As a physical therapist, my initial experience in wound care was limited to hospital rehabilitation departments, where blood glucose monitoring is generally not available. I had always discussed the relationship between wound healing and blood glucose levels with my patients; however, I was dependent on them to report to me any issues they were having with their blood glucose levels. So, when I was given the opportunity to develop a multidisciplinary outpatient wound center at Archbold Medical Center in Thomasville, GA, in 1999, I was very excited about the opportunity to utilize finger stick blood glucose values as an additional assessment tool for all of my patients. As a clearly defined component of the protocol at our wound clinic from the day our doors opened, we made it routine to check finger stick blood glucose at each visit for any patient with a known history of diabetes or who reported having been diagnosed with diabetes. This practice was made a formality to catch elevations that might indicate a developing infection. Much to my surprise, the majority of our patients were found to be living with chronically high glucose values. Our initial plan to reverse this trend had been to educate our patients about the negative effects that elevated glucose poses to wound healing and to encourage them to follow up with their primary care physician (PCP) about proper monitoring. As one might suspect, this resulted in very little change. However, our collection of objective evidence for elevated blood glucose levels across our patient population did accomplish justifying the need to recruit a certified diabetes educator (CDE) for the clinic. While some patients declined their opportunities to meet with a dietician, many of them were receptive to this option — and those who participated experienced positive outcomes including lower hemoglobin A1c levels and reduced visits to the emergency department for blood glucose-related problems. The CDE was additionally successful in facilitating placement of insulin pumps among appropriate patients, which, to nobody’s amazement, resulted in improved wound healing outcomes. However, our ability to offer this great CDE resource to our patients was short-lived (she would relocate to another area after about two years). Without another CDE employed within the health system and the always-tightening budget constraints faced by administration, we lost the funding needed to keep the position filled. Although our dietary department’s staff members have given us support over the subsequent years whenever possible, the sporadic nature of their availability has made it hard to be as effective as we were when we had a dedicated CDE, which allowed us the “luxury” of more narrowly focusing our education.
Dealing With The AdjustmentDespite the lack of a certified CDE, we continued to finger stick each patient during all visits. While we were able to appropriately manage those who recorded low levels (as well as those with levels “too high to read”), we weren’t as successful when it came to patients whose blood glucose was chronically in the 200s or even 300s. Having known many of these patients for several years, we had become accustomed to sharing their finger stick values with their PCPs and becoming complacent when we never noticed much change. As providers, when patients come into your clinic 2-3 times per week for negative pressure wound therapy or compression bandaging, it can become all too convenient to accept high glucose as “normal” for those patients. Admittedly, we had become part of the problem. How many of our patients were walking out of the clinic with the idea that their elevated blood glucose was “OK” because we had failed to say it wasn’t? Were we passively reinforcing their lack of concern? In an effort to stop this trend, we made a decision to actively engage patients in a discussion regarding any out-of-range blood glucose during each visit. Today, if a patient attributes their high blood sugar to having “just eaten lunch,” our clinicians will question them about what they had for lunch, what they ate for breakfast and what was planned for dinner. By investigating in this manner, we find that we can often focus on particular bad habits and spark a conversation to promote change. Common traits like drinking sweet tea or soda throughout the day, eating potatoes at every meal, or skipping breakfast are easy starting points. Additionally, to help patients and providers visualize their care, we keep “vital sign flow sheets” on each of them and use them to track particular issues being discussed. We send copies of the flow sheets to the PCP when we know patients have follow-up appointments to allow the physician to also see how the patient’s blood glucose has been running.
Addressing ‘Compliancy’Many patients who live with diabetes get labeled as “noncompliant” when the reality may be they don’t understand what they’re being educated on. This is a patient population that is typically given a wealth of instruction over a short period of time with long periods between follow-up appointments. The high frequency at which we see our patients allows us to conduct timely clarification. One recent patient of ours returned to the clinic three days after having met with a dietician and his blood glucose was higher than usual. He said he had followed his dietician’s recommendations to “add more fruit to his diet” — claiming he had eaten four strawberry pastries that day. There was definitely some clarification needed. We’ve also uncovered other obstacles that our patients face in managing their diabetes through our more aggressive screening tactics. We have had patients who bring their meters in to us for one-on-one instructions on their usage. We’ve seen patients with meters who’ve said they couldn’t afford strips, only to discover that their insurance covers them. Patients who weren’t regularly taking their medication because they “couldn’t afford it” are now discussing less costly medications and/or are being connected to the health department because we engaged their PCP in related conversations. Our greatest success story from an education perspective may be the phone call we received from a patient who took the time in a grocery store to ask us for advice on a food purchase. Still, we’ve also learned that taking a more inquisitive interest in our patients can actually lead to negative outcomes on occasion. One patient decided to quit coming to the clinic because he felt he was being “nagged” about his blood glucose. Another patient stopped coming after she was asked on several visits to bring in a food diary she had agreed to keep. We later discovered that she was hiding the fact that she couldn’t write. While not all patients are interested in the education we offer, many have embraced the opportunity to learn at their individual pace. Overall, we have seen chronically high glucose levels become lowered and remain down. We have embraced our roles as advocates for patients who are trying to make changes in their lives but need assistance in making the adjustments. Is cutting sweet tea out of the diet of someone who typically has a blood glucose higher than 300 going to bring it to a normal range? No, but neither will ignoring it. And by asking more questions than we make assumptions, we’ve put ourselves in a unique position to help our patients make small, albeit meaningful, changes toward better control of their diabetes. Tere Sigler is the clinical director of the Archbold Center for Wound Management at Archbold Memorial Hospital, Thomasville, GA.