emergent cases to a baseline that’s equal to those who enter a hospital with their diabetes already in control. When moments count in critical illness and injury, lack of glycemic control should never be a mitigating factor. Not in the 21st century.
My health system has helped providers alleviate the impact of the social determinants of health on patients with diabetes by utilizing glucose surveillance and insulin dosing software. Patients without access to adequate healthcare may not know they are struggling with their glycemic management and moreover, their medical records likely will not indicate the need for insulin therapy. This software helps identify patients who have multiple instances of hyperglycemia during their stay so our team can initiate insulin therapy if appropriate. Hyperglycemia is known to negatively impact a body’s ability to heal, so it is imperative that a patient’s blood glucose challenges are identified and well managed during their hospital stay to ensure instances of hyperglycemia are treated in a safe, timely fashion.
In addition to safely titrating insulin to maintain stable levels for patients in critical need and reducing instances of hyper- and hypoglycemia, a key benefit of utilizing this technology is the acceleration of time to blood glucose target. We no longer have to manually calculate insulin adjustments. When a blood glucose measurement is put into the eGlycemic Management System (eGMS), the software will respond by telling us how much of an insulin adjustment is required and drive the patient into target range as quickly and safely as possible. This replaces the need to call and wait for a physician’s order, which can sometimes take up to an hour or longer. By that time, the patient’s blood sugar is completely different from when the call was initially placed. This readily available technology has narrowed the measurement intervention gap to roughly five seconds.
It’s difficult to quantify the value of reducing that gap. 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 insulin adjustment. Narrowing the measurement intervention gap not only increases patient safety, but it also significantly improves provider workflow. The technology, which is universally available, is one small, but potent step, rapidly moving us forward in addressing the personal needs of each patient in each situation regardless of status. When these needs are unmet and patients maintain poor blood glucose management, increased complications may occur, creating significantly higher patient costs, longer lengths of stay in the hospital and even death.
Objective, scientifically correct glucose management is one of the great equalizers in healthcare, leveling the pathophysiologic playing field for those who enter the hospital at greater risk due to socioeconomic disadvantages. Implementing similar technology is a step all hospitals can take today towards the elimination of healthcare disparities, inequities and the social determinants of health. Reducing the cost of CGMs and outpatient technology is important too and is inevitable over time. But well before that happens, hospitals and health systems must set the standard for inpatient care by lowering barriers, leveling the playing field and bringing impactful technology to communities with the greatest need.
About Barbara McLean, RN
Barbara McLean, MN, RN, CCRN, CCNS-BC, NP-BC, FCCM the advancing evidence-based practice clinical specialist at the Grady Health System, a large, urban, safety net hospital, in Atlanta, Georgia. Barbara has been in clinical care practice for 40 years and has first-hand experience treating people with glycemic management issues in the ICU and emergency department. She has made more than 3,000 presentations nationally and internationally covering many areas of critical care and access. Barbara has written 24 chapters, 23 articles, and is a regular reviewer for Critical Care Medicine, Intensive Care Medicine and NEJM.
