In the present treatment paradigm, hospitalized patients’ acute medical issues are fully addressed, but their comorbidities receive limited care. Evergreen Healthcare in Kirkland, Wash., is going a step further in this latter realm by offering proactive diabetes care to inpatients in hopes of giving them the skills and confidence to manage the disease more effectively. 
By: John Parkinson, Clinical Content Coordinator,  
An obese, middle-aged male is brought into the emergency room complaining of chest pains. An EKG confirms the patient has suffered a heart attack, and the ER personnel begin to take the necessary steps to treat him. In the course of the patient’s workup, a medical history is taken, which shows this patient has a number of comorbidities, including type 2 diabetes.
Upon stabilization, the patient is brought into a private room. During the course of the patient’s hospital stay, he might have a number of medical providers come to see him to explain his condition; be given an appropriate course of medications; and scheduled for follow-up appointments and tests for his acute health issue. However, for his type 2 diabetes, it is likely the patient may only be given a precursory, quick course in survival skills.
In terms of the patient’s health priorities, the diabetes might not be the acute health problem, but doesn’t a chronic disease that could lead to numerous other health ailments, and which may help land the patient back in the hospital, deserve more medical attention? 
Evergreen Healthcare has taken what might be the first step on the road to a more significant emphasis being placed on comprehensive inpatient care for comorbidities.
Evergreen recently earned an Advanced Certification in Inpatient Diabetes from The Joint Commission. This certification was awarded to Evergreen based on criteria that includes evidence-based clinical practice guidelines, nationally established best practices for successful models of care, and an interdisciplinary approach to patient education, glucose control, and management.
Evergreen is a community-based healthcare organization serving a public hospital district in eastern King County, Wash. It has built its 40-year reputation in part by providing distinguished care in the inpatient spectrum.  For example, Evergreen won the 2011 Outstanding Patient Experience Award from HealthGrades, a provider of independent hospital ratings.

Evergreen is also the only hospital in Washington state to be recognized with the Distinguished Hospital Award for Clinical Excellence for the past four years running and thus ranks among the nation`s top 5 percent of hospitals.
James Colquhoun, MD, is medical director of the Evergreen Healthcare diabetes program and was part of the team that went through the inpatient certification process. As a hospitalist, Dr. Colquhoun knows firsthand how the traditional hospital treatment paradigm has been limited to teaching patients survival skills. Therefore, he says there is a great opportunity to reach a segment of the patient population that is chronically sick who could benefit significantly from more comprehensive inpatient care of comorbidities like diabetes. spoke with Dr. Colquhoun (pictured, lower right) about the process of achieving the certification, what it means to offer comprehensive inpatient diabetes care, and what the certification means to Evergreen from an organizational standpoint. Can you provide an overview of what the Advanced Certification in Inpatient Diabetes is exactly?
Colquhoun: There are a number of elements to it, but some of the biggest components that the Joint Commission wanted to learn from us was how we were dealing with safety issues in terms of hypoglycemia; what hospital procedures we chose to improve upon; that we were ensuring patients have an A1c test when they come into the hospital; and that we were providing diabetes education skills prior to discharge. Those were the main components along with training everyone for bedside care. Generally speaking, the emphasis placed on inpatient diabetes care is different from outpatient care in most medical settings, with the latter getting greater attention. Why the decision by Evergreen to pursue the certification in an inpatient setting?
Colquhoun: It’s part of Evergreen’s strategic plan to connect our inpatient and outpatient diabetes services. If you hold hospital medical personnel to a higher standard on the inpatient side, the patients will be better prepared to handle their diabetes when they leave and become part of the outpatient continuum. Our administration sees it as a cornerstone of quality and safety. Is this inpatient emphasis on diabetes care a departure from the traditional paradigm?
Colquhoun: Unless someone is in the midst of a hypoglycemic episode or suffering from diabetic ketoacidosis, no one really comes into the ER complaining about their diabetes. Rather a person comes in for routine surgery and the patient’s blood sugar is 250. Or someone comes in with a heart attack and there is a fair chance the patient has unrecognized diabetes. In addition to the acute problem, an inpatient hospitalization is an opportunity to recognize, address, and work on a patient’s chronic ailments.
If you acknowledge as a healthcare organization that there are those patients who have different conditions like heart failure, stroke, or COPD when they come into the hospital, and you are looking for a way to improve their care, what is the one thing they might have in common in terms of their chronic disease management?  Often it is diabetes. This is a big comorbidity that is only growing in prevalence. That is why this certification is an important part of our overall care strategy. Can you explain the processes you had to complete as part of your certification?
Colquhoun: The certification process has been going on for several years and we have had a number of updated elements and protocols that our staff had to follow. For example, we had to implement bedside insulin infusion and safety protocols.

We are also moving away from teaching the traditional sliding scale insulin delivery model and being proactive when we can. When appropriate, we are working on getting uncontrolled diabetic patients to go on long-acting insulin. We also have standardized protocols for people who come into the hospital with hypoglycemia or who develop hypoglycemia in the course of their care.
We have also created a computerized physician order system, so we are translating all of our past paper orders to an electronic system so everything will be consolidated and standardized. Was there a lot of training by staff in getting everyone up to speed for the certification’s requirements?
Colquhoun: In reflecting back on the certification process, it has been a lot of work. We held quarterly staff meetings with nurses and additional meetings with our clinical advisory boards where we had to get physicians from various specialties on board with the inpatient program. So, we had to review with all physicians--from general surgeons to cardiologists--as to why the certification matters and how it impacts the care of their patients.
The education component alone has been a monumental effort. There has been a lot of online teaching with the nursing staff, including clinical skills labs. For physicians, we have had CME sessions that are focused solely on diabetes. Upon release from the hospital, does Evergreen have a plan in place for patients to transition to outpatient diabetes care? 
Colquhoun: In order to understand how severe a patient’s diabetes is, you have to have good electronic systems and communication protocols in place. This includes everything from accessing past A1cs, to recording a current A1c, to how to communicate those results to the patient at discharge and to the next provider in care. All these elements take a set of rules and infrastructure and some of that can be done in how you build your systems and how information flows across your computer system. This is something we have been working towards. 
Some of that is also a huge cultural shift in educating people about how important the A1c is, so we are transitioning our outpatient clinics to the same computer system in the hopes that the flow of information is going to be a lot easier. This way, whether someone is an inpatient physician or outpatient physician, an inpatient diabetes educator or outpatient diabetes educator, everyone will be able to access the same labs and we can all see the care that has been provided. What does the certification mean to patients on an everyday clinical level and to Evergreen organizationally?
Colquhoun: If you look at the CDC population graphs which detail the incidence rates of diabetes by county in the individual U.S. states, I expect that more and more Americans are going to suffer from both obesity and type 2 diabetes over the next 15 to 20 years.
Our administration recognizes this is a huge health problem in the near future, and so we are delivering high-quality care that is both efficient and cost effective and, most importantly, still meaningful to the patient at the bedside.
If you are a patient at Evergreen, it means you are going to get quality care from the moment you arrive in the ER until you are discharged. You will be very safe from hypoglycemic or hyperglycemic episodes; you are going to understand your medications before being discharged; and you are going to get diabetes supplies and teaching prior to discharge.
From an organizational standpoint, I believe we are still working on communicating our aims to the greater community at large. We are the first and only program that has achieved this certification in Washington state, but what does that mean organizationally? How do you leverage that with insurance companies or partner with other health systems in the area to get people the right diabetes care they need?
For example, we have a lot of patients coming to Evergreen from other health systems and how do we get vital patient information to the right people that are not on the same computer system as Evergreen? We are still trying to figure out elements like that, but this certification is a great start in trying to improve and standardize how we deliver inpatient diabetic care.