Diabetic Education and Management Report and Tool

Assessment of Inpatient Diabetes Care Management and Education
in Wisconsin Critical Access Hospitals
Authors: The Critical Access Hospital Diabetes Project Workgroup

November 2006
TABLE OF CONTENTS
INTRODUCTION .............................................................................................................................................................. 3
PART 1: SUMMARY OF FINDINGS ............................................................................................................................ 7

SECTION A: GENERAL INFORMATION ............................................................................................................................. 7
SECTION B: INPATIENT CARE .......................................................................................................................................... 7
SECTION C: INPATIENT STAFF CONTINUING EDUCATION .............................................................................................. 8
SECTION D: INPATIENT DIABETES EDUCATION .............................................................................................................. 9
SECTION E: BARRIERS.................................................................................................................................................... 10
SECTION F: DISCHARGE PLANNING ............................................................................................................................... 10
SECTION G: COMMUNITY OUTREACH ........................................................................................................................... 11
SECTION H: QUALITY I MPROVEMENT ........................................................................................................................... 12
SECTION I: INPATIENT DATA PRACTICES ...................................................................................................................... 12
SECTION J: MISCELLANEOUS ......................................................................................................................................... 13
PART 2: CONCLUSIONS AND RECOMMENDATIONS ...................................................................................... 16
PART 3: DETAILED ANALYSIS FINDINGS ........................................................................................................... 20

SECTION A: GENERAL INFORMATION ........................................................................................................................... 20
SECTION B: INPATIENT CARE ........................................................................................................................................ 24
SECTION C: INPATIENT STAFF CONTINUING EDUCATION ............................................................................................ 30
SECTION D: INPATIENT DIABETES EDUCATION ............................................................................................................ 32
SECTION E: BARRIERS.................................................................................................................................................... 39
SECTION F: DISCHARGE PLANNING ............................................................................................................................... 40
SECTION G: COMMUNITY OUTREACH ........................................................................................................................... 48
SECTION H: QUALITY I MPROVEMENT ........................................................................................................................... 51
SECTION I: INPATIENT DATA PRACTICES ...................................................................................................................... 53
SECTION J: MISCELLANEOUS ......................................................................................................................................... 58
METHODS ........................................................................................................................................................................ 66
LIMITATIONS ................................................................................................................................................................. 68
REFERENCES.................................................................................................................................................................. 69
RESOURCES .................................................................................................................................................................... 71
ACKNOWLEDGEMENTS ............................................................................................................................................ 72
APPENDIX 1: ASSESSMENT TOOL.......................................................................................................................... 73
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INTRODUCTION
Diabetes: A Major Health Problem

The National Centers for Disease Control and Prevention (CDC) proclaims that diabetes is
disabling, deadly, and on the rise. National statistics indicate that more than 20.8 million
Americans have diabetes; 6.2 million of these dont even know they have the disease. The
number diagnosed with diabetes is increasing at an alarming rate, doubling over the past 15
years. New evidence shows that 1 in 3 Americans born in 2000 will develop diabetes sometime
during their lifetime. In addition to the millions with diabetes, an estimated 41 million U.S.
adults aged 4074 years have a condition called pre-diabetes, meaning their blood sugar levels
are elevated, but not high enough to be classified as diabetes. These people are at high risk for
developing type 2 diabetes in the future. (1, 2)
Statistics indicate that people with diabetes have a 2.2 to 4-fold increased rate of hospitalization
and incur a two-fold increase in costs for inpatient care than someone without diabetes. (3) In
2002, the inpatient cost for people with diabetes was $40.3 billion. (4) Since most people with
diabetes are admitted to the hospital for comorbid conditions, not primarily for diabetes
treatment, diabetes management is usually not the focus of inpatient care. Diabetes was listed as
a diagnosis in 12.4% of hospital discharges in 2000; however, since diabetes is often a secondary
diagnosis, it is likely underreported in discharge records. Diabetes was listed as a principal
diagnosis in only 8% of those 2000 hospitalizations. It is estimated that discharge diagnosis
codes may underestimate diabetes in hospitalized patients by as much as 40%. In addition, some
estimates indicate that for every two patients in the hospital with known diabetes, there may be
an additional one with newly noted hyperglycemia. Reports indicate as many as 60% of patients
with no prior history of diabetes who are found to have hyperglycemia during hospitalization are
likely to have diabetes at follow-up testing. (5, 6) Evaluation of hyperglycemia in hospitalized
patients presents an opportunity for early detection and management.
Quality of Diabetes Care

Over the past few years, increasing national attention has been focused on improving diabetes
care in the outpatient setting through the implementation of evidenced-based guidelines and
promotion of chronic care approaches that emphasize prevention and improving outcomes. The
value of tight glycemic control is now widely accepted for outpatient management of diabetes.
However, little direction has been provided on useful approaches to improve inpatient diabetes
care delivery, even though the national burden for inpatient diabetes care is significant.
Recently the American College of Endocrinology (ACE), along with the American Diabetes
Association (ADA) released a joint consensus statement with recommendations for improving
inpatient diabetes and glycemic control. The statement referred to major studies that showed a
strong association between hyperglycemia and poor clinical outcomes among hospitalized
patients and concluded that multiple institutional and attitudinal barriers still exist to improved
care that have created a significant and growing gap between what we know and what we do.
(7) Their consensus statement identifies strategies for implementing improved diabetes
management in hospitalized patients. Some of their recommendations include:
An appropriate level of administrative support for the long-term investment of time and
resources
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Establishment of a multi-disciplinary steering team to promote the development of
initiatives
Assessment of current processes, quality of care, and barriers to necessary changes in
practice
Development and implementation of interventions, such as standardized order sets,
protocols, policies, and algorithms
Creation of educational programs for all hospital personnel caring for people with
diabetes
Evaluation systems to track hospital glucose data on an ongoing basis and guide quality
improvement
Plans for a smooth transition from hospital to outpatient care with appropriate diabetes
management and follow-up for patients with newly recognized glucose abnormalities
The ACE/ADA recommendations are similar to those identified in the Institute of Medicines
(IOM) 2001 report, Crossing the Quality Chasm. The IOM report identified major gaps in the
quality of todays healthcare and made the following recommendations for organizational
redesign:
Better systems of finding best practices and assuring best-known clinical models
Better use of informational technology to improve access to information and to support
clinical decision-making
More consistent development of effective teams and teamwork
Improved workforce knowledge and skills
Better coordination of care among services and settings, both within and among
organizations, especially with respect to the care of people with chronic illnesses
More sophisticated, extensive, and informative measurement of performance and
outcomes. (8)
The good news is that diabetes is controllable. Research shows that many diabetes-related
complications and hospitalizations are preventable with improved care delivery, early detection,
and better self-management education. For example, studies have demonstrated that use of a
team to provide inpatient care can reduce length of stay and the rate of recurrent hospitalization,
that good glycemic control can improve outcomes, and that medication errors can be reduced
through the use of protocols. Outreach visits and academic detailing with respected experts and
local champions have been shown to lead to improvements in professional practice. (9-27)
Rapid advances in health care over the past decade have created significant challenges to hospital
staff who serve as generalists in caring for patients with a wide array of complex health
conditions, requiring ever expanding needs for ongoing continuing education and competency.
Although diabetes is mainly a self-managed disease, CDC reports indicate that people with
diabetes still receive little education on how to self-manage their disease. Shorter hospital stays,
higher acuity levels, and time limitations often make it difficult to provide inpatients with
essential self-management training. Discharge planning that is deliberate and comprehensive,
including an assessment of social and economic issues as well as referrals for necessary follow-
up care and education, can impact the patients ability to manage their care safely at home and
prevent re-hospitalization.
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The National Diabetes Quality Improvement Project (DQIP) and state-led initiatives with
Wisconsins health maintenance organizations and community health centers have led to
improvements in diabetes-related outcome measures in the outpatient setting. These initiatives
rely heavily on administrative support, the use of guidelines, protocols, and diabetes teams,
provision of self-management support, ongoing staff education, community linkages, and
information technology and surveillance systems that are able to generate data to facilitate
proactive care and evaluation of quality of care. Collaborators use a learning model, regularly
sharing strategies, experiences, and resources with one another. This collaborative model may
also serve to be a useful approach for improving diabetes care delivery in the hospital setting.
Project to Evaluate Diabetes Care in Rural Hospitals

This year the Wisconsin Office of Rural Health (WORH) embarked on a project to begin to
evaluate inpatient diabetes care, specifically addressing hospitals in rural areas. The WORH has
been providing technical assistance to help hospitals achieve critical access hospital (CAH)
status and develop rural networks to improve access to care through the Flex Program since
2001. Rural hospitals that meet specific federal requirements qualify for this special designation
as a critical access hospital. This designation provides a different reimbursement system that is
intended to improve their financial status and reduce hospital closures. Some of the reported
benefits, in addition to potential financial advantages, include flexible staffing, access to
technical assistance through the Flex Program, and a focus on the community. The critical
access hospitals must operate in rural areas, have no more than 25 beds, and have an annual
average length of stay of no longer than 96 hours. While their existence is important to
preserving access to care in rural areas, these small hospitals are particularly challenged in caring
for a wide array of complex health conditions with limited resources.
The WORH provides technical assistance with staff training, collaboration, and evaluation
activities. The Program also provides mini-grants for the development of community coalitions,
several recently allocated for improving diabetes care.
The WORH collaborated with the Wisconsin Diabetes Prevention and Control Program
(WDPCP), the Wisconsin Hospital Association (WHA), and representatives from several critical
access hospitals to implement this project to assess inpatient diabetes care. The project
objectives are to:
Identify barriers and challenges that impede the delivery of quality inpatient diabetes care
management and education services in critical access hospitals
Provide recommendations to help hospitals meet identified diabetes care challenges
Identify potential resources and linkages that may help support inpatient diabetes care
and quality improvement activities
A review of the literature and contact with other state Diabetes Prevention and Control Programs
across the nation revealed that little is known about the state of diabetes care delivery within
critical access hospitals.
The collaborators developed an assessment tool that was distributed to the administrators of 58
critical access hospitals throughout Wisconsin. Participation was voluntary. Each administrator
was encouraged to have the person who was likely to know the most about how inpatient
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diabetes care management and education services are handled at their facility complete and
return the assessment tool within 30 days. Respondents had the option to complete the
assessment tool either electronically or by hand. A private contractor was hired to coordinate the
workgroup activities, develop materials for review, coordinate the distribution of the assessment
tool, analyze the data, prepare reports, and maintain confidentiality of submitted information.
The workgroup reviewed the summary of assessment findings and developed recommendations
for this report.
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PART 1: SUMMARY OF FINDINGS
Forty-six of fifty-eight critical access hospitals completed and returned an assessment tool, for a
79% response rate. A summary of findings is reported for each section of the assessment tool. A
detailed analysis of the data is included in Part 3: Detailed Analysis Findings.
Section A: General Information

Information received for this section of the assessment shows:
Respondents had an average length of employment at their facility of 12.25 years, with a
wide range of 1 month to 39 years.
Twenty (43%) indicated there was a staff person specifically identified to coordinate care
for inpatients that have diabetes; approximately half of these have advanced training in
diabetes care management. The average length of time the coordinator has been
providing diabetes care services was 8 years, with a range of 1 year to 20 years.
The defined role of the inpatient diabetes coordinator varied widely from: providing
minimal education on a need to know basis to the provision of more comprehensive
diabetes education, including responsibilities for staff education and the development of
guidelines and policies.
The specific number of other staff members who provide diabetes care and/or education
was unable to be determined due to a flaw in the survey tool. However, other survey data
shows that 18 of the 46 (39%) participating hospitals had access to at least one certified
diabetes educator (CDE) for inpatient services.
Many respondents indicated that most of their staff members that are not CDEs had not
received continuing education related to diabetes within the past 3 years. Actual numbers
are not available.
Few respondents reported having access to diabetes-related information for their facility.
23 respondents (50%) reported data on admissions in the past year for diabetic
ketoacidosis (DKA); the average was 3.22 admissions and the range was 0-9 admissions
16 respondents (35%) reported data on admissions in the past year for hyperosmolar
hyperglycemic state; the average was 2.13 admissions and the range was 0-12 admissions
24 respondents (52%) reported data on average length of stay for a person with a primary
diagnosis of diabetes; the range was 2.80 days and the range was 0-5 days
17 respondents (37%) reported data on admissions for average length of stay for a person
with a secondary diagnosis of diabetes; the average was 3.40 days; and the range was 2-5
days
Only 8 respondents (17%) reported data on the percent of patients with diabetes who are
readmitted within 30 days; the average was 14% and the range was 0% to 66%
Section B: Inpatient Care

Protocols
Responses showed wide variation in the use of standardized protocols to direct the provision of
inpatient care. The most widely used protocols reported are: hypoglycemia (80%), insulin
sliding scale (72%), intravenous insulin infusion (67%), and bedside blood glucose monitoring
(61%).
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Other protocol use was reported as: hyperglycemia (50%), immunization standing orders (48%),
diabetic ketoacidosis (39%), pre-op pertaining to diabetes (22%), standing admission orders
specific to diabetes (17%), insulin correction dose (15%), hyperosmolar hyperglycemic state
(11%), screening inpatients for diabetes (11%), insulin pump protocols (11%), post-op pertaining
to diabetes (9%), discharge (9%), and referral to specialty care (4%). One respondent indicated
they also use a protocol for diabetes education.
All 46 respondents indicated they were interested in receiving the recommendations for inpatient
diabetes care that are being developed by the Wisconsin Diabetes Advisory Group; the majority
(85%) indicated that they were willing to work to implement them at their hospital.
Insulin Therapy
About 2/3 of respondents (67%) reported that patients admitted to their hospital who required
insulin therapy would most likely continue to stay at their hospital, as opposed to being
transferred elsewhere.
Children with Type 1 Diabetes

About half of respondents (54%) reported that their hospital admits and treats children with type
1 diabetes. Nineteen reported information on the number of children with type 1 diabetes who
were admitted in the past year; the average was 1.5 and the range was 0-5.
Multidisciplinary Team
Only 26% of respondents reported having a designated inpatient multidisciplinary diabetes
team. Team members listed most often included: RN (100%), the pharmacist (100%), the
primary care provider (93%), and an RD (93%). Social worker was reported by 42%.
Admitting Physician
All 46 respondents indicated that the admitting physician assumes responsibility for the patients
diabetes care management while hospitalized.
Hospitalist
Only 2 respondents (4%) reported that their facility uses hospitalists.
Access to Diabetes Specialists

Half of the respondents reported having access to diabetes specialists. The numbers reporting
specialty access by type were: specialist provides continuing education to hospital staff (15),
telemedicine consults (8), specialist makes on-site visits to the inpatients (6), and internet/web
consults (5).
Nine respondents identified other specialty access as: telephone consults (3), certified diabetes
educator (1), contacting Madison doctors (1), a specific clinic (1), specialist makes on-site visits
to outpatients (1), podiatry (1), and referral to specialist from primary MD (1).
Section C: Inpatient Staff Continuing Education

The most widely used methods reported for inpatient staff continuing education were: time off
for conferences (89%), internet (83%), in-house seminars (76%), on-line access to education
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(76%), and consultation with diabetes experts (54%). Less used methods were: competency-
based in-house modules (41%), grand rounds and case reviews (22%), and telemedicine (17%).
Three respondents listed other methods used as: satellite access, members of the advisory
board, and physician updates.
Only 10 respondents (22%) reported that their hospital requires inpatient staff participation for
continuing education related to diabetes care management.
Section D: Inpatient Diabetes Education

Admission Process
Sixteen respondents (35%) reported there was a routine method during the admission process for
hospital staff to ask whether the person with diabetes has ever had diabetes education.
Diabetes Knowledge/Skills
Seventeen respondents (37%) reported there was a method to document each inpatients level of
diabetes knowledge and skills.
Resources for Diabetes Education:

Major resources for inpatient diabetes education identified were: voluntary organizations (76%),
professional organizations (57%), government (57%), and pharmaceutical companies (57%).
Lesser reported sources were: the American Association of Diabetes Educators (43%), the
International Diabetes Center (41%), standardized diabetes education curriculum (41%), and
purchase from private health education company (30%). Several respondents listed other
resources as: updates from a clinic, Logicare, and self-made.
Nineteen respondents (41.3%) reported that they use a standardized diabetes education
curriculum. These curricula were identified as: American Diabetes Association (5), International
Diabetes Center (4), locally developed (3), and a health education company [Logicare] (3). The
other four did not specify their curriculum.
Approximately half (53%) reported they had a process to periodically review patient education
materials for accuracy and relevancy; the average review frequency was 10 months. Those
indicating they had a review process were asked to describe the process. Major responses
indicated that reviews were done through a multidisciplinary committee, patient education
committee, advisory committee, a CDE, a vendor, and through affiliations with major clinics.
Other responses were non-specific.
Diabetes Education Topics Taught

The topics reported as most frequently taught to inpatients prior to discharge were:
hypoglycemia, medication, nutrition management, self-monitoring of blood glucose, contacting
the provider, and insulin adjustment.
Methods for Diabetes Education

The most widely used methods reported for providing diabetes education were: individual
inpatient instruction (92%), outpatient referral (80%), preprinted handouts only (76%), and
videos (67%). Less used methods were: support group (41%), patient access to the Internet in
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the hospital (28%), CD ROM/DVD with inpatient computer access (13%), group inpatient
instruction (4%), and cassette tapes (2%).
Documentation
Twenty respondents (61%) reported the use of standardized methods to document inpatient
diabetes care and education.
Section E: Barriers
Barriers to providing inpatient diabetes care management and education services that were cited
the most were:
High acuity levels and short hospital stays, limiting patients learning capacity (74%)
Lack of diabetes specialty physicians to consult with on inpatient issues (70%)
Lack of protocols for inpatient diabetes care management (67%)
Lack of an inpatient diabetes team to coordinate care (67%)
Lack of available, trained diabetes educators for inpatient care and consultation (65%)
Lack of documentation protocols (59%)
Inadequate staffing resulting in lack of time to effectively assess and educate patients
(54%)
Lack of knowledge about insulin protocols and newer medications (54%)
No standardized diabetes education curriculum (52%)
Lack of computerized patient chart/records (52%)
Not enough access to staff continuing education opportunities (46%)
Section F: Discharge Planning

The RN and social worker were the staff most frequently listed as responsible for discharge
planning for inpatients with diabetes. The primary care provider, RD, and pharmacist were listed
less frequently. Six respondents listed others involved in discharge planning as: discharge
planner, utilization review, diabetes educator, care management, clinical coordinator, and dietary
manager.
The majority of respondents (91%) reported that their hospital does not use standardized
protocols for diabetes-related discharge orders.
Respondents were also asked to describe their discharge planning process. Their responses are
summarized in Part 3: Detailed Analysis Findings, Section F.
Community Referral for Other Diabetes Education and Resources:

Thirty-eight respondents (83%) reported that they refer patients with diabetes to education
programs or other resources in the community. Individual responses regarding their referral
process varied and are summarized in Part 3: Detailed Analysis Findings, Section F.
Barriers
Barriers to referrals for community diabetes education that were cited the most were:
Patient lack of interest or unwillingness to attend diabetes education (63%)
Lack of perceived value of diabetes education by patients (59%)
Physician does not refer (48%)
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Patients lack sufficient insurance coverage for diabetes education (43%)
Distance patient must travel to receive diabetes education (43%)
Personal cost to patients for receiving diabetes education in the community (39%)
Lack of public transportation to help patient get to diabetes education (37%)
Community health practices are more crisis-oriented than preventive (37%)
Other barriers and/or comments listed by respondents were:

Number of hours allowed versus number of hours needed (reimbursement)
Minimum number of patients so is difficult to achieve appropriate staff competence
Lack of perceived value or need by nursing
Only done if ordered by provider
Lack of community diabetes education services
Work conflicts added to class/education schedule not convenient for patient
Physicians do not value education as a team effort
Pre-diabetes not covered
No budget for diabetes education team
Fear and misunderstanding of diabetes
Medicare guidelines not allowing patient to be seen by RN and RD on same day. We
live in a rural area where transportation is often a challenge to arrange. Some persons
travel over 40 miles one way to get to appointments. Its a senseless Medicare rule that
needs revisiting. Gas prices and asking patients to make separate or frequent trips hinder
quality care delivery.
It should be noted that a high number of respondents indicated dont know/not sure to each of
the barriers listed in this section. The range of dont know responses ranged from 13% to a
high of 57% for some of the barrier choices.
Section G: Community Outreach

The majority of respondents (72%) reported that their hospital offers outreach services to
increase diabetes awareness and promote diabetes prevention in local community settings.
The majority of these reported using health fairs and community events
More than half of these reported using worksites and/or employee wellness programs,
newspaper articles/radio messages, community diabetes support groups, diabetes
community screening programs, and home care
Almost half reported using hospital newsletters
About a third reported using meal-site programs community/fraternal organizations and
schools
Few respondents reported using churches or grocery stores/malls
Other settings added by respondents were local cable/TV program and bus rides
organized for people to attend local diabetes expo with pick up from several sites
Collaboration
Only 17% of respondents reported that their hospital was involved in community diabetes-related
health care collaborations.
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The names of the community collaborations are not included in this report due to confidentiality.
Various community organizations reported as involved in collaborations include: hospitals, local
clinics, UW Extensions, local county public health and human service departments, Lions clubs,
Big Brothers/Big Sisters, schools, family planning, county circuit court, parent resource centers,
police/sheriff departments, child care organizations, head start, clergy associations, hospices,
commissions on aging, and community members with diabetes.
General activities reported for their current collaborative activities were:

Providing information via news media and billboards on highways
Conducting health fairs and community events
Screening and education at worksites
Community nutrition and physical activity coalitions working on the root causes of
diabetes lifestyle choices
Promoting individual and family well-being
Assessing the needs of the community
Improving inpatient and outpatient diabetes education
Identifying quality improvement efforts and desired outcomes
Working closely with health systems and following guidelines and protocols developed
based on best practice
Offering patient management tools for clinical practice to improve diabetes care at the
hands of the provider
Tracking blood pressure, LDL, and diabetes quality standards
Section H: Quality Improvement

Diabetes Measures
Few respondents (9%) reported that their hospital had a formal quality improvement program
that included inpatient diabetes care outcome measures; 17% of respondents reported dont
know/not sure. No respondents reported any specific diabetes-related inpatient measures being
tracked by their hospital. One respondent indicated they only measure outpatient at this point.
Satisfaction
Six respondents (13%) reported their hospital assesses patient satisfaction with inpatient diabetes
care and education services; 8 respondents (17%) indicated dont know/not sure.
Three respondents provided additional comments regarding assessment of patient satisfaction

with diabetes care management and education services. Comments were:
Just started checking patient follow-up rates, satisfaction, and inpatient length of stay
This is an assessment of all inpatient care, not specific to diabetes
Patients are given 1-800 number to call with problems, concerns, and satisfaction with
program
Section I: Inpatient Data Practices

New Cases of Diabetes
Only 3 respondents (7%) reported they use a specific process to identify new cases of diabetes in
inpatients. Two listed initial nursing assessment and the other listed diagnosis by health care
provider.
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Medical Records
Twenty-two respondents (48%) reported they use paper records for inpatient care; four (9%)
reported using electronic records; and twenty (43%) reported using a combination of paper and
electronic records.
Database
Nineteen respondents (41%) reported having a system, such as a database or electronic medical
record that can identify inpatients that have diabetes, seventeen (37%) said they did not, and ten
respondents (22%) indicated they didnt know or were not sure.
System names reported were: CSPI, Cerner, Meditech, Phamous, HBIC, HMS, PCI, Epic,
IMPACT, and ABS Diagnostic.
Six respondents indicated that diabetes care and education data were entered into a computer
program for monitoring and evaluation purposes. Responses given for who enters data into the
system were: RN (6), RD (3), PCP (2), pharmacist (1), psychologist (1), and social worker (1).
Queries
Responses to the question asking about the types of queries their system can generate is difficult
to analyze, since the responses outnumber those who initially reported having a database or
system. Since many reported dont know/not sure as their answer, only those who indicated
that they can generate a specific query are reported in the summary below.
Track inpatient glycemic management (7)
Identify new cases of diabetes (6)
Assist with disease surveillance (5)
Provide inpatient diabetes-related data for QI activities (4)
Track inpatient education services (4)
Track inpatient outcomes of care (3)
Help coordinate referrals (2)
Identify persons who may have pre-diabetes (2)
Identify need for follow-up care (1)
Identify the need for outreach services (1)
Several of those who reported they could generate a query to track inpatient glycemic
management indicated that the report only provides individual-level summary data, not
aggregate (population-level) reports.
Nine respondents (29%) reported that another mechanism is used to monitor inpatient diabetes
care; all of those nine reported chart review.
Section J: Miscellaneous
Education Program Recognition
Fifteen respondents (33%) reported that their hospital has recognition by the American
Diabetes Association (ADA) for its diabetes education services.
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Twelve respondents (38%) indicated that their hospital was interested in applying for ADA
recognition for diabetes education services. Eleven respondents indicated dont know/not
sure.
Nineteen respondents (41%) reported their hospital collaborates with a local ADA recognized
diabetes education program. Five indicated dont know/not sure.
Listserv
Twenty-nine respondents (63%) indicated an interest in participating in a diabetes listserv to
share strategies and resources with colleagues. Fifteen respondents (33%) indicated dont
know/not sure. Only two respondents indicated no.
Specific Training or Resources Requested

Respondents were asked to identify specific training and resources that would help their hospital
improve its diabetes care management and education services. General comments reported have
been combined and are summarized below into major categories of the chronic care model.
Research has shown that interventions that include elements of the chronic care model improve
processes of care and clinical outcomes (28).
Organizational Support
Access to a certified diabetes educator
Promotion of diabetes education to hospital staff
More departments to coordinate patient care and get ADA certified
A budget that would cover expenses such as teaching materials, materials purchased for
our community meetings, annual diabetic educators convention
Increased staffing hours to effectively provide inpatient diabetic management; several
respondents reported that they do not routinely see all inpatient diabetics with current
staff hours and have difficulty meeting the needs of current outpatients
Financial resources and funding for education resources and software
Clinical Information Systems and Evaluation

Ways to track without computerized medical records access
Computerized system which has the plan of care incorporated into EMR
Easy way to collect outcome data
Quality assurance program
Mechanism for periodic evaluation and updating of the materials we do have
Up-to-date materials for evaluation of the patient's knowledge of diabetes care
Decision Support
Evidence-based protocols for management, medication alteration, insulin drips, glucose
monitoring, correction-dose insulin, insulin pumps, diabetes education, referrals,
documentation
Support in revamping our system and resources
Diabetic education specialist to inservice education training with staff nurses
Training on evidence-based practice for diabetes
Physician education on new meds and approaches
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On-site training and guest speakers
Staff updates and newsletters
Delivery System Design

Our own diabetic champion to review protocols and bring them back to staff
Better coordination between staff
Articles on benefit of inpatient CDE to justify cost savings
Policies/procedures on when to consult CDE for inpatients
A systematic education program with appropriate staff training and discharge planning to
improve the consistency and continuity of our diabetic education
Self-Management Support
New tools to streamline documentation for diabetes education
A more structured program with materials that are more current
(Several respondents mentioned having very limited time to teach patients.)
Community
Need to work with the community to establish our own resources here
Collaboration with another facility on how to develop an efficient and thorough inpatient
diabetic education program
Other General Comments for Specific Training or Resources

All would be greatly appreciated and helpful. We have a well established OP program but
nothing for inpatient.
Unsure what is available and what reimbursement issues there are
Training and Resource Preferences

Preferred methods for receiving updated diabetes training and resource materials were: samples
in print format (96%), web-based resources (93%), professional in-state conferences (89%),
identification of trainings with CEUs (89%), identification of informal continuing education
sources (89%), sharing strategies with colleagues via listserv (87%), resources available on CD-
ROM (87%), group teleconferences with diabetes experts (78%), linkage with local experts,
such as certified diabetes educators (78%), and listings of relevant national conferences (48%).
Respondents reported varied familiarity with state diabetes control efforts and several other
useful diabetes improvement resources as indicated below:
Wisconsin Diabetes Prevention and Control Program 57%
Wisconsin Essential Diabetes Mellitus Care Guidelines 65%
National Diabetes Education Program 46%
Chronic Are Model and components 22%
Quality Improvement Model 35%
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PART 2: CONCLUSIONS AND RECOMMENDATIONS
Major inpatient diabetes care management needs that were identified through the critical access
hospital assessments are reported as priorities below. Listed after each identified need are some
suggested recommendations for hospital staff to consider that may help improve inpatient
diabetes care. These recommendations were developed by the Critical Access Hospital Diabetes
Project Workgroup and are reasonably consistent with those identified in the joint ACE/ADA
consensus statement on inpatient diabetes and glycemic control (7). The challenge for critical
access hospital staff will be to try to decide on improvements that are feasible to undertake given
the competing demands for limited resources at the local level. Facilities are encouraged to
assess their hospital environment and work to implement at least a few recommendations that
may be pertinent to improve their inpatient diabetes services.
During the critical access hospital assessment process, many respondents indicated that they
were willing to share various useful resources and tools, such as protocols, policies, and
documentation forms that they use to facilitate inpatient diabetes care. In order to help support
an open forum for colleagues to share these resources as well as diabetes-related concerns with
each other, the Wisconsin Office of Rural Health has developed a diabetes listserv. This listserv
also provides the opportunity for hospital staff to share experiences regarding the lessons learned
from various interventions and approaches, as well as a means to post up-to-date web-based,
journal, and local continuing education opportunities to enhance diabetes-related skills. Staff
members who provide services to inpatients with diabetes are encouraged contact the Wisconsin
Office of Rural Health to sign up for this listserv.
Priority Need #1: Improve staff development skills regarding diabetes care
Many critical access hospital respondents reported that theyre encountering more complex
inpatient care needs due to shorter hospital stays and higher acuity levels. Despite the increased
level of care needs, personnel indicated they have limited access to convenient, relevant,
continuing education and training on current diabetes care management.
Project Workgroup Recommendations

Identify and promote convenient, free or low-cost, self-directed continuing education
opportunities, such as web-based training, teleconferences, audio-conferences, CD-ROM,
on-line libraries, and other distance learning technology, to enhance diabetes
management skills and maximize staff resources; share identified opportunities on the
diabetes listserv
Identify and promote basic competency standards for staff that provide inpatient diabetes
care
Explore the capacity for in-house staff training, such as regular updates with a local
diabetes expert or (e.g., certified diabetes educator, registered dietitian, pharmacist, etc.)
16
Priority Need #2: Enhance access to inpatient diabetes expertise
Many critical access hospital respondents indicated that their facilities lacked access to diabetes
experts, such as registered dietitians, certified diabetes educators, pharmacists, or specialty
physicians, to consult with on diabetes inpatient management concerns.

Explore opportunities to expand access to expert diabetes consultation and management
updates through evolving technology channels, telemedicine, and/or academic detailing
Consider increasing hours for inpatient diabetes specialty staff (e.g., registered dietitians,
diabetes educators, pharmacists)
Consider the feasibility of sharing a certified diabetes educator among the hospitals
inpatient, outpatient, nursing home, and home care settings (or even with other hospitals
or clinics)
Priority Need #3: Standardize protocols and policies to guide inpatient diabetes care
management
Many critical access hospital respondents reported that their facilities lacked standardized
guidelines to facilitate consistent diabetes care management across the continuum of care.
Assessment data revealed disparate use of various inpatient diabetes-related protocols.

Develop a systems approach to standardize diabetes care delivery through the
development of hospital protocols (e.g., such as for the prevention and treatment of
hypoglycemia, hyperglycemia treatment, insulin delivery, DKA treatment, bedside
glucose monitoring, referral, discharge, etc.)
Share existing samples of inpatient diabetes protocols though the diabetes listserv
Adopt inpatient diabetes protocol recommendations currently under development by the
Wisconsin Diabetes Advisory Group, once they become available
Develop a method to regularly review existing protocols for safety and appropriateness
Priority Need #4: Promote multidisciplinary steering teams to assess current processes and
barriers to care and to help guide improvement interventions
Personnel reported a lack of multidisciplinary teams and/or local champions in their facilities
who could guide inpatient diabetes care management and lead improvement initiatives, such as
the development and implementation of policies and protocols. Many respondents also reported
a lack of consistent methods for the provision of inpatient diabetes education services, such as
facilitation of referrals, assessment of patient knowledge and skills, regular review of education
materials, and documentation. Assessment information also showed there were inconsistencies
with discharge planning and limited staff awareness of barriers concerning referrals to outpatient
education services and community resources.

Utilize the diabetes listserv to facilitate the exchange of strategies and resources to
improve inpatient diabetes care with colleagues
Identify local champions who are interested in improving diabetes care to lead your
facilitys intervention efforts (such as the development and implementation of protocols,
17
provider education, quality improvement, etc.) and to help leverage necessary resources
and support
Explore development of a multidisciplinary team, or even a modified team, to guide
inpatient chronic disease management, to explore local barriers to effective care, and to
improve communication and coordination of care
Establish a system to standardize diabetes education materials and for a regular review
process to ensure accuracy and relevancy; ensure ready availability of designated
materials to inpatient staff
Explore use of a preadmission/admission questionnaire and a skills assessment process
for patients with diabetes (even those admitted for another condition) to direct further
inpatient and outpatient diabetes education needs
Formalize a referral and discharge process to facilitate a smooth transition from hospital
to outpatient care and to help assure appropriate follow-up and linkage to community
diabetes education programs; include provision for follow-up needs for further screening
for patients identified with hyperglycemia during hospitalization
Develop a listing of community resources to help link patients and families to essential
supportive services
Explore opportunities to develop and expand community linkages to increase awareness
about the growing epidemic of diabetes, risk factor reduction, and diabetes prevention
strategies
Priority Need #5: Promote systems that can evaluate diabetes-related data on an ongoing
basis and guide quality improvement efforts
Few respondents reported the availability of diabetes-related data for their facilities, making it
difficult to discern the extent of the capacity of their data systems to generate either individual-
level or facility-wide reports. While it was suggested that respondents might need to consult with
other hospital staff to complete some sections of the assessment tool, many dont know
responses to the data questions were received. The short timeline for completion and return of
the assessment tool may have been a limiting factor in obtaining data-related information. This
may also have been a factor in the limited reporting for the section on barriers concerning
referrals to community diabetes education services.

Explore opportunities (e.g., through the diabetes listserv or meetings) to dialogue with
other critical access hospital staff to share experiences with data management
programs/systems
Explore the capacity of existing data systems to collect, monitor, and evaluate inpatient
diabetes-related outcomes
Commit more resources to data system improvement and data management
Explore the use of standardized documentation methods and forms to promote efficiency,
timely access to critical clinical information to facilitate decision-making and plan of care
revisions, and ease of data retrieval through chart abstraction in the absence of the
capacity to track care through electronic data systems
Identify persons with diabetes in the medical record at the time of admission to the
hospital and also at the time of discharge (for those identified during their hospitalization)
Expand existing satisfaction surveys to include for evaluation of diabetes care services
18
Promote collaboration with affiliated health systems, insurers, and other potential data
partners to expand quality improvement capacity and opportunities for shared learning
Promote the development of national, standardized inpatient measures to facilitate
accurate collection and comparability
Other Project Workgroup Recommendations

The Critical Access Hospital Diabetes Project Workgroup encourages the WORH Flex
Program Coordinator to continue to serve as a representative on the Wisconsin Diabetes
Advisory Group (DAG), a network of the states major diabetes organizations. This
membership provides the means for potential access to collaborate with these
organizations, as well as linkage with the Wisconsin Diabetes Prevention and Control
Program (WDPCP). The WDPCP coordinates the DAG and many of its collaborative
activities and has extensive knowledge about diabetes care and resources. For example,
the DAG partners are currently collaborating on a project to develop recommendations
for inpatient diabetes protocols. These recommendations are very relevant to the needs
identified in the critical access hospital assessment and can be shared via the listserv once
they become available.
The project workgroup encourages the Wisconsin Office of Rural Health Flex Program
Coordinator to share the results of this assessment report with the Wisconsin Diabetes
Advisory Group.
The project workgroup also recommends that the Wisconsin Office of Rural Health
establish a link from its webpage to that of the Wisconsin Diabetes Prevention and
Control Program to facilitate identification of relevant diabetes resources.
19
PART 3: DETAILED ANALYSIS FINDINGS
Section A: General Information
Questions 1, 2, and 3 asked for information on the date the survey was completed, the name of
the participating hospital, contact information, and the length of time the contact has been
employed at this hospital. Identifying information is not presented here due to confidentiality.
Length of employment responses ranged from one month to 39 years. The average length of
employment was 12.25 years.
4. IS THERE A STAFF PERSON AT THIS HOSPITAL WHO HAS SPECIFICALLY BEEN

IDENTIFIED TO COORDINATE THE CARE OF INPATIENTS WHO HAVE DIABETES ?
[E.G., CDE, RN, RD, HEALTH EDUCATOR, ETC.]
20 respondents selected yes (43%)
26 respondents selected no (57%)
Yes
No
43.5%
56.5%
If respondents answered yes to question 4 indicating there was a person specifically identified
to coordinate the care of inpatients with diabetes, they were asked to also answer questions 4a,
4b, and 4c.
4A. COULD YOU PLEASE DESCRIBE WHAT THIS PERSON DOES TO COORDINATE
INPATIENT DIABETES CARE AT YOUR HOSPITAL ?
Twenty individual responses to this question are included below.

Inpatient education; referral for outpatient education
Provide video tapes, handouts to staff along with supplies to teach injection; have also
done inpatient teaching
20
We receive consults at our clinic and then coordinate with hospital staff on the need to
know info so that we can educate the patient, get them discharged and have them follow
up with us at the clinic
Designated day every other week to see inpatients who are diabetic; visists are somewhat
limited to focusing on whether or not the patient is having any problems or concerns
about diabetic care at home, and if so how could we be of service; all other days, the RN
assigned to the patient addresses any concerns that may come up during the hospital stay
and at discharge
Inpatient referrals are generated by either the MD, or are the result of a screening process
developed by our department that is done on admission. Nurses may also refer patients
later in the admission if it seems appropriate
Standardized Diabetes Educational Packets; teaches about the disease process, treatment:
oral agents, insulin, complications, use of glucometer and self-injection, etc.
Be sure patients receive written materials, glucometer, and if applicable, see dietitian.
Coordinate care/appointments as patients progress to outpatient status
She starts education in the inpatient setting; upon discharge the physician orders
outpatient diabetic education to follow up
Coordinates documentation, educational materials to the patients and staff regarding
diabetes; all education/coordination of care is evidence-based with the help of an
endocrinologist
Develops guidelines for diabetic teaching inpatient program; provides outpatient
mangement/education for community members with diabetes; coordinates diabetes
education programs. [Respondent was backup for 3 years; just transitioned to primary
coordinator.]
Create and complete care plans and education plans for patients and provide patient
education; provide staff inservice
Responsible for maintaining certification of the program, including policy
review/revision, patient teaching, staff education, statistics, communication to physicians
and staff
Provides education to staff, see all inpatients with diabetes, consult with MDs and other
entities while patients are hospitalized
Upon referral to diabetes RN, she sees patient and coordinates pharmacist and dietitian to
see the patient
Coordinator meets with all newly diagnosed diabetes patients as well as those with
problems managing their blood sugars as inpatients. New patients meet with the
coordinator for about 1 hours; she reviews delayed meals, no-nutritional sweeteners,
diabetic resources, glucometers, sharps program, blood sugar goals, carbohydrate
counting, diet, symptoms of hypoglycemia, foot care, label reading, etc.
Monitors patient response to treatment; works with MDs and pharmacists to
develop/revise protocols
Initial visit with all patients diagnosed with diabetes
Patients are referred to the outpatient setting for diabetes education
Only upon referral will diabetic educator see an inpatient to review diabetic management.
CDE will revise policy/procedure for management of insulin
[Name removed] and the dietitian see patients for diabetic education on an individual
basis. She has also set up a protocol for sliding scale insulin
21
4 B. DOES THIS PERSON HAVE ADVANCED TRAINING OR CREDENTIALS IN DIABETES
CARE MANAGEMENT AND/OR DIABETES EDUCATION SERVICES ? [E.G.,
CERTIFIED DIABETES EDUCATOR (CDE) OR BOARD CERTIFICATION IN
A total of 20 respondents answered yes to the initial question 4 indicating there was a person
specifically identified to coordinate the care of inpatients with diabetes; however, 22 responded
to question 4b. Of these 22 respondents:
4C. PLEASE INDICATE THE ESTIMATED LENGTH OF TIME THAT THIS PERSON HAS
BEEN PROVIDING INPATIENT DIABETES CARE MANAGEMENT AND/OR DIABETES
A total of 20 respondents responded to this question, indicating a range of 12 months to 29 years.

The average time was 8 years.
5. ARE YOU AWARE OF ANY OTHER INPATIENT STAFF THAT PROVIDES DIABETES
CARE MANAGEMENT AND/OR DIABETES EDUCATION SERVICES AT YOUR

2 respondents answered dont know/not sure (4%)
3 respondents did not answer the question (7%)
6.5%
Yes
4.3%
No
4.3%
Don't know/Not sure
No Answer
84.8%
Those responding to Question 5 were asked to complete a table to collect additional information
regarding the their inpatient staff who provide diabetes care management and/or diabetes
education services (e.g., title, number in each discipline, number of those who are certified
22
diabetes educators, and if they were not CDEs an indication regarding whether they had training
in diabetes care and/or education within the past 3 years).
Data for this table is not included in this report because of incomplete survey responses due to a
flaw in the design of the electronic survey tool. However, other survey data collected showed
that 18 of the 46 participating hospitals (39%) had access to at least one certified diabetes
educator for inpatient care management and education services.
Although actual numbers are not available, many respondents indicated that most of their staff
who are not certified diabetes educators have not received continuing education in diabetes care
management and/or education within the past three years.
6. HOW MANY PATIENTS WITH DIABETES WERE ADMITTED TO YOUR HOSPITAL IN

THE LAST CALENDAR YEAR FOR THE FOLLOWING CONDITIONS ?
Diabetic ketoacidosis (23 respondents provided numerical answers)

Average = 3.22 persons
Range = 0 9 persons
23 other respondents selected dont know/not sure
Hyperosmolar hyperglycemic state (16 respondents provided numerical answers)

Average = 2.13 persons
Range = 0 12 persons
7. WHAT IS THE AVERAGE LENGTH OF STAY AT YOUR HOSPITAL FOR A PATIENT

Primary diagnosis of diabetes? (24 respondents provided numerical answers)
Average = 2.80 days
Range = 0 5 days
Secondary diagnosis of diabetes? (17 respondents provided numerical answers)

Average = 3.40 days
Range = 2 5 days
8. ARE YOU AWARE OF THE PERCENT OF PATIENTS WITH DIABETES WHO ARE
READMITTED WITHIN 30 DAYS (DIABETES LISTED AS ANY DIAGNOSIS)?
Average = 14% (only 8 respondents provided numerical answers)

Range = 0 66%
1 respondent did not answer the question
23
Section B: Inpatient Care
1. PLEASE INDICATE WHETHER YOUR HOSPITAL USES ANY STANDARDIZED

PROTOCOLS [SUCH AS THE EXAMPLES GIVEN] TO DIRECT THE PROVISION OF
INPATIENT DIABETES CARE. ALSO, PLEASE SPECIFY WHETHER YOUR FACILITY
IS WILLING TO SHARE A COPY OF ANY PROTOCOLS THAT YOU DO USE.
Table 1 reflects the number and percent (of total) of responses regarding use of each of the
inpatient protocols.
Table 1: Responses to the Question Regarding Inpatient Standardized Protocol Use
Standardized Protocol Willing to Share?
Yes No DK/NS No Yes No No

Answer Answer
Standing admission order sets specific to 8 (17%) 35 (76%) 1 (2%) 2 (4%) 3 (38%) 0 (0%) 5 (63%)
diabetes
Bedside blood glucose monitoring 28 (61%) 17 (37%) 1 (2%) 0 (0%) 12 (43%) 1 (4%) 15 (54%)
protocols
Hypoglycemia protocols 37 (80%) 8 (17%) 0 (0%) 1 (2%) 20 (54%) 1 (3%) 16 (43%)
Hyperglycemia protocols 23 (50%) 21 (46%) 0 (0%) 2 (4%) 10 (43%) 0 (0%) 13 (57%)
Intravenous insulin infusion protocols 31 (67%) 14 (30%) 0 (0%) 1 (2%) 14 (45%) 1 (3%) 16 (52%)
Insulin pump protocols 5 (11%) 39 (85%) 1 (2%) 1 (2%) 2 (40%) 1 (20%) 2 (40%)
Diabetic ketoacidosis protocols 18 (39%) 26 (57%) 0 (0%) 2 (4%) 7 (39%) 1 (6%) 10 (56%)
Hyperosmolar hyperglycemic state 5 (11%) 38 (83%) 0 (0%) 3 (7%) 2 (40%) 0 (0%) 3 (60%)
protocols
Pre-op protocols pertaining to diabetes 10 (22%) 32 (70%) 3 (7%) 1 (2%) 4 (40%) 0 (0%) 6 (60%)
Post-operative protocols pertaining to 4 (9%) 37 (80%) 4 (9%) 1 (2%) 3 (75%) 0 (0%) 1 (25%)
diabetes
Insulin sliding scale protocols 33 (72%) 13 (28%) 0 (0%) 0 (0%) 12 (36%) 1 (3%) 20 (61%)
Insulin correction dose protocols 7 (15%) 36 (78%) 2 (4%) 1 (2%) 3 (43%) 0 (0%) 4 (57%)
Insulin to carbohydrate ratio protocols 5 (11%) 36 (78%) 3 (7%) 2 (4%) 2 (40%) 0 (0%) 3 (60%)
Immunization standing orders 22 (48%) 22 (48%) 2 (4%) 0 (0%) 8 (36%) 1 (5%) 13 (60%)
Transfer protocols, specific to diabetes 0 (0%) 44 (96%) 1 (2%) 1 (2%) 0 (0%) 0 (0%) 0 (0%)
Referral to specialty care protocols 2 (4%) 42 (91%) 1 (2%) 1 (2%) 0 (0%) 0 (0%) 2 (100%)
Protocols to screen inpatients for 5 (11%) 40 (87%) 0 (0%) 1 (2%) 1 (20%) 0 (0%) 4 (80%)
diabetes
Discharge protocols 4 (9%) 40 (87%) 1 (2%) 1 (2%) 0 (0%) 0 (0%) 4 (100%)
Protocols to assess diabetes self- 5 (11%) 37 (80%) 2 (4%) 2 (4%) 2 (40%) 0 (0%) 3 (60%)
management knowledge and skills
Percentages may not add to 100, due to rounding.
One respondent listed use of a protocol for diabetes education under the other category.
24
2. THE WISCONSIN DIABETES ADVISORY GROUP IS IN THE PROCESS OF
DEVELOPING RECOMMENDATIONS FOR INPATIENT DIABETES CARE
MANAGEMENT WOULD YOU BE INTERESTED IN RECEIVING THESE WHEN THESE
All 46 respondents (100%) selected yes.
2A. ARE YOU WILLING TO WORK TO IMPLEMENT THESE RECOMMENDATIONS IN

7 respondents selected dont know/not sure (15%)
15.2%
Yes
Don't know/Not sure
84.8%
25
3. IF A PATIENT IS ADMITTED TO YOUR HOSPITAL THAT RE QUIRES INTENSIVE
INSULIN THERAPY, IS THIS PERSON MOST LIKELY TO:
31 respondents selected continue to stay to be cared for at your hospital (67%)

11 respondents selected need to be transferred to another hospital (24%)
8.7%
Stay at hospital
Transferred
Don't know/Not sure
23.9%
67.4%
4. DOES YOUR HOSPITAL ADMIT AND TREAT CHILDREN WITH TYPE 1 DIABETES ?
10.9% Yes
34.8% No
Don't know/Not sure
54.3%
26
4A. CAN YOU TELL ME HOW MANY CHILDREN WITH TYPE 1 DIABETES WERE
ADMITTED TO YOUR HOSPITAL IN THE PAST YEAR?
Average = 1.5 children

Range = 0 5 children
19 respondents provided numerical answers (41%)
9 respondents did not provide an answer (20%)
5. DOES YOUR HOSPITAL USE A DESIGNATED INPATIENT MULTIDISCIPLINARY

DIABETES TEAM ?
1 respondent selected dont know/not sure (2%)
71.7%
Yes
No
Don't know/Not sure
2.2%
26.1%
Those responding yes to question 5, Does your hospital use a designated inpatient
multidisciplinary diabetes team, were asked to also answer the following question:
5A. PLEASE INDICATE WHAT DISCIPLINES THE INPATIENT DIABETES TEAM
Even though only 12 respondents selected yes for question 5 [indicating that their hospital uses
a designated inpatient multidisciplinary diabetes team], additional persons answered yes to
having certain disciplines on their team. Numbers and percents of responses are provided in
Table 2. For details on how the percents were calculated, please see the methodology section.
27
Table 2: Responses to the Question Regarding Inpatient Diabetes Team Members
Discipline Included in Yes No Dont know/not Did not answer
Inpatient Diabetes Team sure question (of the 12)
Primary care provider 13 (93%) 1 (7%) 0 (0%) n/a
RN 14 (100%) 0 (0%) 0 (0%) n/a
RD 13 (93%) 1 (7%) 0 (0%) n/a
Pharmacist 12 (100%) 0 (0%) 0 (0%) 0 (0%)
Psychologist 0 (0%) 8 (67%) 0 (0%) 4 (33%)
Social Worker 5 (42%) 5 (42%) 1 (8%) 1 (8%)
Other 1 0 0 n/a
One respondent reported other and specified exercise physiologist.
6. IN YOUR HOSPITAL, DOES THE ADMITTING PHYSICIAN ASSUME RESPONSIBILITY

FOR THE PATIENTS DIABETES CARE MANAGEMENT WHILE HOSPITALIZED? IF
YOU SPECIFY NO, PLEASE INDICATE WHO DOES ASSUME RESPONSIBILITY.
All 46 respondents (100%) answered yes.
7. DOES YOUR FACILITY USE HOSPITALISTS ?

Those answering yes to question 7, Does your facility use hospitalists, were asked to also
answer the following question:
7A. DESCRIBE THE ROLE OF THE HOSPITALIST AT YOUR FACILITY.
There were two responses to this question:

If the patient doesnt have a physician or if the physician doesnt have privileges at our
facility, the patient is assigned to the hospitalist.
The hospitalist would care for the patient if requested by the physician.
28
8. DO YOUR INPATIENTS AND HOSPITAL STAFF HAVE ACCESS TO DIABETES
SPECIALISTS, SUCH AS ENDOCRINOLOGISTS OR DIABETOLOGISTS ?

45.7%
Yes
No
Don't know/Not sure
4.3%
50.0%
Those who answered yes to question 8 were asked to also answer the following question:
8A. THE FOLLOWING ARE TYPES OF INPATIENT DIABETES SPECIALTY ACCESS.

COULD YOU PLEASE INDICATE WHETHER OR NOT YOUR HOSPITAL HAS ACCESS
Twenty-three respondents selected yes for question 8 indicating they had access to diabetes
specialists. However, in some cases, more than 23 respondents answered question 8a concerning
type of specialty access. Numbers and percents of responses are provided in the Table 3. For
details on how the percents were calculated, please see the methodology section.
Table 3: Responses to the Question Regarding Diabetes Specialty Access

Diabetes Specialty Areas Yes No Dont know/
not sure
Specialists make on-site visits to the inpatients 6 (21%) 22 (79%) 0 (0%)
Telemedicine consults 8 (29%) 19 (68%) 1 (4%)
Internet/web consults 5 (19%) 18 (69%) 3 (12%)
Specialist provides continuing education to hospital staff 15 (52%) 13 (45%) 1 (3%)
Other 9 0 0
29
Nine respondents indicated the other types of specialty access they had as:
Telephone consults (3)
Podiatry (1)
Certified diabetes educator (1)
We contact Madison doctors (1)
A specific diabetes clinic (1)
Specialist makes on-site visits to outpatients (1)
Referral to specialist from primary MD (1)
Section C: Inpatient Staff Continuing Education
1. THERE ARE VARIOUS WAYS TO OBTAIN CONTINUING EDUCATION. THE

FOLLOWING IS A LIST OF POSSIBILITIES. PLEASE RESPOND WHETHER OR NOT
YOUR HOSPITAL USES THIS METHOD TO KEEP STAFF INFORMED ABOUT
CURRENT DIABETES CARE MANAGEMENT AND EDUCATION PRACTICES.
Numbers and percent of respondents reporting use for each continuing education method are
listed in Table 4.
Table 4: Responses to the Question Regarding Continuing Education Methods

Continuing Education Yes No Dont know/ No answer
not sure
In-house seminars 35 (76%) 10 (22%) 1 (2%) 0 (0%)
Consultation with diabetes experts 25 (54%) 20 (43%) 1 (2%) 0 (0%)
Competency-based in-house modules 19 (41%) 24 (52%) 1 (2%) 2 (4%)
Grand rounds and case reviews 10 (22%) 28 (61%) 3 (7%) 5 (11%)
On-line access to education 35 (76%) 8 (17%) 2 (4%) 1 (2%)
Time off for conferences 41 (89%) 4 (9%) 1 (2%) 0 (0%)
Internet 38 (83%) 6 (13%) 1 (2%) 1 (2%)
Telemedicine 8 (17%) 29 (63%) 3 (7%) 6 (13%)
Other 3
Three respondents listed other methods; they specified them as the following: satellite access,
members of the advisory board, and physician updates.
30
2. DOES THE HOSPITAL RE QUIRE INPATIENT STAFF PARTICIPATION FOR
CONTINUING EDUCATION FOR DIABETES-RELATED CARE MANAGEMENT ?
10 respondents selected yes (22 %)

4.3%
21.7%
Yes
No
73.9% Don't know/Not sure
Those responding yes to question 2 were asked to also answer the following question:
2A. HOW OFTEN ARE INPATIENT STAFF RE QUIRED TO PARTICIPATE IN THIS

CONTINUING EDUCATION?
9 respondents provided a numerical answer; the average response was 12.33 months; the
range was 9 to 18 months.
2 respondents chose dont know/not sure
31
Section D: Inpatient Diabetes Education
1. DURING THE ADMISSION PROCESS, IS THERE A ROUTINE METHOD FOR

HOSPITAL STAFF TO ASK WHETHER A PERSON WITH DIABETES HAS EVER HAD

2.2%
34.8%
63.0% Yes
No
Don't know/Not sure
2. IS THERE A METHOD TO DOCUMENT EACH INPATIENTS LEVEL OF DIABETES

KNOWLEDGE AND SKILLS ?

63.0%
Yes
No
37.0%
32
3. THE FOLLOWING IS A LIST OF POSSIBLE RESOURCES FOR DIABETES PATIENT
EDUCATION MATERIALS. AFTER EACH ONE, PLEASE INDICATE IF YOUR
HOSPITAL USES THIS RESOURCE FOR INPATIENT EDUCATION MATERIALS ?
Numbers and percents of respondents reporting use of specified education resources are listed in
Table 5.
Table 5: Responses to the Question Regarding Sources for Patient Education Resources
Resources for Diabetes Patient Education Materials Yes No Dont know/ No answer
not sure
Standardized diabetes education curriculum (if yes, please 19 (41%) 22 (48%) 4 (9%) 1 (2%)
specify the name of the curriculum):
Voluntary organizations [e.g., American Diabetes
Association, American Heart Association, National 35 (76%) 4 (9%) 6 (13%) 1 (2%)
Kidney Foundation, etc.]
Government [Centers for Disease Control and Prevention,
National Institutes of Health, National Diabetes Education 26 (57%) 15 (33%) 4 (9%) 1 (2%)
Program, National Diabetes Information Clearinghouse,
State Health Department, etc.]
International Diabetes Center 19 (41%) 16 (35%) 10 (22%) 1 (2%)
American Association of Diabetes Educators 20 (43%) 16 (35%) 8 (17%) 2 (4%)
Professional organizations [American Dietetic 26 (57%) 11 (24%) 9 (20%) 0 (0%)
Association, etc.]
Pharmaceutical companies 26 (57%) 13 (28%) 6 (13%) 1 (2%)
Purchase from private health education company 14 (30%) 24 (52%) 4 (9%) 4 (9%)
Other 5 0 0 0
Fifteen of the nineteen respondents who indicated that they use a standardized curriculum listed a
specific source for their curriculum rather than the name of the curriculum. These included:
American Diabetes Association (5)
International Diabetes Center (4)
Locally developed (3)
Health education company [Logicare] (3)
Five respondents listed other resources they use as:

Updates from a particular clinic (2)
Logicare (2)
Self-made
33
4. DOES THE HOSPITAL HAVE A PROCESS TO PERIODICALLY REVIEW PATIENT
EDUCATION MATERIALS FOR ACCURACY AND RELEVANCY?

15.2% Yes
No
Don't know/Not sure
52.2%
32.6%
Those responding yes to question 4 were asked to also answer the following question:
4A. PLEASE DESCRIBE HOW THIS PROCESS IS DONE.
Twenty of the twenty-four respondents who answered yes listed the following responses:
Diabetes educator provides current materials
Annually review all education materials; use Logicare and PET System
Majority of materials are ordered over the intranet; through main [name removed] Clinic;
all of the materials are reviewed periodically before being approved
Patient education committee reviews education materials
Logicare gets updates every 6 months; we also stay current with the newest editions of
the IDC publications; they seem to update every 3-4 years. We do not have a set protocol
for updating other materials used, we just try to keep things current within about 2 years
Patient education committee
Annual review of all patient and family education materials
Every three years ADA recommendations used; also twice a year the system workgroup
meets with [name removed] Center on materials
Each year the [name removed] Diabetes group reviews, updates, and makes sure
materials are standardized
We look into best practice for diabetes continually. Every month it seems like new
statistics/studies come out. We then take a look at them to see how we can comply with
the latest and greatest on diabetes management. Within this last year we had an
endocrinologist come and speak and give us input on our current diabetes management.
34
Myself [clinical educator] and a general practice physician went to the hospital where
[name removed] endocrinologist practices and went over policies and protocols around
diabetes. Like anything, it has taken time to develop new diabetes standards within our
hospital setting. We are always open-minded about changing the way we do things to do
whats best for our patients.
Review materials for relevance and maintain info of no greater than 3 years
Annual review
We have a multidisciplinary education group that meets quarterly
Diabetes advisory committee reviews education every 6 months
Diabetes committee reviews twice a year
A recent review was conducted with the hospitals RD and 2-3 RNs familiar with
diabetes patient education; current standards were reviewed and education materials were
updated and/or replaced to reflect current standards [not regularly]
CDE reviews annually and updates [delete/revise/add] information
We have a subscription to Micromedex for internet-based teaching materials; these are
periodically updated by the company according to best practice standards and updates are
made automatically. Our diabetes educator [RN] based in the clinic also periodically
reviews her pre-printed materials from the IDC, ADA, and AADE; she then updates us
on the materials available through her
ADA requirement; curriculum review every year
We utilize a lot of material from [name removed] health system at this time due to limited
staff resources; unsure of their frequency but we do have one RN from our staff that is
attending the education meetings monthly looking to have another attend the patient
education meetings
The twenty-four respondents answering yes to question 4 were also asked the following
question:
CAN YOU TELL ME HOW FRE QUENTLY THIS PROCESS IS COMPLETED?
19 respondents provided a numerical answer

3 respondents selected dont know/not sure
2 respondents did not provide an answer
Of the 19 respondents providing an answer, the average reported review timeframe was
10 months
It should be noted that a couple of people provided a range, and the midpoint of the range
was used to determine averages.
35
5. FOLLOWING IS A LIST OF DIABETES EDUCATION TOPICS THAT ARE TYPICALLY
TAUGHT TO THE PERSON WITH DIABETES. CAN YOU PLEASE CHECK THE TOP 5
EDUCATION TOPICS THAT ARE MOST FRE QUENTLY TAUGHT TO INPATIENTS
Diabetes education topics listed most frequently by respondents were: nutrition management;
self-monitoring of blood glucose and targets; medication; and hypoglycemia symptoms,
treatment, and prevention; insulin adjustment; and when to contact the provider. The figure
below indicates the total number of respondents for each education topic area.
45 42 41
40 38 39
35
30
Number
25
20
15 13 12 13
9
10
6 6
5 2 3
1 0 0 1
0
ng
e
ns
g
er
l
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36
6. FOLLOWING IS A LIST OF POSSIBLE METHODS USED TO PROVIDE DIABETES
PATIENT EDUCATION. AFTER EACH ONE, CAN YOU PLEASE INDICATE IF YOUR
HOSPITAL USES THIS METHOD TO PROVIDE INPATIENT DIABETES EDUCATION?
Numbers and percents of respondents reporting use for each diabetes education method are
indicated in Table 6.
Table 6: Responses to the Question Regarding Patient Education Method

Methods to Provide Diabetes Education Yes No Dont know/ No answer
not sure
Preprinted handouts only 35 (76%) 10 (22%) 0 (0%) 1 (2%)
Individual inpatient instruction 42 (91%) 2 (4%) 1 (2%) 1 (2%)
Group inpatient instruction 2 (4%) 39 (85%) 1 (2%) 4 (9%)
Videos 31 (67%) 12 (26%) 1 (2%) 2 (4%)
Cassette tapes 1 (2%) 38 (83%) 3 (7%) 4 (9%)
CD ROM/DVD with inpatient computer access 6 (13%) 36 (78%) 1 (2%) 3 (7%)
Patient access to the Internet in the hospital 13 (28%) 29 (63%) 1 (2%) 3 (7%)
Support group 19 (41%) 25 (54%) 1 (2%) 1 (2%)
Outpatient referral 37 (80%) 5 (11%) 1 (2%) 3 (7%)
Other: 2 0 0 0
Two respondents listed other methods as hands on demonstrations and insulin pump
program for outpatients.
37
7. DOES YOUR HOSPITAL USE STANDARDIZED METHODS TO DOCUMENT INPATIENT
DIABETES CARE AND EDUCATION, SUCH AS FLOW SHEETS OR STANDARDIZED

37.0%
2.2%
Yes
No
Don't know/Not sure
60.9%
Those who selected yes to question 7 were asked to also indicate whether they were willing to
share a copy of their standardized method. Seventeen (61%) provided an answer.
38
Section E: Barriers
1. THIS IS A LIST OF POSSIBLE BARRIERS IN PROVIDING INPATIENT DIABETES

CARE MANAGEMENT AND DIABETES EDUCATION SERVICES. COULD YOU PLEASE
INDICATE WHETHER OR NOT YOUR HOSPITAL FACES ANY OF THESE AS A
Numbers and percents of respondents reporting inpatient barriers are indicated in Table 7.
Table 7: Responses to the Question Regarding Inpatient Barriers

Barrier Yes No Dont know/ No answer
not sure
Lack of diabetes specialty physicians to consult with on 32 (70%) 11 (24%) 3 (7%) 0 (0%)
inpatient issues
Lack of available, trained diabetes educators for inpatient 30 (65%) 15 (33%) 1 (2%) 0 (0%)
care and consultation
Lack of registered dietitian to provide medical nutrition 10 (22%) 35 (76%) 1 (2%) 0 (0%)
therapy
Inadequate staffing resulting in lack of time to effectively 25 (54%) 20 (43%) 0 (0%) 1 (2%)
assess and educate patients
Lack of an inpatient diabetes team to coordinate care 31 (67%) 12 (26%) 3 (7%) 0 (0%)
Lack of protocols for inpatient diabetes care management 31 (67%) 12 (26%) 1 (2%) 2 (4%)
Lack of access to new technologies 17 (37%) 24 (52%) 4 (9%) 1 (2%)
Provider lack of knowledge about diabetes 18 (39%) 20 (43%) 7 (15%) 1 (2%)
Lack of knowledge about insulin protocols and newer 25 (54%) 15 (33%) 5 (11%) 1 (2%)
medications
Not enough access to staff continuing education 21 (46%) 23 (50%) 1 (2%) 1 (2%)
opportunities
Lack of documentation protocols 27 (59%) 13 (28%) 5 (11%) 1 (2%)
Lack of computerized patient charts/records 24 (52%) 18 (39%) 3 (7%) 1 (2%)
Disorganized patient charts 3 (7%) 39 (85%) 3 (7%) 1 (2%)
Inadequate educational materials 13 (28%) 32 (70%) 0 (0%) 1 (2%)
No standardized education curriculum 24 (52%) 18 (39%) 1 (2%) 3 (7%)
Inadequate inpatient facilities available for conducting 15 (33%) 27 (59%) 3 (7%) 1 (2%)
education
High acuity levels and short hospital stays, limiting patients 34 (74%) 11 (24%) 1 (2%) 0 (0%)
learning capacity
Education referral must be requested from physician before it 16 (35%) 28 (61%) 2 (4%) 0 (0%)
can be provided
Provider resistance 8 (17%) 29 (63%) 8 (17%) 1 (2%)
Lack of administrative support 5 (11%) 34 (74%) 6 (13%) 1 (2%)
Other 2 0 0 0
No barriers 0 (0%) 0 (0%) 0 (0%) 46 (100%)
39
Two respondents listed other barriers as:
It would be nice to have inpatient privileges for management (this respondent had
indicated she had advanced diabetes training)
Patients overwhelmed as inpatients
Additional comments noted:

One respondent added for gestational and children with diabetes and via phone
sometimes as issue after the barrier lack of available trained diabetes educators for
inpatient care and consultation
One respondent added not enough time for CDE to be able to do her job after the
barrier inadequate staffing resulting in lack of time to effectively assess and educate
patients
One respondent added not all providers but some lack knowledge of new changes in
guidelines for blood sugar management, meds, insulins after the barrier provider lack
of knowledge about diabetes
One respondent added variation in system after the barrier lack of documentation
protocols
One respondent added no to education, yes to protocols after the barrier provider
resistance
One respondent added need for increased hours after the barrier lack of administrative
support
Section F: Discharge Planning
1. WHO DOES DISCHARGE PLANNING FOR INPATIENTS WITH DIABETES AT YOUR
Since respondents could select more than one answer (asked to check all that apply), the total
number of responses is greater than 46. The graph below shows the number of responses who
reported each specific discipline as involved in discharge planning.
PCP 17
RN 41
RD 15
Pharmacist 8
Psychologist 0
Social Worker 29
Other 6
Don't know/Not sure 1
0 5 10 15 20 25 30 35 40 45
Number
40
The six respondents that selected the other category provided the following specific answers:
discharge planner, utilization review, dietary manager, clinical coordinator, patient educator, and
care management.
2. DOES YOUR HOSPITAL USE STANDARDIZED PROTOCOLS FOR DIABETES-

RELATED DISCHARGE ORDERS ?

8.7%
Yes
No
91.3%
Those responding yes to question 2, indicating they had protocols for diabetes-related
discharge orders, were also asked if they were willing to share copies. Three of these four
provided an answer and indicated yes.
3. PLEASE DESCRIBE THE DISCHARGE PLANNING PROCESS FOR PATIENTS WITH

DIABETES AT YOUR HOSPITAL.
35 respondents provided responses (76%) that are detailed below

11 respondents did not provide an answer (24%)
The answers that respondents provided are included below.

Physician prescribes home medications, frequency of glucose monitoring, follow up
clinic appointment, home care, if patient requires specific training as in injections,
glucose testing, referral is forwarded to nurse who completes outpatient diabetes
education.
Referral to outpatient services if needed; we have an outpatient diabetes program
available for referrals and education post discharge from inpatient
I have met with patient and instructed them who to contact if questions or problems arise
Not different from other patients. Medication orders reviewed, called in to pharmacy if
needed, outpatient follow-up appointments scheduled if needed; home health/home meals
set up as needed
41
Social worker coordinates discharge; oftentimes not notifying diabetes services until day
of discharge that patient needs education
RN, PCP, and social worker plan discharge; we dont have any specific process for
patients with diabetes
The patient is taught how to do accuchecks and what to do about the results, he/she is
assisted in getting a blood glucose meter and strips, given an appointment with the local
diabetes educator, taught self-administration of insulin, if necessary, and set up with a
follow up provider appointment
Since there is not a specific team to provide for discharge planning in the hospital the
standard discharge planning team reviews the patients history, condition, plan of care,
etc. and then recommends further treatments or discharge preparation/teaching
MD facilitated; daily patient care conferences beginning at admission of patient; referral
to appropriate specialist, support group, or outpatient diabietic clinic
Not sure
Just in time training/education done and then finished through diabetic educators at the
clinic
The discharge protocols are related to patients with insulin pumps and these are brand
new. There are no standard discharge protocols for most diabetic patients. Our discharge
planners review every chart for discharge needs and they do look at the diabetes
education needs screening assessment done on admission. Sometimes we receive
referrals for a diabetes education visit from them, and when we then see the patients we
determine what their discharge needs are: e.g., need new meter, need diabetes education,
etc. Otherwise there is really nothing specific set up, unfortunately. We need to work on
this!
Interdisciplinary team meets and discusses educational need and personal issues that
affect the patient. They make appropriate referrals for any needs identified
Logicare
Once patient is stabilized, PCP determines discharge; RD plays a part; diabetic nurse
educator sees as inpatient and coordinates outpatient visits for continuity of care
Discharge planning is done by the social worker and the RN if the patient is in need of
follow up education; then the physician is asked for an order to outpatient diabetic
management
There is a multidisciplinary team composed of a social worker, registered nurse, rehab
services professionals, registered dietitian and activity director; nursing then
communicates with physician
We do multidisciplinary rounds M, W, F to talk about the needs of our patients. The
following disciplines participate: social/spiritual services, RD, RN caring for the patient,
discharge planner, inpatient supervisor, and rehab services. Discharge needs are
frequently discussed in these rounds.
Patients are given education as needed while inpatients, follow up appointments are made
for patients to see CDE in clinic as outpatient; in-home assistance is set up by social
worker as needed
Screen high risk patients over 65 or new diagnosis
It is based on the individual needs
If newly diagnosed, order is obtained by RN or social worker for outpatient instructions
42
Discharge RN reviews discharge order and does medication reconcilliation. There is no
referral to NP who is board certified in diabetes management.
Follow up appointments made with dietary and clinic diabetes educator
Not treated any differently than other discharges
The physician orders medications and diet, patient is then educated on them during their
entire stay. Nurse educates patient on basics of diabetes and dietitian is consulted
possibly for follow up care. Patients are then informed of the diabetic support group we
hold at the hospital each month.
Discharge planning includes standardized Logicare documents, Rx for meds, and info
regarding medical follow-up. New diabetics are not discharged without demonstrating
proper methods of testing blood sugar and self-injecting insulin. RD meets with all
patients with a diagnosis of diabetes [new] or those having difficulties with managing
their sugars. Currently we are not utilizing a standardized discharge form, but have
recently developed a tool for this purpose.
Patient education initiated by RN; top 5 topics already discussed previously; diet
counseling by RD; follow up with physician at clinic; also follow up with RN at clinic for
additional education
Discharge goals and planning should begin with initiation of care plan and usually does,
although not always documented. Discharge planning occurs with a multidisciplinary
approach at the daily grand rounds, with RN and Social Services taking responsibility for
acquisition of testing materials, any equipment needs at home, and printed information.
Functional testing and referrals to rehab, if appropriate, are made at time of RN
assessment or shortly thereafter, and home visits to patient home are made as necessary.
Referral to outpatient diabetes educator is generally addressed at the daily rounds and, if
possible and ordered, the educator will do a visit prior to discharge. Teaching is done by
the multidisciplinary team and a printed set of discharge instructions [including follow-
up, exercise and diet, medications, etc.] and any pre-printed handouts are given prior to
discharge. We have a phone follow up program, with a phone call within a few days of
discharge preferred. Any problems noted are referred to primary MD.
All disciplines involved in the patients care to review plan of care; goals/accomplished,
etc; needs assessed for home care/supplies
Many of our patients are seen in the hospital by the diabetes educator who comes from
[name removed] to see patients. Most often plans are made for follow up in an outpatient
setting with the diabetes educator to continue education.
If new to diabetes, generally diabetic supplies are sent with patient and outpatient order
by the CDE
Assessment of patients understanding of diabetes, cognitive level and resources made on
admission. Social worker involved if patient/family havaing coping/self-management
issues. Teaching done at opportune moments throughout stay; medicine changes or care
at home issues being primary focus; when discharge orders written, RN determines
appropriate tools available and will review with patient/significant other. Return
demo/verbalization of understanding obtained and documented.
No standard planning process for inpatient diabetes discharge planning
There is a discharge planning committee that plans for all inpatients. There is no separate
entity for diabetic patients.
43
4. DOES YOUR HOSPITAL REFER PATIENTS WITH DIABETES TO OTHER DIABETES
EDUCATION PROGRAMS AND RESOURCES IN YOUR COMMUNITY, SUCH AS
CLINICS, RECOGNIZED DIABETES EDUCATION PROGRAMS, OTHER HOSPITALS,
PUBLIC HEALTH DEPARTMENTS, HOME CARE AGENCIES, LOCAL PHARMACIES,

4.3%
Yes
13.0%
No
Don't know/Not sure
82.6%
Those who answered yes to question 4 were asked to also answer the following question:
4A. PLEASE DESCRIBE HOW THIS REFERRAL PROCESS IS DONE.
Thirty-six of the 38 respondents (95%) indicating yes to question 4 provided descriptions that
are detailed below.
By physician order (3)
Provider telephones or forwards prescription for education in self management of
diabetes to outpatient educator
Order sent for outpatient services
Orders for diabetes education processed through outpatient
Scheduled through clinic appointments
Patient is seen in hospital by CDE and scheduled for follow up right there or patient is to
be discharged from hospital before being seen by CDE and is scheduled for clinic visit
with CDE
RN, PCP make referral and call clinic to schedule outpatient follow up
[Name removed] clinic diabetes educators see patients at the clinic in [name removed]
city twice a month. There is significant wait time for an appointment.
If the patient needs further care related to their diabetes, the registered dietician makes a
referral to the clinic RD/CDE. This person then can see the patient while still in the
hospital and/or schedule outpatient visits as needed.
44
MDs refer patients to outpatient clinic; RD refers to outatient support group; MD to MD
specialist referrals
Referral is received from the physician; the referral is faxed to the outpatient diabetes
educators, and they in turn contact the patient to set up their first visit
Same answer as discharge planning one: Just in time training/education done and then
finished through diabetic educators at the clinic
Patients are basically referred to a couple of things: either diabetes education program
(here at the hospital) or an individual RD visit. Our program includes RD visits, but
sometimes MDs just refer the patient to the RD. Referrals are made either by the MD
just writing this in the physicianss orders, or if we have seen the patients, we put our
diabetes education referral form in the chart for the MD to sign.
Patient will be assisted in making follow up appoinments with physician, clinic CDE, or
informed of support group meeting times
PCP refers with recommendations from other disciplines
Written referrals from a physician for outpatient medical nutrition therapy are at times
provided and verbal communications from nursing or dietitian regarding the local
diabetic support group is given
We do refer [name removed] clinic patients to the [name removed] Clinic diabetic
educator
MD writes order upon discharge; appointment is then made for patient to be seen in our
outpatient diabetic program
Referrals made to outpatient hospital dietitian
Social worker manages all referrals
Our hospital has a recognized program meeting ADA guidelines as an outpatient;
referrals from inpatients are limited; patients are to be scheduled with advanced practice
diabetes nurse practitioner, then program is coordinated and counseling is started
Written referral is used internally as we have CDEs in house and voice mail for us to see
patient
Initial appointment made on discharge and follow ups as needed
RD, CDE schedules appointments for further outpatient education or refers to diabetes
support group as needed; other referrals are completed - RN and CDE follow up with
agencies as needed
If patient requests or the physician orders
Information about community support groups and education programs is provided by the
hospital RD and during discharge. The RD does a follow up call about 1 week after
discharge and reminds patient of community-based education. Additional patient
education is done at [name removed] clinic; however, this referral takes place on an
outpatient basis.
Home health is notified if patient will qualify; otherwise frequent follow up with MD and
RN at medical clinic
Primary care physician or nurse makes the referral to endocrinologist or clinics. Provide
information requested so that there is no delay in follow up care
The request for referral is initiated by anyone on the multidisciplinary team [but most
often the RN] or by the patient. If an order is written, phone contact is usually made with
the diabetes educator and, if possible, she will meet with the patient prior to discharge.
Appointments for outpatient education are made through the clinic.
45
Discharge plan meetings and patient care conferences; depends on the patients level of
understanding and compliance to care recommendations
Done if ordered by MD; [name removed] has a system but all done by that hospital; we
need to work with our PHD to coordinate services up here
Patients are referred to the outpatient setting for diabetes education
Only if diabetic referral ordered by PCP
(Respondent commented that this was the same as their response for discharge planning)
Patients are given education as needed while inpatients; follow-up appointments are
made for patients to see the CDE in clinic as outpatients, in-home assistance is set up by
social worker as needed
46
5. FOLLOWING IS A LIST OF POSSIBLE BARRIERS CONCERNING REFERRALS TO
COMMUNITY DIABETES EDUCATION SERVICES. PLEASE INDICATE WHETHER OR
NOT YOUR HOSPITAL FACES ANY OF THESE AS A BARRIER
Numbers and percents of respondents reporting community education barriers are indicated in
Table 8.
Table 8: Responses to the Question Regarding Community Education Barriers

Barrier Yes No Dont know/ No Answer
not sure
Length of time patient has to wait for outpatient 13 (28%) 23 (50%) 10 (22%) 0 (0%)
diabetes education
Physician does not refer 22 (48%) 18 (39%) 6 (13%) 0 (0%)
Lack of perceived value of diabetes education by 16 (35%) 19 (41%) 10 (22%) 1 (2%)
provider
Prior authorization for diabetes education is required by 11 (24%) 23 (50%) 12 (26%) 0 (0%)
insurer
Patients lack sufficient insurance coverage for diabetes 20 (43%) 13 (28%) 12 (26%) 1 (2%)
education
Personal cost to patients for receiving diabetes 18 (39%) 10 (22%) 17 (37%) 1 (2%)
education in the community
Other education reimbursement problems (please 6 (13%) 12 (26%) 26 (57%) 2 (4%)
specify):
Class/education schedule not convenient for patient 15 (33%) 17 (37%) 14 (30%) 0 (0%)
Community health care practices are more crisis- 17 (37%) 14 (30%) 13 (28%) 2 (4%)
oriented than preventive
Lack of public transportation to help patient get to 17 (37%) 16 (35%) 12 (26%) 1 (2%)
diabetes education
Distance patient must travel to receive diabetes 20 (43%) 12 (26%) 13 (28%) 1 (2%)
education
Patients lack of interest or unwillingness to attend 29 (63%) 7 (15%) 9 (20%) 1 (2%)
diabetes education
Lack of perceived value of diabetes education by 27 (59%) 6 (13%) 11 (24%) 2 (4%)
patients
High patient cancellation rates for diabetes education 14 (30%) 15 (33%) 15 (33%) 2 (4%)
services
Other 4 0 0 0
No barriers 0 (0%) 0 (0%) 0 (0%) 46 (100%)
Respondents listed other barriers to community diabetes education as:

Fear and misunderstanding of diabetes
Lack of community diabetes education services
No budget for diabetes education team
Lack of perceived value or need by nursing
47
Additional comments added by respondents in the section included:
Work conflicts was added after the barrier class/education schedule not convenient for
patient
Number of hours allowed versus number of hours needed and Pre-diabetes not
covered was added after the barrier other education reimbursement problems
Minimum number of patients and therefore difficult to achieve appropriate staff
Only done if ordered by provider (referral)
Physicians do not value education as a team effort
Medicare guidelines not allowing patient to be seen by RN and RD on same day. We
live in a rural area where transportation is often a challenge to arrange. Some persons
travel over 40 miles one way to get to appointments. Its a senseless Medicare rule that
needs revisiting. Gas prices and asking patients to make separate or frequent trips hinder
quality care delivery.
Section G: Community Outreach
1. DOES YOUR HOSPITAL OFFER ANY OUTREACH SERVICES TO INCREASE

DIABETES AWARENESS AND DIABETES PREVENTION IN YOUR LOCAL
?
8.7% Yes
No
Don't know/Not sure
19.6%
71.7%
Those selecting yes to question 1 were asked to also answer the following question:
48
1A. FOLLOWING IS A LIST OF POSSIBLE COMMUNITY SETTINGS FOR OUTREACH
SERVICES AND ACTIVITIES. PLEASE INDICATE WHETHER YOUR HOSPITAL
USES ANY OF THESE SETTINGS FOR OUTREACH?
Even though only 33 respondents selected yes for question 1 (indicating their hospital offers
any outreach services to increase diabetes awareness and diabetes prevention in their local
community), additional persons provided specific information on the different community
settings. Numbers and percents of responses are provided in Table 9. For details on how the
percents were calculated, please see the methodology section.
Table 9: Responses to the Question Regarding Community Outreach Settings

Community Settings Yes No Dont know/
not sure
Community diabetes support group 21 (58%) 12 (33%) 3 (8%)
Home care 20 (56%) 16 (44%) 0 (0%)
Worksites and/or employee wellness programs 24 (67%) 10 (28%) 2 (6%)
Meal-site programs 13 (36%) 20 (56%) 3 (8%)
Schools 11 (31%) 22 (61%) 3 (8%)
Health fairs and/or community events 34 (92%) 3 (8%) 0 (0%)
Diabetes community screening programs 20 (56%) 14 (39%) 2 (6%)
Churches 5 (14%) 26 (74%) 4 (11%)
Grocery stores or malls 4 (12%) 26 (76%) 4 (12%)
Community/fraternal organizations [e.g., Lions, etc.] 11 (32%) 19 (56%) 4 (12%)
Hospital newsletter 17 (49%) 16 (46%) 2 (6%)
Other media [newspaper articles, radio messages, etc.] 20 (65%) 8 (26%) 3 (10%)
Other 3 0 0
Three respondents indicated other community settings as: local cable/TV programs; one last
year sponsored by local Lions Club; and bus rides organized for respondents to attend Diabetes
Expo with pick up from several sites.
49
2. IS YOUR HOSPITAL INVOLVED IN ANY COMMUNITY DIABETES-RELATED HEALTH
CARE COLLABORATIONS, SUCH AS A TASK FORCE, COALITION, OR ADVISORY

13.0%
17.4%
Yes
No
Don't know/Not sure
69.6%
Respondents who selected yes indicating they were involved in a diabetes-related healthcare
collaboration were asked to list the name of the entity, what community organizations are
involved, and to describe their current activities. The names of the entities are not included in
this report due to confidentiality.
Respondents listed various community organization involved as: hospitals, local clinics, UW
Extensions, local county public health and human service departments, Lions clubs, Big
Brothers/Big Sisters, schools, family planning, county circuit court, parent resource centers,
police/sheriff departments, child care organizations Head Start, clergy associations, hospices,
commissions on aging, and community members with diabetes.
Current activities listed by respondents included:

Information via news media
Health fairs and community events
Screening and education at worksites
Community nutrition and physical activity coalition working on the root causes of
diabetes lifestyle choices
Improving inpatient and outpatient diabetes education
Billboards on highway
Identifying quality improvement efforts and desired outcomes
Working closely with health system & follow guidelines and protocols that they develop
based on best practice
50
Offering patient management tools for clinical practice to improve diabetes car at the
hands of the provider; tracking of blood pressure, LDL, and all DQIP standards
Promoting individual and family well-being
Assessing needs of community
Discussing program goals; in first year of program initiation; no formal QI program
approved yet
Section H: Quality Improvement
1. DOES YOUR HOSPITAL HAVE A FORMAL QUALITY IMPROVEMENT PROGRAM

THAT INCLUDES INPATIENT DIABETES CARE OUTCOME MEASURES ?

8.7%
17.4%
Yes
No
Don't know/Not sure
73.9%
Respondents who selected yes to question 1 were asked to answer two additional questions.
One question asked the respondent to list the inpatient diabetes outcome measures tracked and
the latest results, if known. The only two responses received for this question were:
We only measure outpatient at this time
We change outcome measures yearly
The second question asked respondents to list the disciplines and departments that participate in
a formal quality improvement that includes inpatient diabetes care outcome measures. Only one
response was received: disciplines involved are MD, CDE, RN, and RDs.
51
2. DOES YOUR HOSPITAL ASSESS PATIENT SATISFACTION WITH THEIR INPATIENT
DIABETES CARE AND EDUCATION SERVICES ?

13.0%
17.4%
Yes
No
Don't know/Not sure
69.6%
The six respondents who responded yes to question 2 were asked if they were willing to share
their assessment tools. Four of the six (67%) provided an answer. Three of these four (75%)
indicated a willingness to share their assessment tool.
The six respondents who selected yes to question 2 were also asked to report how the
assessment is used to improve the program. Only one of these six respondents answered,
indicating that they modified the diabetes education survey to include some outcome questions
and plan to utilize this data for tracking outcomes.
Three respondents provided additional comments regarding assessment of patient satisfaction

with diabetes care management and education services. They were:
Just started checking patient follow-up rates, satisfaction, and inpatient length of stay
This is an assessment of all inpatient care, not specific to diabetes
Patients are given 1-800 number to call with problems, concerns, and satisfaction with
program
52
Section I: Inpatient Data Practices
1. DOES YOUR HOSPITAL USE A SPECIFIC PROCESS TO IDENTIFY NEW CASES OF

DIABETES IN INPATIENTS ?

8.7% 6.5%
Yes
No
Don't know/Not sure

84.8%
The three respondents that selected yes were asked to explain their process to identify new
cases of diabetes. Responses were:
Initial nursing assessment (2)
Diagnosis by health care provider
53
2. DOES YOUR HOSPITAL USE PAPER OR ELECTRONIC MEDICAL RECORDS FOR
22 respondents selected paper (48%)

4 respondents selected electronic (9%)
20 respondents selected combination of paper and electronic (43%)
Paper
Electronic
Combination
43.5%
47.8%
8.7%
3. DOES YOUR HOSPITAL HAVE A SYSTEM, SUCH AS A DATABASE OR ELECTRONIC

MEDICAL RECORD THAT CAN IDENTIFY INPATIENTS THAT HAVE DIABETES ?

17 respondents selected no (37 %)
21.7%
41.3%
Yes
No
37.0%
Don't know/Not sure
54
Those who answered yes to question 3 were also asked to also answer questions 3a, 3b, and 3c.
Although nineteen respondents replied to question 3, eighteen respondents answered question 3a
and more than nineteen respondents replied to questions 3 b and 3 c.
3A. WHAT IS THE NAME OF THE SYSTEM?
Eighteen responses included:

CSPI (3) HMS (3)
Meditech (2) Cerner
AS 400 HBIC
PCI IMPACT
Epic Phamous
ABS Diagnostic Dont know the name of the system
One respondent that indicated they had a system did not answer this specific question.
3 B. ARE DIABETES CARE AND EDUCATION INPATIENT DATA ENTERED INTO A

COMPUTER PROGRAM FOR MONITORING AND EVALUATION PURPOSES ?
Twenty-nine respondents answered this question.

The respondents that responded yes to question 3b were also asked the question, Who enters
the data into the system? Respondents were encouraged to check all that applied. The figure
below indicates the number of respondents reporting each specific discipline that enters data into
their computer program.
7
6
6
4
Number
3
3
2
2
1 1 1 1
1
0
0
t
st
er
r
P
is
RN
RD
S
ke
PC
gi
/N
th
ac
or
lo
DK
O
rm
W
ho
ha
al
yc
ci
P
Ps
So
55
One respondent added the comment, Data is added as the plan of care but not used for
evaluation purposes.
3C. COMPUTER SYSTEMS CAN ALLOW THE OPPORTUNITY TO QUERY AGGREGATE

INFORMATION ON INPATIENT DATA FOR A NUMBER OF REASONS. FOLLOWING
IS A LIST OF POSSIBLE QUERIES. CAN YOU INDICATE AFTER EACH ONE IF
YOUR HOSPITALS COMPUTER SYSTEM HAS THE ABILITY TO DO THAT
Even though only 19 respondents selected yes for question 3 (indicating that their hospital has
a system that can identify inpatients that have diabetes) additional persons answered the question
relating to whether or not they could perform certain queries using the hospitals system.
Numbers and percents of responses are provided in Table 10. For details on how the percents
were calculated, please see the methodology section.
Table 10: Responses to the Question Regarding Computer Queries

Possible Queries Yes No Dont know/
not sure
Track inpatient glycemic management 7 (28%) 13 (52%) 5 (20%)
Track inpatient outcomes of care 3 (13%) 14 (58%) 7 (29%)
Track inpatient education services 4 (16%) 15 (60%) 6 (24%)
Help coordinate referrals 2 (8%) 16 (67%) 6 (25%)
Identify the need follow-up care 1 (4%) 16 (67%) 7 (29%)
Identify need for outreach services 1 (4%) 16 (67%) 7 (29%)
Identify new cases of diabetes 6 (25%) 10 (42%) 8 (33%)
Identify persons who may have pre-diabetes 2 (8%) 15 (63%) 7 (29%)
Provide inpatient diabetes-related data for QI activities 4 (18%) 12 (55%) 6 (27%)
Assist with disease surveillance 5 (21%) 12 (50%) 7 (29%)
No one listed any other type of query.
56
4. IS ANOTHER MECHANISM USED TO MONITOR INPATIENT DIABETES CARE?
EXAMPLES WOULD BE A MANUAL CHART REVIEW OR A SURVEY.
There appeared to be some confusion regarding this question. Persons were instructed to skip
question 4 if they answered yes to question 3 and then subsequently answered questions 3a,
3b, and 3c. A total of 19 people fit into this group. Those answering no or dont know/not
sure to question 3 (27 people) were asked to answer question 4. A total of 31 people answered
question 4.
19.4%
29.0%
Yes
No
Don't know/Not sure
51.6%
Those responding yes were also to specify their method to monitor inpatient diabetes care.
Seven of the nine (78%) who responded indicated their monitoring method was chart review.
57
Section J: Miscellaneous
1. DOES YOUR HOSPITAL HAVE RECOGNITION BY THE AMERICAN DIABETES

ASSOCIATION (ADA) FOR ITS DELIVERY OF DIABETES EDUCATION SERVICES ?

2.2%
32.6%
65.2%
Yes
No
Don't know/Not sure
58
Those respondents that chose no or dont know/not sure (31) were asked to answer the
following question:
1A. IS YOUR HOSPITAL INTERESTED IN APPLYING FOR ADA RECOGNITION FOR ITS
DIABETES EDUCATION SERVICES ?
Even though 31 respondents selected no or dont know/not sure for question 1 [indicating
that their hospital does not have recognition or does not know if they have recognition], one
additional person answered question 1a. Numbers and percents of responses are provided below.
For details on how the percents were calculated, please see the methodology section.
34.4%
37.5%
Yes
No
Don't know/Not sure
28.1%
59
2. DOES YOUR HOSPITAL COLLABORATE WITH A LOCAL ADA RECOGNIZED
DIABETES EDUCATION PROGRAM?

1 respondent did not select an answer (2%)
2.2%
10.9%
41.3%
Yes
45.7% No
Don't know/Not sure
No Answer
3. WOULD YOU OR SOMEONE ELSE AT YOUR HOSPITAL BE INTERESTED IN

PARTICIPATING IN AN INFORMATIONAL DIABETES LISTSERV TO SHARE
STRATEGIES AND RESOURCES WITH YOUR COLLEAGUES ?
Yes
No
63.0%
4.3%
60
4. WHAT SPECIFIC TRAINING AND/OR RESOURCES WOULD HELP YOUR HOSPITAL
IMPROVE ITS INPATIENT DIABETES MANAGEMENT AND EDUCATION SERVICES ?
A total of 36 respondents provided answers to this question that are included in detail below.
On-site training/materials program to educate nursing; quality assurance program;
funding for education/software
Protocols, policies, procedures, documentation
Need better coordination between staff and easy way to collect outcome data
Articles on benefit on inpatient CDE to justify cost savings; policies/procedures on when
to consult CDE for inpatients; everything
We could use more up-to-date materials for evaluation of the patients knowledge of
diabetes care. We also need a mechanism for periodic evaluation and updating of the
materials we do have. Our current aim is to help a new diabetic to begin monitoring
sugars and taking prescribed insulin until they can get into a comprehensive education
program.
Staff education on care of patients with diabetes, such as carbohydrate counting,
correction factors, and use of medication therapies; also standardized protocols and care
plans for patients with diabetes would be very helpful
Diabetic Education Specialist to inservice education training with staff nurses on updates,
medications, evidence-based practice for diabetes
A more structured program with materials that are more current; we recently now have a
connection with the diabetes educator at the clinic who will come and see our patients as
well; we have very limited new diabetics, so the time we spend with them needs to be
more organized and the nurses need to feel more comfortable with the information
Not sure; we are struggling with this currently; we have some ideas for strategies but
when anything involves more nursing FTEs it is tough to sell to administration!
Guest speakers
Diabetes nurse educator
Training guidelines to help nurses become more comfortable with insulin drips; were
currently working on an insulin drip protocol and connection dose protocol; examples
of protocols such as this and others would be helpful, so that we do not have to reinvent
the wheel looking back at this survey and seeing all that we lack is a bit daunting.
Support in revamping our system and resources to help with this would be very helpful
Members to Diabetes Advisory Board; have resources both in Appleton and Oshkosh;
routinely attend conferences need to obtain 16 CEUs/year for recognition program;
receive publications dealing with diabetes
Updates to education
Ongoing continuing education for all providers [MD.s, nurses, dietitians]; facility
standardized protocols for addressing education referrals and materials to be utilized
Being a CAH, we dont always have the financial resources to support diabetes as we
should; I think sharing ideas is always a good thing for the best care for our patients; why
recreate the wheel if other hospitals have good diabetes management in place.
All would be greatly appreciated and helpful. We have a well established outpatient
program, but nothing for inpatient
Physician education on new meds and approaches
All would be very helpful
61
The availability of more certified educators; also promote diabetes education to hospital
staff
Nurse training, RN and CDE
Physician education CEUs for physicians to help enhance the importance of education
during inpatient stay; physician support managing hyperglycemia
Due to a very short length of stay, we have chosen to focus our efforts on education
patients when they are well; we start initial contact during the inpatient stay but focus on
survival skills and then have them in for diabetes education when they are in healthier
state
Ways to track without computerized medical records access
Nursing education on how to teach patients basic diabetes information
Collaboration with another facility on how to develop an efficient and thorough inpatient
diabetic education program
Having a systematic education program with appropriate staff training and discharge
planning could dramatically improve the consistency and continuity of our diabetic
education
Anything
Any of the protocols that are identified as best practice for management or education;
evidence-based best practices regarding blood glucose monitoring and appropriate
alterations in medication doses; insulin pump usage; medication updates [new meds];
new tools to streamline documentation for diabetes education
Staff updates/newsletters
Our own diabetic champion to review protocols within [name removed] organization
and bring back to staff; our charting is mostly paper; a computerized system which has
POC incorporated into electronic medical records would be very helpful; if home
instructions tied into this to personalize; need to work with community to establish our
own resources here
Financial resources
Having a CDE would help
Unsure what is available and what reimbursement issues there are
Increased staffing hours to effectively provide inpatient diabetic management; we do not
routinely see all inpatient diabetics with current staff hours; we have difficulty meeting
the needs of our current outpatients
More departments to coordinate patient care and get ADA certified; a budget that would
cover expenses such as teaching materials, materials purchased for our community
meetings, annual diabetic educators convention; examples of ADA certified education
programs to help figure out how to start ours
5. FOLLOWING IS A LIST OF SEVERAL METHODS FOR RECEIVING UPDATED

DIABETES TRAINING AND RESOURCE MATERIALS, SUCH AS GUIDELINES,
PROTOCOLS, AND EDUCATIONAL MATERIALS , ETC. COULD YOU INDICATE
WHETHER OR NOT YOU WOULD WELCOME RECEIVING MATERIALS IN EACH OF
Table 11 shows the numbers and percent of responses regarding preferred methods for receiving
updated training and resource materials.
62
Table 11: Responses to the Question Regarding Preferred Training and Resource Methods
Methods for Receiving Updated Diabetes Training Yes No Dont know/ No answer
not sure
Samples of resources in print format 44 (96%) 0 (0%) 0 (0%) 2 (4%)
Resources available on CD ROM 40 (87%) 3 (7%) 1 (2%) 2 (4%)
Web-based resources 43 (93%) 0 (0%) 0 (0%) 3 (7%)
Professional in-state conferences 41 (89%) 1 (2%) 3 (7%) 1 (2%)
Listings of relevant national conferences 22 (48%) 13 (28%) 6 (13%) 5 (11%)
Group teleconferences with diabetes experts 36 (78%) 5 (11%) 3 (7%) 2 (4%)
Sharing strategies with colleagues via listserv 40 (87%) 3 (7%) 1 (2%) 2 (4%)
Identification of trainings with CEUs 41 (89%) 3 (7%) 0 (0%) 2 (4%)
Identification of informal continuing education sources 41 (89%) 2 (4%) 0 (0%) 3 (7%)
Linkage with local experts, such as certified diabetes 36 (78%) 6 (13%) 2 (4%) 2 (4%)
educators
No respondents provided any other suggestions.
6. ARE YOU FAMILIAR WITH THE WISCONSIN DIABETES PREVENTION AND

CONTROL PROGRAM? [HTTP://WWW.DHFS.STATE.WI.US/HEALTH/DIABETES /]
37.0%
6.5%
Yes
No
63
7. ARE YOU FAMILIAR WITH THE WISCONSIN E SSENTIAL DIABETES M ELLITUS
CARE GUIDELINES ?
6.5% Yes
No
Don't know/Not sure
28.3%
65.2%
8. ARE YOU FAMILIAR WITH THE RESOURCES OF THE NATIONAL DIABETES

EDUCATION PROGRAM? [HTTP://NDEP.NIH.GOV/]

2.2% Yes
13.0% No
Don't know/Not sure
No Answer
45.7%
39.1%
64
9. ARE YOU FAMILIAR WITH THE CHRONIC CARE MODEL AND ITS COMPONENTS ?
[HTTP://WWW.IMPROVINGCHRONICCARE.ORG/CHANGE /MODEL /COMPONENTS.H

2.2%
15.2% 21.7%
Yes
No
Don't know/Not sure
No Answer
60.9%
10. ARE YOU FAMILIAR WITH THE QUALITY IMPROVEMENT MODEL ?

[HTTP://WWW. IHI.ORG/IHI/TOPICS/IMPROVEMENT/IMPROVEMENTMETHODS/HOWTOI
21.7%
34.8%
Yes
No
Don't know/Not sure
43.5%
65
METHODS
Distribution of Assessment Tool

The assessment tool was electronically distributed to all 58 critical access hospitals (CAH) on
August 1, 2006. Contacts from CAHs were asked to respond by August 28, 2006. The survey
was set up in Microsoft Word, so that respondents could directly enter their answers by using
check boxes and text boxes. There was an area of one question (Question 5 in Section A) where
a flaw in the design of the electronic survey tool was found; there is incomplete data for this
particular question.
Calculation of Percentages
All calculated percentages were rounded off to the nearest whole percent. Therefore, the sum of
percents for a particular question may not add up to 100, due to rounding. To provide additional
information to the reader, percents with one place after the decimal point are provided in the
figures.
Numerical Answers
Some of the survey questions asked respondents to provide numerical answers to questions. In a
few cases, a respondent provided a range of numbers instead of a single number. In these cases,
the midpoint of the range was used to calculate the average for that particular question. This
occurred for one or two respondents for the following questions: Section A, Question 6,
Section A, Question 7, Section B, Question 4a, Section C, Question 2a, and Section D,
Question 4a.
Multiple-part Questions
There were several multiple-part questions in the assessment tool. In the case of these multiple-
part questions, if a respondent answered a certain way, they were asked to answer subsequent
related questions. In several instances throughout the survey, a certain number of people
answered a particular question, but additional people answered the subsequent questions. An
example is demonstrated for questions 8 and 8a in Section B. Question 8 asks Do your
inpatients and hospital staff have access to diabetes specialists, such as endocrinologists or
diabetologists? People responding Yes to this were asked to answer question 8a, while those
who responded No or Dont know/not sure were asked to skip to question 9 (and therefore,
not answer 8a). A total of 23 people answered yes to question 8, and therefore, 23 people were
expected to answer question 8a. However, 28 people responded to the Specialists make on-site
visits to the inpatients option, 28 people responded to the Telemedicine consults option, 26
people responded to the Internet/web consults option, and 29 people responded to the
Specialist provides continuing education to hospital staff option. In these cases, when
calculating percentages for each of these options, the denominator that was used was the total of
people that responded to each of the options (instead of the original and expected denominator of
23).
The above situation happened in the following instances:

Section A General Information, Questions 4 and 4b
A total of 20 people answered yes for Question 4; these people were asked to complete
Questions 4a, 4b, and 4c. The number of people that answered 4b was 22.
66
Section B Inpatient Care, Question 5 and 5a
Question 5a. There were six disciplines listed in Question 5a; for three of these, 14
people provided answers, even though only 12 had answered Question 5.
Section B Inpatient Care, Questions 8 and 8a
Question 8a. Four diabetes specialty areas were listed in Question 8a; 28 people
provided answers for two of those areas, 26 people provided answers for one of those
areas, and 29 people provided answers for the last area.
Section C Inpatient Staff Continuing Education, Questions 2 and 2a
Question 2a. The number of people that answered 2b was 11.
Section G Community Outreach, Questions 1 and 1a
Question 1a. Several community settings were listed in Question 1a; for the majority of
them, additional people provided answers from the 33 that were expected to answer
Question 1a.
Section I Inpatient Data Practices, Questions 3, 3b, and 3c
Questions 3a, 3b, and 3c. A total of 29 people answered Question 3b. Several possible
queries were listed in Question 3c; for the majority of them, additional people provided
answers from the 19 that were expected to answer Question 3c.
Section I Inpatient Data Practices, Question 4
Based on the fact that 27 people answered no or dont know/not sure to Question 3 in
this section (and therefore were asked to skip to question 4), it would be expected that 27
people would answer Question 4. However, a total of 31 people answered this question.
Section J Miscellaneous, Questions 1 and 1a
A total of 31 people answered no or dont know/not sure to Question 1 (and therefore
were asked to answer Question 1a). However, 32 people answered Question 1a.
67
LIMITATIONS
There are several limitations to the findings of the assessment. These are discussed below.
The thoroughness and completeness of the answers on the assessment tool may have been
limited by a number of factors. First, the length of the assessment tool was quite long (16
pages), and this may have contributed to respondent fatigue in answering the tool, which may
have led to incompleteness in some answers. Second, the assessment tool was distributed
electronically on August 1, 2006, and respondents were expected to complete and return the tool
by August 28, 2006. This quick turnaround time for returning the survey may have limited the
thoroughness of answers from the respondents. This turnaround time may have also limited
respondents from asking others (in their organization) for assistance in answering questions they
might not know the answers to. Finally, in some cases, it is possible that the respondent did not
know some of the answers and did not have anyone available at his/her organization to assist
with answering them. This likely led to several dont know/not sure choices, and in some
cases, no answer selected.
Another limitation is that there were several questions in the assessment tool that required
following a particular skip pattern. For example, based on an answer to one question (yes,
no, or dont know/not sure), this would either guide the respondent to answer additional
questions or skip one or more questions. Because the assessment tool was distributed
electronically and not administered as an interview over the phone, it required respondents to
follow the skip pattern and answer/skip questions when appropriate. Though we attempted to
make the skip pattern easy to follow, it is challenging to ask a respondent to answer the
questions, as well as follow the proper skip pattern. A survey with a skip pattern is sometimes
easier to administer over the phone, as the interviewer can use the proper skip pattern to ask the
appropriate questions based on the respondents answers. (However, there would have been
limitations to administering the assessment tool on the phone as well. For example, for many of
the questions, the respondent might not have known the answers at the time of the interview and
would have had to obtain the information and follow-up.) Nonetheless, the presence of a skip
pattern may have caused confusion for respondents and made it difficult for them to answer
some questions. This is best explained by providing an example: For Question 2 in Section C of
the Assessment Tool, 10 respondents answered yes. These people were asked to completed
2a, but the number of respondents that ended up answering 2b was actually greater than the
number that was expected (11). This is further detailed in the Methodology section.
68
REFERENCES
1) National diabetes fact sheet: General information and national estimates on diabetes in the
United States, 2005. Atlanta Georgia: US Department of Health and Human Services,
Centers for Disease Control and Prevention, 2005, available at:
http://www.diabetes.org/uedocuments/NationalDiabetesFactSheetRev.pdf; accessed
September 28, 2006.
2) Narayan KM, Boyle JP, Thompson TJ, et al. Lifetime risk for diabetes mellitus in the United
States. JAMA. 2003; 290:1884-1890.
3) Moghissi E, Hirsch I. Hospital management of diabetes. Endocrinol Metab Clin of North
Am. 2005; 34:99-116.
4) Direct and indirect costs of diabetes. American Diabetes Association. Available at:
http://www.diabetes.org/diabetes-statistics/cost-of-diabetes-in-us.jsp. Accessed September
28, 2006.
5) Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in
hospitals. Diabetes Care. 2004; 27:553-591.
6) Levetan CS, Passaro M, Jablonski K, et al. Unrecognized diabetes among hospitalized
patients. Diabetes Care. 1998; 21:246-249.
7) ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and
American Diabetes Association consensus statement on inpatient diabetes and glycemic
control. Endocr Pract. 2006; 12:458-468.
8) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New
Health System for the 21st Century. Institute of Medicine. Washington DC, 2001.
9) Levetan CS, Salas JR, Wilets IF, et al. Impact of endocrine and diabetes team consultation
on hospital length of stay for patients with diabetes. Am Journal Med. 1995; 99:22-28.
10) Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in
hospitalized patients with diabetes. Diabetes Care. 1997; 20:1553-1555.
11) Davies M, Dixon S, Currie CJ, et al. Evaluation of a hospital diabetes specialist nursing
service: a randomized controlled trial. Diabet Med. 2001; 18:301-307.
12) Breyer-Ash M, Garber A. Point: Inpatient glucose management: the emperor finally has
clothes. Diabetes Care. 2005; 28:973-975.
13) Roman SH, Chassin MR. Windows of opportunity to improve diabetes care when Patients
with Diabetes are Hospitalized for Other Conditions. Diabetes Care. 2001; 24 (8): 1371-
1376.
14) Deepak PJ, Sunitha K, Nagaraj J, et al. Inpatient management of diabetes: survey in a
tertiary care center. Postgrad Med J. 2003; 79:585-587.
69
15) Thompson C, Dunn K, Menon M, et al. Hyperglycemia in the hospital. Diabetes Spectrum.
2005; 18:20-27.
16) Baldwin D, Villanueva G, McNutt, R, et al. Eliminating inpatient sliding-scale insulin: a
reeducation project with medical house staff. Diabetes Care. 2005; 28:1008-1011.
17) Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment
but also prevention. Endocr Pract. 2004; 10(Suppl 2):89-99.
18) Tomky D. Detection, prevention, and treatment of hypoglycemia in the hospital. Diabetes
Spectrum. 2005; 18:39-44.
19) Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting.
Endocr Pract. 2004; 10 (Suppl 2):100-108.
20) Donihi AC, DiNardo MM, DeVita MA, et al. Use of a standardized protocol to decrease
medication errors and adverse events related to sliding-scale insulin. Qual Saf Health Care.
2006; 15:89-91.
21) Goldberg P, Roussel M, Inzucchi S. Clinical results of an updated insulin infusion protocol
in critically ill patients. Diabetes Spectrum. 2005; 18:188-191.
22) Quevedo S, Sullivan E, Kington R, et al. Improving diabetes care in the hospital using
guideline-directed orders. Diabetes Spectrum. 2001; 14:226-233.
23) American Diabetes Association. Bedside blood glucose monitoring in hospitals. Diabetes
Care. 2004; 27(Suppl 1):S104.
24) Greene H, de Ruiter HP, Atkins N, et al. Diabetes expertise: a subspecialty on a general
medical unit. Medsurg Nurs. 2002; 11:281-288.
25) Swift C, Boucher J. Nutrition care for hospitalized individuals with diabetes. Diabetes
Spectrum. 2005; 18(1):34-38.
26) Leichter S, August G, Moore W. The business of hospital care of diabetic patients: 2. A new
model for inpatient support services. Clinical Diabetes. 2003; 21:136-139.
27) Nettles A. Patient education in the hospital. Diabetes Spectrum. 2005; 18(1):44-48.
28) National Diabetes Education Program. Making System Changes for Better Diabetes Care.
available at http://www.improvingchroniccare.org/change/model/components.html, accessed
September 28, 2006.
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RESOURCES
1) Bourgeois P. Insurance: what our patients need to know. Diabetes Spectrum. 2005;
18(1):62-64.
2) Patient Information. Diabetes in the hospital: taking charge. Diabetes Spectrum. 2005;
18(1).
3) Ellerbeck EF, Totten B, Markello S, et al. Quality improvement in critical access hospitals:
addressing immunizations prior to discharge. J Rural Health. 2003; 19:433-438.
4) Wisconsin Essential Diabetes Mellitus Care Guidelines, revised 2004. Wisconsin Diabetes
Advisory Group, available at: http://dhfs.wisconsin.gov/Health/diabetes/DBMCGuidelns.htm
5) Wisconsin Diabetes Surveillance Report 2005. Wisconsin Diabetes Prevention and Control
Program, available at:
http://dhfs.wisconsin.gov/Health/diabetes/pdf_files/DBSurveillanceRprt2005.pdf
6) Diabetes Resource Guide for Consumers and Health Care Professionals. Wisconsin Diabetes
Prevention and Control Program, May 2003, available at:
http://dhfs.wisconsin.gov/health/diabetes/pdf_files/resources/PPH43011.pdf, accessed
September 28, 2006
7) The Wisconsin Collaborative Diabetes Quality Improvement Project: 2005, available at:
http://dhfs.wisconsin.gov/health/diabetes/pdf_files/CollabDQIP2005Report.pdf
8) Wisconsin Diabetes Advisory Group, Wisconsin Diabetes Strategic Plan 2004 2009,
available at: http://dhfs.wisconsin.gov/Health/diabetes/pdf_files/StrategicPlan2004.pdf
9) National Diabetes Education Program, Making Systems Changes for Better Diabetes Care
(includes information on the Chronic Care Model), available at:
http://www.betterdiabetescare.nih.gov/NEEDSchroniccaremodel.htm, accessed September
28, 2006
10) US Department of Health and Human Services, Centers for Disease Control and Prevention,
At A Glance 2006, Diabetes: Disabling, deadly and on the rise, available at:
http://www.cdc.gov/nccdphp/publications/aag/pdf/aag_ddt2006.pdf, accessed September 28,
2006
How to Locate Diabetes Specialists

11) American Diabetes Association locate a recognized diabetes education program in your
community http://www.diabetes.org/education/eduprogram.asp
12) American Association of Diabetes Educators locate a diabetes educator
http://members.aadenet.org/scriptcontent/map.cfm 1-800-TEAMUP4
13) American Dietetic Association locate a nutrition professional
http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_4874_ENU_HTML.htm
14) American Association of Clinical Endocrinologists locate an endocrinologist
http://www.aace.com/resources/memsearch.php
71
ACKNOWLEDGEMENTS
The Wisconsin Office of Rural Health extends recognition and appreciation to the Critical
Access Hospital Diabetes Project Workgroup collaborators for their generous contributions of
time and expertise in guiding this assessment initiative and for their ongoing commitment to
improving rural health.
Workgroup collaborators include:
Jenny Camponeschi, MS Kaaron Keene, MS, RN

Epidemiologist Vice President, Nursing
Wisconsin Diabetes Prevention and Control Program Memorial Health Center
Kathleen Caron, MBA Bobbi Knudson, RN

Director of Quality Systems Director of Nursing
Wisconsin Hospital Association, Inc. St. Josephs Community Health Services
Linda Charles, GNP Brenda Krupa, RN, MSN, PNP

Director of Senior Services Diabetes Educator
Moundview Memorial Hospital and Clinics St. Josephs Community Health Services
Byron Crouse, MD Leah Ludlum, RN, BSN, CDE

UW School of Medicine and Public Health Director
Wisconsin Office of Rural Health Wisconsin Diabetes Prevention and Control Program
John Eich, BA Pam Myhre, RN, BSN, CDE

Acting Director Nursing Instructor
Wisconsin Office of Rural Health Southwest Wisconsin Technical College
Beth Esser, RN-C Shelly Russell, RN, BA, CMC

Performance Improvement/Infection Control Manager Director of Quality Services
Indianhead Medical Center Memorial Health Center
Faye Gohre, RN, BSN Cheryl Vulstek, RN, BSN

CAH Diabetes Project Consultant Director of Quality and Education
Gohre Consulting LLC St. Josephs Community Health Center
Rosalyn Haase, RD/CD, CDE, MPH, BC-ADM Char White, BS

Registered Dietitian/Certified Diabetes Educator Former Flex ProgramCoordinator
Memorial Health Center Wisconsin Office of Rural Health
Maureen Kartheiser, MSEd

Former Director
Wisconsin Office of Rural Health
The workgroup collaborators wish to thank all of the participating critical access hospital
administrators and staff who generously donated their time to complete an assessment tool for
this project.
Funding for this report was provided by the Wisconsin Office of Rural Health (WORH).
72
APPENDIX 1: ASSESSMENT TOOL
73
INPATIENT DIABETES CARE MANAGEMENT AND EDUCATION ASSESSMENT OF
CRITICAL ACCESS HOSPITALS IN WISCONSIN
SURVEY TOOL
Directions: Please complete this survey, which specifically focuses on inpatient hospital care not
outpatient or clinic-based care. You can either fill it out electronically or print it out and write
your answers on it. Please return this survey by Monday, August 28th to Faye Gohre, Wisconsin
Office of Rural Health Consultant, either by mail at 1120 Drake Street, Madison, WI 53715 or via
e-mail at fayegohre@earthlink.net. Email or phone Faye at (608) 255-7550 with any questions.
A. GENERAL INFORMATION (Please fill in the blanks/boxes as appropriate.)

(1) Date of survey completion: August , 2006
(2) Name of Critical Access Hospital:
(3) Name of contact person completing this assessment form:
Credentials/position:
Telephone number: ( ) - Ext
Email address: @
Length of time employed at this hospital: years months
(4) Is there a staff person at this hospital who has specifically been identified to coordinate the care of
inpatients who have diabetes? [e.g., CDE, RN, RD, health educator, etc.]
Yes (if yes, please specify his/her name, credentials, and contact information, if different than
yourself) [please complete 4a, 4b, and 4c]
Name of this person:
Credentials/position:
Telephone number: ( ) - Ext
Email address: @
No [skip to question 5]
Dont know/not sure [skip to question 5]
(4) (a) Could you please describe what this person does to coordinate inpatient diabetes care at your hospital?
(4) (b) Does this person have advanced training or credentials in diabetes care management and/or diabetes
education services? [e.g., certified diabetes educator (CDE) or board certification in advanced
diabetes management (ADM)]
Yes
No
Dont know/not sure
74
(4) (c) Please indicate the estimated length of time that this person has been providing inpatient diabetes care
management and/or diabetes education services.
years months
(5) Are you aware of any other inpatient staff that provides diabetes care management and/or diabetes
education services at your hospital?
Yes (if so, which of the following)
How many of these If not CDEs, have they had training or
How are certified diabetes continuing education in diabetes care
Many? educators (CDE)? management and/or diabetes education
Title within the past 3 years?
RN (#) Dont Yes No Dont know
know
RD (#) Dont Yes No Dont know
know
Physician (#) Dont Yes No Dont know
know
Physician Assistant (#) Dont Yes No Dont know
know
Nurse Practitioner (#) Dont Yes No Dont know
know
Health Educator (#) Dont Yes No Dont know
know
Pharmacist (#) Dont Yes No Dont know
know
Other: (#) Dont Yes No Dont know
know
Other: (#) Dont Yes No Dont know
know
No
Dont know/not sure
(6) How many patients with diabetes were admitted to your hospital in the last calendar year for the following
conditions?
Diabetic ketoacidosis Dont know/not sure
Hyperosmolar hyperglycemic state Dont know/not sure
(7) What is the average length of stay at your hospital for a patient who has a . . .
Primary diagnosis of diabetes? Days Dont know/not sure
Secondary diagnosis of diabetes? Days Dont know/not sure
Diabetes ICD-9 codes: 250 Diabetes Mellitus. EXCLUDES: gestational diabetes (648.8), hyperglycemia NOS (790.6),
neonatal diabetes mellitus (775.1), non-clinical diabetes (790.2) complicating pregnancy, childbirth, puerperium (648.0)
(8) Are you aware of the percent of patients with diabetes who are readmitted within 30 days (diabetes listed
as any diagnosis)?
% Dont know/not sure
75
B. INPATIENT CARE (Please fill in the blanks/boxes as appropriate.)
(1) Please indicate whether your hospital uses any standardized protocols [such as the examples given] to
direct the provision of inpatient diabetes care. Also, please specify whether your facility is willing to share
a copy of any protocols that you do use.
Standardized Protocol Does your hospital use? Willing to Share?
Standing admission order sets specific to diabetes Yes No Dont know Yes No
Bedside blood glucose monitoring protocols Yes No Dont know Yes No
Hypoglycemia protocols Yes No Dont know Yes No
Hyperglycemia protocols Yes No Dont know Yes No
Intravenous insulin infusion protocols Yes No Dont know Yes No
Insulin pump protocols Yes No Dont know Yes No
Diabetic ketoacidosis protocols Yes No Dont know Yes No
Hyperosmolar hyperglycemic state protocols Yes No Dont know Yes No
Pre-op protocols pertaining to diabetes Yes No Dont know Yes No
Post-operative protocols pertaining to diabetes Yes No Dont know Yes No
Insulin sliding scale protocols Yes No Dont know Yes No
Insulin correction dose protocols Yes No Dont know Yes No
Insulin to carbohydrate ratio protocols Yes No Dont know Yes No
Immunization standing orders Yes No Dont know Yes No
Transfer protocols, specific to diabetes Yes No Dont know Yes No
Referral to specialty care protocols Yes No Dont know Yes No
Protocols to screen inpatients for diabetes Yes No Dont know Yes No
Discharge protocols Yes No Dont know Yes No
Protocols to assess diabetes self-management Yes No Dont know Yes No
knowledge and skills
Other protocol (specify): Yes No Dont know Yes No
Other protocol (specify): Yes No Dont know Yes No
(2) The Wisconsin Diabetes Advisory Group is in the process of developing recommendations for inpatient
diabetes care management. Would you be interested in receiving these when these are finalized?
Yes [go to question 2a]
(2) (a) Are you willing to work to implement these recommendations in your hospital?
Yes
No
Dont know/not sure
76
(3) If a patient is admitted to your hospital who requires intensive insulin therapy, is this person most likely
to:
Continue to stay to be cared for at your hospital
Need to be transferred to another hospital
Dont know/not sure
(4) Does your hospital admit and treat children with type 1 diabetes?
(4) (a) Can you tell me how many children with type 1 diabetes were admitted to your hospital in the past
year?
Number of Children Dont know/not sure
(5) Does your hospital use a designated inpatient multidisciplinary diabetes team?
(5) (a) Please indicate what disciplines the inpatient diabetes team includes?
Discipline Included in inpatient diabetes team?
Primary care provider Yes No Dont know
RN Yes No Dont know
RD Yes No Dont know
Pharmacist Yes No Dont know
Psychologist Yes No Dont know
Social Worker Yes No Dont know
Other (specify): Yes No Dont know
(6) In your hospital, does the admitting physician assume responsibility for the patients diabetes care
management while hospitalized? If you specify no, please indicate who does assume responsibility.
Yes
No Who does assume responsibility?
Dont know/not sure
(7) Does your facility use hospitalists?
77
(7) (a) Please describe the role of the hospitalist at your facility.
(8) Do your inpatients and hospital staff have access to diabetes specialists, such as endocrinologists or
diabetologists?
(8) (a) The following are types of inpatient diabetes specialty access. Could you please indicate whether or
not your hospital has access to any of these?
Diabetes specialty areas Does hospital have access?
Specialists make on-site visits to the inpatients Yes No Dont know
Telemedicine consults Yes No Dont know
Internet/web consults Yes No Dont know
Specialist provides continuing education to hospital staff Yes No Dont know
C. INPATIENT STAFF CONTINUING EDUCATION (Please fill in the blanks/boxes as appropriate.)

(1) There are various ways to obtain continuing education. The following is a list of possibilities
please respond whether or not your hospital uses this method to keep staff informed about current
diabetes care management and education practices.
Continuing education Does hospital use this method?
In-house seminars Yes No Dont know
Consultation with diabetes experts Yes No Dont know
Competency-based in-house modules Yes No Dont know
Grand rounds and case reviews Yes No Dont know
On-line access to education Yes No Dont know
Time off for conferences Yes No Dont know
Internet Yes No Dont know
Telemedicine Yes No Dont know
78
(2) Does the hospital require inpatient staff participation for continuing education for diabetes-related care
management?
No [skip to section D]
Dont know/not sure [skip to section D]
(2) (a) How often are inpatient staff required to participate in this continuing education?
Every Months OR Every Years Dont know/not sure
D. INPATIENT DIABETES EDUCATION (Please fill in the blanks/boxes as appropriate.)

(1) During the admission process, is there a routine method for hospital staff to ask whether a person with
diabetes has ever had diabetes education?
Yes
No
Dont know/not sure
(2) Is there a method to document each inpatients level of diabetes knowledge and skills?
Yes
No
Dont know/not sure
(3) The following is a list of possible resources for diabetes patient education materials. After each one,
please indicate if your hospital uses this resource for inpatient education materials?
Resources for diabetes patient education materials Does hospital use this resource?
Standardized diabetes education curriculum (if yes, please specify the Yes No Dont know
name of the curriculum):
Voluntary organizations [e.g., American Diabetes Association, Yes No Dont know
American Heart Association, National Kidney Foundation, etc.]
Government [Centers for Disease Control and Prevention, National
Institutes of Health, National Diabetes Education Program, National Yes No Dont know
Diabetes Information Clearinghouse, State Health Department, etc.]
International Diabetes Center Yes No Dont know
American Association of Diabetes Educators Yes No Dont know
Professional organizations [American Dietetic Association, etc.] Yes No Dont know
Pharmaceutical companies Yes No Dont know
Purchase from private health education company Yes No Dont know
79
(4) Does the hospital have a process to periodically review patient education materials for accuracy and
relevancy?
(4) (a) Please describe how this process is done.
Can you tell me how frequently this process is completed?

Every Months OR Every Years Dont know/not sure
(5) Following is a list of diabetes education topics that are typically taught to the person with diabetes. Can
you please check the top 5 education topics that are most frequently taught to inpatients prior to
discharge.
Insulin adjustment
Hypoglycemia symptoms, treatment, and prevention
Medication
Nutrition management
Self-monitoring of blood glucose and targets
Sick day management
Self-management goal setting
Lifestyle/behavior change
Advice about treatment/regimen options
Complication prevention
Physical activity recommendations
Foot care
Psychosocial/emotional issues
Insulin pump training
Preconception care, pregnancy, and gestational diabetes counseling
When to contact provider
Other (please describe):
Other (please describe):
80
(6) Following is a list of possible methods used to provide diabetes patient education. After each one, can
you please indicate if your hospital uses this method to provide inpatient diabetes education?
Methods to provide diabetes education Does hospital use this method?
Preprinted handouts only Yes No Dont know
Individual inpatient instruction Yes No Dont know
Group inpatient instruction Yes No Dont know
Videos Yes No Dont know
Cassette tapes Yes No Dont know
CD ROM/DVD with inpatient computer access Yes No Dont know
Patient access to the Internet in the hospital Yes No Dont know
Support group Yes No Dont know
Outpatient referral Yes No Dont know
(7) Does your hospital use standardized methods to document inpatient diabetes care and education, such as
flow sheets or standardized diabetes care plans?
Yes (if yes, would you be willing to share copies?) Yes No
No
Dont know/not sure
81
E. BARRIERS (Please fill in the blanks/boxes as appropriate.)
(1) This is a list of possible barriers in providing inpatient diabetes care management and diabetes
education services. Could you please indicate whether or not your hospital faces any of these as a barrier?
Barrier Does hospital face this barrier?
Lack of diabetes specialty physicians to consult with on inpatient issues Yes No Dont know
Lack of available, trained diabetes educators for inpatient care and Yes No Dont know
consultation
Lack of registered dietitian to provide medical nutrition therapy Yes No Dont know
Inadequate staffing resulting in lack of time to effectively assess and Yes No Dont know
educate patients
Lack of an inpatient diabetes team to coordinate care Yes No Dont know
Lack of protocols for inpatient diabetes care management Yes No Dont know
Lack of access to new technologies Yes No Dont know
Provider lack of knowledge about diabetes Yes No Dont know
Lack of knowledge about insulin protocols and newer medications Yes No Dont know
Not enough access to staff continuing education opportunities Yes No Dont know
Lack of documentation protocols Yes No Dont know
Lack of computerized patient charts/records Yes No Dont know
Disorganized patient charts Yes No Dont know
Inadequate educational materials Yes No Dont know
No standardized education curriculum Yes No Dont know
Inadequate inpatient facilities available for conducting education Yes No Dont know
High acuity levels and short hospital stays, limiting patients learning Yes No Dont know
capacity
Education referral must be requested from physician before it can be Yes No Dont know
provided
Provider resistance Yes No Dont know
Lack of administrative support Yes No Dont know
No barriers Yes No Dont know
F. DISCHARGE PLANNING (Please fill in the blanks/boxes as appropriate.)

(1) Who does discharge planning for inpatients with diabetes at your hospital? (check all that apply)
PCP RN RD Pharmacist Psychologist Social Worker
Other (specify): Dont know/not sure
82
(2) Does your hospital use standardized protocols for diabetes-related discharge orders?
Yes (if yes, would you be willing to share these?) Yes No
No
Dont know/not sure
(3) Please describe the discharge planning process for patients with diabetes at your hospital.
(4) Does your hospital refer patients with diabetes to other diabetes education programs and resources in your
community, such as clinics, recognized diabetes education programs, other hospitals, public health
departments, home care agencies, local pharmacies, coalitions, or diabetes support groups?
(4) (a) Please describe how this referral process is done.
83
(5) Following is a list of possible barriers concerning referrals to community diabetes education services.
Please indicate whether or not your hospital faces any of these as a barrier.
Barrier Does hospital face this barrier?
Length of time patient has to wait for outpatient diabetes education Yes No Dont know
Physician does not refer Yes No Dont know
Lack of perceived value of diabetes education by provider Yes No Dont know
Prior authorization for diabetes education is required by insurer Yes No Dont know
Patients lack sufficient insurance coverage for diabetes education Yes No Dont know
Personal cost to patients for receiving diabetes education in the Yes No Dont know
community
Other education reimbursement problems (please specify): Yes No Dont know
Class/education schedule not convenient for patient Yes No Dont know

Community health care practices are more crisis-oriented than Yes No Dont know
preventive
Lack of public transportation to help patient get to diabetes education Yes No Dont know
Distance patient must travel to receive diabetes education Yes No Dont know
Patients lack of interest or unwillingness to attend diabetes education Yes No Dont know
Lack of perceived value of diabetes education by patients Yes No Dont know
High patient cancellation rates for diabetes education services Yes No Dont know
No barriers Yes No Dont know
84
G. COMMUNITY OUTREACH (Please fill in the blanks/boxes as appropriate.)
(1) Does your hospital offer any outreach services to increase diabetes awareness and diabetes prevention
in your local community?
(1) (a) Following is a list of possible community settings for outreach services and activities. Please indicate
whether your hospital uses any of these settings for outreach?
Community settings Does hospital use?
Community diabetes support group Yes No Dont know
Home care Yes No Dont know
Worksites and/or employee wellness programs Yes No Dont know
Meal-site programs Yes No Dont know
Schools Yes No Dont know
Health fairs and/or community events Yes No Dont know
Diabetes community screening programs Yes No Dont know
Churches Yes No Dont know
Grocery stores or malls Yes No Dont know
Community/fraternal organizations [e.g., Lions, etc.] Yes No Dont know
Hospital newsletter Yes No Dont know
Other media [newspaper articles, radio messages, etc.] Yes No Dont know
(2) Is your hospital involved in any community diabetes-related health care collaborations, such as a task
force, coalition, or advisory body?
Yes If yes, please complete questions below.
No
Dont know/not sure
What is the name of the entity?
What community organizations are involved?
Describe their current activities
85
H. QUALITY IMPROVEMENT (Please fill in the blanks/boxes as appropriate.)
(1) Does your hospital have a formal quality improvement program that includes inpatient diabetes care
outcome measures?
Yes If yes, ask please answer the questions below.
No
Dont know/not sure
Please list the inpatient diabetes outcomes measures tracked and the
latest results, if known
Please list the disciplines and departments that participate?
(2) Does your hospital assess patient satisfaction with their inpatient diabetes care and education services?
Yes If yes, please answer the questions below.
No
Dont know/not sure
Would you be willing to share your assessment tool? Yes No
How is the assessment used to improve the program?
I. INPATIENT DATA PRACTICES (Please fill in the blanks/boxes as appropriate.)

(1) Does your hospital use a specific process to identify new cases of diabetes in inpatients?
Yes If yes, please answer the question below.
No
Dont know/not sure
Can you please explain the process to identify new cases of diabetes in
inpatients?
(2) Does your hospital use paper or electronic medical records for inpatient care?
Paper
Electronic
Combination of paper and electronic
Dont know/not sure
86
(3) Does your hospital have a system, such as a database or electronic medical record that can identify
inpatients that have diabetes?
Yes [answer questions 3a, 3b, and 3c, then skip to Section J]
(3) (a) What is the name of the system?
(3) (b) Are diabetes care and education inpatient data entered into a computer program for monitoring and
evaluation purposes?
Yes If yes, please answer the question below.
No
Dont know/not sure
Who enters the data into the system? (check all that apply)
PCP RN RD Pharmacist
Psychologist Social Worker Dont know/not sure

Other (specify):
(3) (c) Computer systems can allow the opportunity to query aggregate information on inpatient data for a
number of reasons. Following is a list of possible queries. Can you indicate after each one if your
hospitals computer system has the ability to do that particular query?
Possible queries Does hospital have ability?
Track inpatient glycemic management Yes No Dont know
Track inpatient outcomes of care Yes No Dont know
Track inpatient education services Yes No Dont know
Help coordinate referrals Yes No Dont know
Identify the need follow-up care Yes No Dont know
Identify need for outreach services Yes No Dont know
Identify new cases of diabetes Yes No Dont know
Identify persons who may have pre-diabetes Yes No Dont know
Provide inpatient diabetes-related data for QI activities Yes No Dont know
Assist with disease surveillance Yes No Dont know
SKIP #4 IF YOU ANSWERED 3a, 3b, and 3c

(4) Is another mechanism used to monitor inpatient diabetes care? Examples would be a manual chart review
or a survey.
Yes If yes, please specify that method?
No
Dont know/not sure
87
J. MISCELLANEOUS (Please fill in the blanks/boxes as appropriate.)
(1) Does your hospital have recognition by the American Diabetes Association (ADA) for its delivery of
diabetes education services?
Yes [skip to question 2]
No [go to question 1a]
Dont know/not sure [go to question 1a/2]
(1) (a) Is your hospital interested in applying for ADA recognition for its diabetes education services?
Yes
No
Dont know/not sure
(2) Does your hospital collaborate with a local ADA recognized diabetes education program?
[http://www.diabetes.org/education/edustate2.asp]
Yes
No
Dont know/not sure
(3) Would you or someone else at your hospital be interested in participating in an informational diabetes
listserv to share strategies and resources with your colleagues?
Yes (if so, please share your contact information below)
Name:
Telephone: ( ) - Ext
Email address: @
No
Dont know/not sure
(4) What specific training and/or resources would help your hospital improve its inpatient diabetes care
management and education services?
88
(5) Following is a list of several methods for receiving updated diabetes training and resource materials, such
as guidelines, protocols, and educational materials, etc. Could you indicate whether or not you would
welcome receiving materials in each of the ways?
Methods for receiving updated diabetes training Do you welcome materials?
Samples of resources in print format Yes No Dont know
Resources available on CD ROM Yes No Dont know
Web-based resources Yes No Dont know
Professional in-state conferences Yes No Dont know
Listings of relevant national conferences Yes No Dont know
Group teleconferences with diabetes experts Yes No Dont know
Sharing strategies with colleagues via listserv Yes No Dont know
Identification of trainings with CEUs Yes No Dont know
Identification of informal continuing education sources Yes No Dont know
Linkage with local experts, such as certified diabetes educators Yes No Dont know
(6) Are you familiar with the Wisconsin Diabetes Prevention and Control Program?
[http://www.dhfs.state.wi.us/Health/diabetes/]
Yes No Dont know/not sure
(7) Are you familiar with the Wisconsin Essential Diabetes Mellitus Care Guidelines?
[http://www.dhfs.state.wi.us/Health/diabetes/DBMCGuidelns.htm]
(8) Are you familiar with the resources of the National Diabetes Education Program? [http://ndep.nih.gov/]
(9) Are you familiar with the Chronic Care Model and its components?
[http://www.improvingchroniccare.org/change/model/components.html]
(10) Are you familiar with the Quality Improvement Model?
[http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/]
Thank you so much for your time and participation in this project.
Please return your completed survey tool by Monday, August 28th either by e-mail to
fayegohre@earthlink.net or by mail to:
Faye Gohre, RN
1120 Drake Street
Madison, WI 53715
The aggregate results of this assessment will be summarized and reported back to participating critical access
hospitals.
89

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Diabetic Education and Management Report and Tool

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Assessment of Inpatient Diabetes Care Management and Education

in Wisconsin Critical Access Hospitals

Authors: The Critical Access Hospital Diabetes Project Workgroup

PART 1: SUMMARY OF FINDINGS ............................................................................................................................ 7

PART 3: DETAILED ANALYSIS FINDINGS ........................................................................................................... 20

APPENDIX 1: ASSESSMENT TOOL.......................................................................................................................... 73

Diabetes: A Major Health Problem

Quality of Diabetes Care

Project to Evaluate Diabetes Care in Rural Hospitals

Section A: General Information

Section B: Inpatient Care

Children with Type 1 Diabetes

Access to Diabetes Specialists

Section C: Inpatient Staff Continuing Education

Section D: Inpatient Diabetes Education

Resources for Diabetes Education:

Diabetes Education Topics Taught

Methods for Diabetes Education

Section F: Discharge Planning

Community Referral for Other Diabetes Education and Resources:

Other barriers and/or comments listed by respondents were:

Section G: Community Outreach

General activities reported for their current collaborative activities were:

Section H: Quality Improvement

Three respondents provided additional comments regarding assessment of patient satisfaction

Section I: Inpatient Data Practices

Specific Training or Resources Requested

Clinical Information Systems and Evaluation

Delivery System Design

Other General Comments for Specific Training or Resources

Training and Resource Preferences

Project Workgroup Recommendations

Project Workgroup Recommendations

Project Workgroup Recommendations

Project Workgroup Recommendations

Project Workgroup Recommendations

Other Project Workgroup Recommendations

Section A: General Information

4. IS THERE A STAFF PERSON AT THIS HOSPITAL WHO HAS SPECIFICALLY BEEN

Twenty individual responses to this question are included below.

A total of 20 respondents responded to this question, indicating a range of 12 months to 29 years.

39 respondents selected yes (85%)

6. HOW MANY PATIENTS WITH DIABETES WERE ADMITTED TO YOUR HOSPITAL IN

Diabetic ketoacidosis (23 respondents provided numerical answers)

Hyperosmolar hyperglycemic state (16 respondents provided numerical answers)

7. WHAT IS THE AVERAGE LENGTH OF STAY AT YOUR HOSPITAL FOR A PATIENT

Secondary diagnosis of diabetes? (17 respondents provided numerical answers)

Average = 14% (only 8 respondents provided numerical answers)

1. PLEASE INDICATE WHETHER YOUR HOSPITAL USES ANY STANDARDIZED

Yes No DK/NS No Yes No No

2A. ARE YOU WILLING TO WORK TO IMPLEMENT THESE RECOMMENDATIONS IN

31 respondents selected continue to stay to be cared for at your hospital (67%)

Don't know/Not sure

Average = 1.5 children

5. DOES YOUR HOSPITAL USE A DESIGNATED INPATIENT MULTIDISCIPLINARY

5A. PLEASE INDICATE WHAT DISCIPLINES THE INPATIENT DIABETES TEAM

One respondent reported other and specified exercise physiologist.

6. IN YOUR HOSPITAL, DOES THE ADMITTING PHYSICIAN ASSUME RESPONSIBILITY

All 46 respondents (100%) answered yes.

7. DOES YOUR FACILITY USE HOSPITALISTS ?

2 respondents selected yes (4%)

7A. DESCRIBE THE ROLE OF THE HOSPITALIST AT YOUR FACILITY.

There were two responses to this question:

23 respondents selected yes (50%)