Diabetes, one of the epidemics of the modern world, affects more and more people. Faced with the rising morbidity figures, a unique initiative of the Rambam diabetes team is working, which has been adopted, through the Ministry of Health, by 26 hospitals in Israel. The vision: Hospital staff will receive tools to properly treat hospitalized diabetic patients.
About a third of those admitted to the hospitals are diabetics. In a significant number of them, the sugar levels in hospitalization are high, sometimes because of the acute illness that led to their hospitalization, and sometimes because they were not balanced even before hospitalization. While the scope of the phenomenon and its consequences among the hospitalized is increasing, the number of specialists entrusted with the treatment of diabetes within the hospitals remains limited - and the gap translates into the care that the patients receive. An initiative born in Rambam is working to change this situation in hospitals in Israel.
"Glucose values that remain high in repeated measurements require attention," explains Rachel Shantel, a clinical specialist nurse in the field of diabetes and diabetes coordinator at Rambam, "Diabetes is a disease that significantly affects morbidity and recovery processes. When the disease is untreated and unbalanced, especially during hospitalization, harmful consequences may occur. Balancing sugar levels is an integral part of the recovery process, and ignoring high sugar levels can harm the body's ability to deal with the acute condition and even make it worse."
"There are studies from around the world that have shown that the introduction of a diabetes treatment protocol in hospitalization leads to better hospitalization outcomes, including shorter hospitalizations, reduction of infections and cost savings," points out Dr. Irit Hochberg, director of diabetes service and senior endocrinologist at Rambam, "improving diabetes treatment during hospitalization has been studied in depth mainly around heart surgeries, where there is clear evidence that sugar balance reduces surgical complications, even in people who are not known as suffering from diabetes," she adds.
A complex and challenging training process
The process of training the staff at the hospital for the correct and safe treatment of diabetes is complex and challenging. Although the hospitals have diabetes coordinator nurses, endocrinologists and internal medicine specialists who provide professional advice in complex cases and provide training to the teams, but due to their limited number, they cannot be personally involved in the treatment of the majority of those hospitalized with unbalanced diabetes.
Recognizing the need for horizontal training for all hospital staff, Chantal and Dr. Hochberg led a national movement to improve nationwide dealing with the issue of treating diabetes during hospitalization. The two, together with Olga Bronstein, director of the quality and control system at the Ministry of Health, developed a study, which includes simulations of Common situations encountered by the medical staff and nurses.
One of the goals of learning is to produce a uniform therapeutic language, in a way that aligns the different fields. The process of creating the study was accompanied by the diabetes coordinators in the hospitals throughout the country, and there is a broad consensus regarding the messages it contains. The learning is accompanied by an applied application, which can be activated from any mobile device, which was also developed at Rambam, by a learning and human capital development system at the medical center.
The learner in the processes of assimilation in the various systems
Within a few months, the learning was distributed, through the Ministry of Health, to no less than 26 general hospitals and is now in the process of assimilation into the various systems. This is a national project, the first of its kind in the world, which has even gained interest from the American Diabetes Association.
Dr. Hochberg explains: "All hospitals have diabetes coordinator nurses, most of them clinical specialist nurses like Rachel, and doctors who coordinate the field of diabetes in hospitalization. Beside them, there are dedicated diabetes nurses in every department, who help in monitoring and implementing situations and solutions. The scope of the problem is large, and only grows year by year. There is more than one way to treat diabetics, so you also need to give a large basket of tools that is suitable for different scenarios and situations.
About a year ago, we completed leading the writing of national recommendations on behalf of the National Diabetes Council, for the treatment of diabetes in hospitalization, and we decided to create a training course in Rambam. We later realized that the course could also help our corresponding teams in all the hospitals in Israel, and make it easier for them to make the recommendations available to the treating teams. There are thousands of doctors and nurses involved. To our delight Prof. Itamar Raz, head of the National Diabetes Council, and my other members The council approved the recommendations and supported the creation of the Lumada, thus allowing us to turn the vision into reality."
"The study was distributed at the same time as a quality index on inpatient diabetes care by the Ministry of Health, which was also approved by the National Diabetes Council and began to be measured this year," Moshefia Chantal, "everything is part of a horizontal, nationwide quality process that must be implemented to allow these patients to receive the best treatment."
The assimilation of learning in the various hospitals will generate important information for future improvement. The project is at the center of research by Dr. Hochberg, who received a grant for the purpose from the Innovation Authority of the Ministry of Science and the Kinneret project, on the effects of the quality index and learning on conduct in the field. The research partners are Dr. Erez Shalom, doctoral student Shay Yaffe and Prof. Yuval Shahar from Ben Gurion University, and A number of doctors leading the treatment of diabetes in hospitals. "It is important to understand the situation and the effectiveness of the tools at our disposal, in order to mark the following goals," say the two.
Diabetes in hospitalization - a window of opportunity for change
As mentioned, many of those admitted to the hospitals suffer from diabetes. Some of them are not even aware of it, and in fact find out about their illness for the first time during the tests carried out during their stay in the hospital. An acute illness can cause an increase in sugar levels even in people who were not known to have diabetes.
"If there are repeated blood sugar measurements above 180 mg/dL, treatment should be started already in the hospital, and later to check if the patient has undiagnosed diabetes," Dr. Hochberg and Chantal point out, and clarify that "this is a real opportunity for those patients to get to know their medical condition for confirmation , to start treatment and learn to control the disease that will accompany them throughout their lives."
"Hospitalization is self-focus," says Chantal, "you are with yourself. No excuses, no worries of the day, without the routine framework that allows the situation to be ignored and neglected. You are focused on yourself, on the problem, and accompanied by relevant experts. For people with diabetes, this is an opportunity to learn good management more of the disease, to change treatment, to understand the various complexities, and to receive important information. We encounter many people who arrive unbalanced, and leave the ward in a better state, with a plan in hand And follow-up by a specialist nurse and endocrinologist after hospitalization. My contact list is full of patients who are success stories. This is exactly the importance of learning," she says, "to help the team read the signs, and give the right treatment and information, in order to achieve an optimal result."
Long distance marathon
With years of experience in the field, both Dr. Hochberg and Chantal understand that this is a long-distance marathon. "It is a complex process that requires patience," the two explain, "but important moves are already being implemented in the field. We need to learn how to become more efficient and adjust our approach in the face of the changing reality. A serious attitude on the part of the staff to the sugar values during hospitalization conveys a message to the hospitalized that the treatment of diabetes is important for their health, and the aspiration is that even after hospitalization they will understand that it is important for them to manage the disease better in order to avoid chronic complications that will harm their quality of life and sometimes lead to further hospitalization later on. As a system, we are able to improve", they conclude.
