Mary Sullivan, AADE Diabetes Educator of the Year
by jeff halpern and tony sheng
We were fortunate to sit down with this year’s American Association of Diabetes Educators (AADE) Diabetes Educator of the Year, Mary M. Sullivan RN, MSN, C-ANP, CDE (University of San Francisco Medical Center, San Francisco) for a frank discussion about the importance of diabetes educators and the state of diabetes therapy—past, present, and future. In this interview, Mary discusses how she got involved with diabetes, nuances in treating patients with diabetes in hospitals, technology, education, and transitioning patients to more advanced care.
background
diaTribe: First of all, we just want to congratulate you again on being named Educator of the Year. We think it's such a great honor and it's a big honor for us to speak with you. Thank you so much for taking the time to talk. Please tell us, first of all, how did you get into taking care of people with diabetes?
Mary Sullivan: I have been doing this for over 30 years. It actually started when I was doing my community health experience as a student nurse. One of my first patients had diabetes. I had to teach her how to use insulin at home using glass syringes.
the inpatient experience
diaTribe: Please tell us more about treating patients with diabetes in the hospital setting. To start, what do you love about inpatient experience?
Mary: The inpatient experience is when the person with diabetes is the most vulnerable, so I think that it is important to have somebody with expertise in diabetes to help patients during their hospital stay.
diaTribe: Yes, that seems like such a difficult time. There's been a lot of controversy lately over how to correctly manage blood glucose in hospitals. Can you tell us what you think about this?
Mary: For years, blood glucose levels were ignored and the glycemic goal was to get the patient home without severe hypoglycemia during their hospital stay. But with the publication of the Van den Berghe study in 2001 (Leuven 1 [published in the New England Journal of Medicine in 2001]), hospitals began to focus on inpatient glycemic control. The study took place in a sample of centers in Belgium.
Results from the Van den Berghe study seemed to indicate that tight glycemic control—keeping the blood glucose level between 80 to 110 mg/dL in the intensive care setting – was beneficial. However, other trials were not able to replicate Van den Berghe’s findings without causing significant hypoglycemia. Now the results of an additional study in patients, the NICE-SUGAR study, has been published. NICE-SUGAR has the advantage of being performed in multiple centers in multiple countries with computerized insulin delivery.
diaTribe: In your view, what are the implications of the NICE-SUGAR? Throughout the diabetes community and beyond, there seems to be the implication that tight control really didn't have that much of a difference in the patient’s outcome. Of course that view is also very controversial in our circles.
Mary: The results seem to indicate that keeping patients’ blood glucose ranges between 80-108 mg/dL is not beneficial because of the increased rates of hypoglycemia. I think that it is important for hospitals to assess their hypoglycemia rates with their insulin delivery and to modify their insulin delivery to reduce hypoglycemia.
technology in the hospital setting
diaTribe: Let’s talk about technology. What kinds of technologies or therapies should we be using in the hospital setting?
Mary: Currently in the hospital setting, we have hospital glucose meters, but we do not have continuous glucose sensors. For a critically ill patient, that potentially means 24 finger sticks in one day. And a lot of times you can't even use their fingers for a fingerstick because of other complications. I would love to see the development of a glucose sensor that's accurate and can be used with IVs.
diaTribe: We see. So the current continuous glucose monitoring technology you don't think would be sufficient in the hospital setting?
Mary: I don't think so. The current sensor technology is inserted into subcutaneous tissue. In-patients have problems with rapid fluid shifts so there may be problems with accurate sensing by the sensor.
diaTribe: What would you say are the biggest challenges and obstacles today for patients with diabetes in the hospital and their families and their healthcare providers?
Mary: I think the patient needs to be as informed as possible about their condition and how diabetes is impacting their current hospital stay. I think the more informed they are, the better they will do.
diaTribe: Do you support patients continuing with their self-care while they're in the hospital?
Mary: Well, in the inpatient setting, hospitals are controlled by regulatory bodies. While I do support patients doing their own diabetes care as much as possible—they can keep their own glucose meter at their bedside—unfortunately, we can't rely on that data for administering insulin. We need to know how the strips were stored prior to hospitalization.
Just yesterday, I was working with a patient who had to go home on insulin. He told me that he had a home glucose meter. I asked him to have his wife bring the meter in so that I could assess the meter’s accuracy and thank God I did because his strips were expired by a year!
Our glucose strips are stored at a regulated temperature and the meter is assessed for accuracy. The same goes for insulin. We can only use our hospital insulin because we need to know how the insulin was stored and when the vial was opened. Regarding insulin pumps, yes, I do support patients being on insulin pumps, but hospitals should develop protocols to make it safe for patients to use pumps in the inpatient setting.
educating patients and their families
diaTribe: You mentioned the importance of relaying to the patients and their families how diabetes is impacting their hospital stay. Do you try to educate both the patient and the family while they're in the hospital in order to, maybe be able to avoid future hospitalizations?
Mary: Yes, I do, particularly if they are in the hospital for repeat hypoglycemia.
diaTribe: What information would you give to patients who are going to be hospitalized?
Mary: Patients who are going to have surgery should have a recent hemoglobin A1c test done within one month of their surgery. They should bring to the hospital a current list of their medications and dosages, a glucose meter, and if on an insulin pump extra reservoirs, infusion sets, and pump batteries. If a patient is on an insulin pump, he/she will need to provide information regarding basal rates, high glucose correction, and carbohydrate ratios. Also, pump patients will need to be able to demonstrate to hospital personnel that they know how to navigate their various insulin pump screens because they may need to change their pump basal rates while hospitalized. They should contact their diabetes care provider for help regarding what they should do with their diabetes medications while withholding foods and fluids prior to surgery or an outpatient procedure.
diaTribe: Great. What's your most successful technique to motivate a patient to improve their self-care?
Mary: Basically, what I do is I ask them how they feel and how they would like to feel. Focusing on how they feel, in my experience, is a very effective strategy when starting patients on insulin.
transitioning patients
diaTribe: That must be one of the more difficult transitions that a patient would make. How does that conversation typically go?
Mary: Well, patients come into the inpatient setting and are not expecting to have to go home on insulin, so the news of needing to go home on insulin comes as a shock to patients. I find that patients prefer to use insulin pens over syringes. There is a negative connotation to having to use a syringe, plus patients have difficulty seeing the numbers on the syringe. When I show patients the insulin pen their faces light up. They also like to use the safety insulin pen needle because the needle is hidden. I think major reasons why patients don't want to use insulin is 1) the social aspect; they think people are going to think they're addicts, 2) they don't want to see the needle, and 3) they don’t have the confidence to know that they're dosing correctly. I cringe when I have to teach patients how to use syringes because the accuracy and precision of dosing is just not there.
diaTribe: And you find with the pens that patients have more confidence in dialing the dose and taking the right amount?
Mary: Yes. They have more confidence in their dose accuracy.
diaTribe: Are you finding still that some insurance carriers don't cover pens?
Mary: It's a huge barrier. I think if the various insulin pen companies could make the cost of the insulin pen the same price as it is for a vial and syringe, or better yet, even less, then I think we would have more pen usage here in the United States. In Europe, all patients are on pens. I think only about 15% of patients use insulin pens in the US.
words of wisdom
diaTribe: What changes do you hope to see in the field of diabetes over the next few years? Clearly, education must be a larger priority.
Mary: Yes, I would like to see increased availability of diabetes education programs. I think diabetes education needs to be provided in primary care. And of course, it would be fabulous if we had an accurate, automatic closed-loop insulin delivery system for patients.
diaTribe: What final words of advice do you have for other educators?
Mary: I think diabetes educators are dedicated individuals who are striving to improve the lives of patients with diabetes. I think anything we can do to change the hearts and minds of people about diabetes, the better the care will be for patients with diabetes.
diaTribe: Mary, thanks so much for sharing your valuable time and insight with us.
