Educator Difficult Case Conference Conference Call Minutes December 12, 2006

Participants: BWMC, Chaleur, DCH, Fremont, MGH, Providence, Southview, SUNY, Swedish Facilitator: Elaine Sullivan

Providence case – 74 yo African American female with Type 1 on 7 units lantus AM & PM and novolog sliding scale; daily hypoglycemia usually 2 – 3 hrs after meals; doesn’t know CHO counting despite repeated education; has had local non-Joslin RD for years; Joslin MD/NP and educators have adjusted CHO:insulin ratio without much success; demonstrates accurate insulin measurement; probably stacking insulin doses

A1C 8.7 and consistently over 8%; 20 lb weight gain in 6 years; frqt BG monitoring up to 10 times/day; MD discussed pump but educators ruled out due to ongoing CHO counting problems; patient suggested symlin and MD prescribed but pt never started; may not be safe choice due to frequent hypoglycemia on current program; does seem to recognize hypo symptoms at 50- 60mg/dl; husband has Type 2 & is somewhat involved; patient finished 12th grade but Joslin hasn’t assessed specifically for math literacy

Suggestions – Goal is get rid of hypoglycemia and then work on A1C; consult with Joslin RD for trial of prescribed set meal plan based on typical foods with fixed insulin doses; have patient fax results; or try 1:15 Insulin:CHO because simplifies math; focus on number of 15 g servings per meal/snack; stop correcting with insulin between meals; try ADA Month of meals or plate method; give patient specific scale sheet that includes CHO and correction so she doesn’t have to do math; Could be good case for CGMS short term; could use BGAT manual for resources to increase awareness of neuroglycopenic symptoms of hypoglycemia before BG is 50 – 60 mg/dl

Elaine Sullivan reported a presentation at AADE Annual Meeting 2006 on “The Importance of Health Literacy and Numeracy in Diabetes Care” by Russell Rothman, MD, MPP at Vanderbilt University. Elaine could not find the research results published yet. REALM is a validated literacy screen. Using a food label can be a good and easy way to assess for math literacy. Another technique he recommended was the “Teach-Back” technique. Ask the patient to teach you what you just taught him/her. If anyone else finds a publication by this author on health literacy, let Elaine know and she will put it in Affiliate Newsletter. Audio from AADE can be ordered as session # T05.

Chaleur case – PCP sent patient in Sept 2005 as new to DM but had symptoms since 2,000; 48 yo man on Diabeta and Crestor, A1c 7.5%, post prandial BG 230, FBS 145, very thin and wasted looking, severe dyslipidemia, insulin deficiency???

Educator requested PCP do GAD antibodies to determine if Type 1; PCP reported patient was alcoholic and 2 ppd smoker; PCP never followed up Months later patient admitted to psychiatric inpatient unit for severe depression; educator requested endocrine consult during inpatient stay; endocrinologist diagnosed Type 1 and will follow; patient refused insulin; Starlix instead; did improve A1C; doesn’t want to self manage care and lives with sister who is not much help

In Canada patients don’t have choice of PCP or legal consequences for poor practice.

Suggestions – If referring physician is resistant to guideline-based educator recommendation, ask Joslin Medical Director to intervene; document concerns, action and explain options to patient; fax or mail copy of documentation to referring MD; identify if problem is patient lack of follow up vs. MD not acting on clinical guidelines; could email or fax appropriate Joslin clinical guideline to physician

Swedish case – Patients with severe hyperglycemia referred for insulin start in Education only site

Suggestions: Don’t accept referral for insulin start if hyperglycemia is severe; advise referring MD to send to ER for evaluation, refer to Joslin Clinical Guideline for Hyperglycemic Emergencies in Adults (Section 1 of the Policy and Procedure Manual) “consider hospitalization if BG > 400”; if patient is in your office and you have ketone testing supplies, check ketones; if patient is spilling moderate to large ketones refer to ER and then notify PCP; if patient refuses ER have them sign “leaving against medical advice” form

Conclusions: Thanks to all who participated in the call especially those who offered case examples. Educators agreed the call was helpful. Will plan future education case conference calls. Request that brief description of case be sent out to participants before call.