Lindsey Boone, DNP, NP-C

Diabetes is a complex, multifaceted illness that requires ongoing monitoring, education, and support. As the population with diabetes increases, providers will continue to face challenges on how to manage these patients in primary and acute care settings.

Currently, 9.3% of the US population is living with diabetes.

This number is expected to continue to rise, with over 86 million adults estimated to have prediabetes.

Diabetes is the seventh leading cause of death, with over 200,000 deaths attributed to the disease each year.

There is increasing concern on how to manage these patients through all areas of care.

With the growing demands on the health care system to produce low-cost options and convenient access to care, retail health clinics are expanding and growing in popularity. Although these clinics direct their care toward minor acute illnesses, they may find themselves caring for patients with chronic conditions. As the population living with a chronic condition increases, the demand to provide holistic care is more prominent in all settings across the health care system. The overall goal for any provider, regardless of setting, is to produce high-quality patient outcomes. With 9.3% of the population living with diabetes and 8.1 million individuals living with undiagnosed diabetes, a provider will likely assess and treat patients with diabetes daily.

As providers, it is important to be aware of the challenges of treating patients with diabetes.

The primary goals of treating and managing patients with diabetes are to obtain optimal glycemic control and reduce complications of the disease. Optimal glycemic control is essential in preventing both acute and long-term diabetes-related complications. Glycemic control can be assessed through patient self-monitoring records, random blood glucose checks, and glycated hemoglobin (A1C) testing. Even favorable glycemic control can be interrupted by stress, illness, trauma, and/or surgery and result in life-threatening conditions such as diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).

Patients who use insulin require more frequent monitoring of blood glucose. Ideally, blood glucose should be monitored before meals and snacks, postprandially, at bedtime, before exercising, and after treating a hypoglycemic episode. Although patients who are noninsulin-dependent require monitoring of blood glucose, the frequency is dependent upon evaluation by their primary care physician. Patients with diabetes who experience an acute condition may require more frequent monitoring to prevent hypo or hyperglycemic episodes. Recommendations for monitoring blood glucose vary based on the current status of their diabetes, severity of illness, current management of diabetes, and medications used to treat the acute illness. Patients with diabetes who present with acute symptoms should be evaluated for hypo- or hyperglycemic states.

Noncritically ill patients, or those who can be maintained in an outpatient setting, should have a pre-meal glucose goal of less than 140 mg/dL or a random glucose measure of less than 180 mg/dL.

Careful consideration should be given to insulin-dependent patients with diabetes whose glucose is less than 100 mg/dL in order to avoid a hypoglycemic episode. Intervention is needed for levels that fall below 70 mg/dL.

The patient’s history, nutritional status, severity of illness, and concurrent use of acute medication regimens, such as steroids, should all be considered when evaluating and treating a patient with diabetes in the acute-care setting.

Patients with diabetes who present with an acute illness, such as upper respiratory symptoms, pharyngitis, diarrhea, nausea, or allergic rhinitis, may seek care at various primary care offices and retail clinics. During an acute illness, blood glucose tends to rise due to the body’s natural response to produce extra hormones to help fight off infections. The increase in hormones, although effective in fighting infections, can inhibit insulin binding, causing an increase in blood glucose. As a result, complications can arise during an acute illness that may result in more serious conditions if not addressed. Complications include, but are not limited to, hyperglycemia, hypoglycemia, dehydration, DKA, and HHS.

Treatment of minor upper respiratory conditions typically includes antibiotics, cough suppressants, pain relievers, fever reducers, and in extreme cases, a tapered dose of steroids. Many OTC liquid medications contain sugar, which can cause spikes in blood glucose when used excessively. Patients with diabetes should use sugar-free medications when available. In addition, although steroid dose packages are commonly prescribed in severe cases of inflammation, steroids can cause hyperglycemia and insulin resistance and their use should be avoided in patients with diabetes when possible. When steroids are used during an acute condition, patients should check their blood glucose frequently and adjust medication dosage as recommended by their primary care provider.

Gastrointestinal (GI) conditions commonly warrant acute care. GI conditions can have an increasing effect on a diabetic patient’s glucose, causing dehydration in some. Although it is common to experience loss of appetite and decreased sensation of thirst when experiencing GI symptoms, it is important for this patient population to continue to consume fluids and the proper amount of carbohydrates to ensure glycemic control. Patients with diabetes should consume 50 g of carbohydrates every 3 to 4 hours to prevent hypoglycemia and the body from producing ketones.

Proper assessment of hydration should be performed on all patients with diabetes who present with GI complaints. When patients cannot tolerate fluids during an acute condition, they may require emergency care.

It is not uncommon for patients with diabetes to experience GI complaints as part of the disease progression. As many as 75% of patients with diabetes report having chronic GI issues

related to progression of the disease, consumption of sorbitol, pancreatic insufficiency, and/or adverse effects from medication, such as those experienced with metformin. As providers, it is important to be aware of the various causes of GI complaints in patients who have diabetes. GI disorders can arise from both acute and chronic hyperglycemia. Typically, these issues are associated with neuron dysfunction, which causes abnormalities in intestinal motility, sensation, secretion, and absorption.

Assessment of a patient with diabetes presenting with GI complaints should be thorough and include a review of the patient’s blood glucose diary, along with an in-office random blood sugar test, assessment of current symptoms and medications, abdominal assessment, and a prompt referral, as appropriate.

Another common condition treated in the retail clinic setting is urinary tract infection (UTI). Diabetes is a risk factor for developing UTIs, which can result in more complicated, potentially life-threatening conditions such as emphysematous pyelonephritis, renal abscess, emphysematous pyelitis/cystitis, and renal papillary necrosis. Complaints of urinary tract infection were present in 9.4% of patients with type 2 diabetes (T2D) compared with 5.7% of patients with no prior history of diabetes.

Glycosuria, neutrophil dysfunction, and increased adherence of the bacteria to uroepithelial cells allow for an environment conducive to bacterial growth.

Patients with diabetes may present with a history of hyperglycemia, dysuria, foul-smelling urine, back pain, and/or blood in the urine. During the physical assessment, the provider may assess abnormal vital signs (fever, tachycardia), positive costovertebral angle tenderness, and pelvic tenderness on palpation. In-office urinalysis may yield positive results for glucose and/or blood. Patients may also present with hyperglycemia. UTIs in patients with diabetes can become complicated quickly, especially in a patient with already uncontrolled glucose. These patients should be started on antibiotics immediately and referred to specialists as needed to avoid complications.

DKA and HHS are two serious and life threatening complications of diabetes. The majority of patients who present with DKA have type 1 diabetes (T1D); however, 33% of DKA patients have T2D. The most common cause of DKA in adults is infection.

DKA is caused by insulin deficiency and increased production of counter-regulatory hormones which, in turn, leads to decreased cell utilization of glucose and ketosis. Patients will commonly present with complaints of nausea, vomiting, abdominal pain, polyuria, and polydipsia. Laboratory testing may reveal hyperglycemia (glucose >250 mg/dL), hyperketonemia, and acidosis. On physical assessment, these patients may display hypotension, tachycardia, fruity smelling breath, and/or Kussmaul respirations.

The mainstay treatment for these patients is insulin therapy and fluid resuscitation, therefore, they should be referred for emergency care.

Patients with HHS most commonly have T2D. These patients may present with similar complaints as with DKA; however, the diagnostic criteria is slightly different. HHS is defined by plasma glucose greater than 600 mg/ dL and an increase in effective plasma osmolarity greater than 320 mOsm/ kg with the absence of ketoacidosis. Treatment goals for HHS are similar to DKA with regard to decreasing blood glucose while restoring fluid and electrolyte balances.

As primary care providers, it is important to address and anticipate complications of an acute illness on diabetic patients. Patients with T1D should monitor their blood glucose every 4 hours and check their urine for ketones during an acute illness. Emphasis should be placed on educating the patient on the importance of notifying their primary care provider of any spikes in glucose that do not respond to their medication regimen. Blood glucose greater than 250 mg/ dL accompanied by polyuria, polydipsia, gastrointestinal symptoms, and/ or changes in respiration is an emergency situation and patients should be clearly informed on the proper course of action. Patients should not adjust their diabetes medication during an acute illness unless directed to do so by a health care provider.

Whether encountering these patients during a primary care or episodic care visit, it is vital to bridge treatment plans and support continuity of care between the patient, community resources, and the primary care physician. Assessment and treatment of the patients with diabetes should address the goals of glycemic control and reduction of diabetes-related complications. Although once scrutinized and questioned for its lack of focus on diverse populations with diabetes, the chronic care model (CCM) is effective at helping practices improve patient health outcomes by changing the way care is delivered, using 6 interrelated system changes designed to make patient-centered, evidence-based care easier to accomplish.

The CCM comprises the health system, self-management support, decision support, delivery system design, clinical information systems, and community resources to improve patient outcomes. Incorporating all 6 components in patient-centered care creates an effective health system aimed at supporting links to community resources, promotion of patient-centered care, and the delivery of comprehensive self-management support services for patients.

Although the CCM is ideal for the primary care setting, its use has shown to be effective in the acute care setting as well. A recent study conducted by Khan, Evans, Shah (2010) adapted the CCM for management of the patient with diabetes in the acute care setting. After the CCM was incorporated in the treatment of 1098 uninsured patients with diabetes who did not have a primary care physician and were seeking care through an urgent care center, researchers noted a decrease in A1C in 76% of patients, an average decrease in systolic blood pressure of 9 mm Hg, an 11-point decrease in low-density lipoprotein cholesterol, and an average weight decrease of 2.3 lbs.

The goals of treating patients with diabetes in the retail health setting remain universal. Providers in the retail health care setting are the forefront of the patient’s first attempt at receiving care and treatment. Whereas the first concern may be focused on addressing the patient’s acute conditions, the patient’s underlying problems should be assessed and evaluated as well. The best way to determine the status of a patient with diabetes is to assess their current glucose level. Educating the patients on the need for more frequent monitoring during an acute illness and assessing their ability to recognize emergency signs and symptoms is key. We cannot assume that a patient with established diabetes will be aware of the proper monitoring and assessment of their diabetes during an acute illness, nor can we assume that a patient knows their diabetes status. As providers, every opportunity should be taken to make a difference in a patient’s life.

is a board certified nurse practitioner with 8 years of health care experience. Lindsey’s career started as a registered nurse in the oncology setting and later went on to work as a nurse practitioner in palliative care and oncology. Lindsey later worked in community health, school health and most currently retail health. Lindsey has a passion to make a different in every life she touches by providing holistic, evidence-based care.

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As the population with diabetes increases, providers will continue to face challenges on how to manage these patients in primary and acute care settings.

Lindsey Boone, DNP, NP-C

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