Raising the Debate on Wound Care and Diabetes Education

  The No. 1 cause of non-traumatic lower limb amputations and the seventh-leading cause of death in the US,¹ diabetes has a large presence in the majority of wound care clinics. This is where comprehensively educated, trained, and credentialed wound care staff members can prove invaluable to patients, especially in those centers where there is an established interdisciplinary team that includes a certified diabetes educator (CDE). While having a CDE is more likely a common trait of larger clinics, smaller centers are considered lucky to have access to a regular, devoted CDE. But what about those individual wound care providers who would like to earn their CDE certification in an effort to bolster their clinical acumen and improve patient care outcomes? Unfortunately, many may find it very challenging (or in some cases relatively impossible) to achieve these initials behind their name due to eligibility requirements.² For patients, this often means making a separate appointment to a CDE at another location (and sometimes being charged another co-pay). For wound care providers, this often means relying on the services of another clinician outside their respective clinics to effectively collaborate with the patient’s wound care (and possibly having nothing more than hope that the patient will follow through with the necessary educational appointments). How should the wound care industry and individual wound care clinics best handle this conundrum? Apparently, there are no easy answers.

Does CDE Fit Wound Care?

  According to the CDC, the number of people who have been diagnosed with diabetes in the US is almost 21 million (or approximately 8% of the total population).^1,3   In my personal experience of managing diabetes and wound care, the average patient is seen in the clinic weekly for approximately 30 minutes. While some patients may feel “forced” to listen to any education we provide, others may actually be more receptive to what their wound care providers have to say due to fear of developing future wounds. Regardless, the provider should view the opportunity as a chance to change someone’s life by providing needed information while possibly improving the patient’s future healthcare through prevention (not to mention reducing their related healthcare costs). After roughly two years of working as a wound care nurse, I began to personally feel as if the education I had been giving my patients was too repetitive and not individually focused, so I decided to pursue a CDE. My pursuit to become credentialed, as it turned out, was not a lengthy one because I apparently do not qualify to provide accredited education in my current role as a staff nurse in an outpatient wound clinic. According to the National Certification Board of Diabetes Educators’ eligibility requirements, one must earn a minimum of 1,000 hours in diabetes self-management education (DSME) within an accredited center, with the hours being accrued in no more than five years time and a minimum of 40% of those hours (400 hours) being accrued in the year preceding application. Furthermore, wound care nurses who work in an outpatient setting do not qualify for the credential on their own merits because “… it is not for those who may perform some diabetes-related functions as part of or in the course of other usual and customary occupational duties …”.² The definition of DSME is quite extensive.⁴ Although I can certainly agree with the requirements being strict, I still sought answers as to why I didn’t qualify for this opportunity as an experienced, licensed wound care provider.   “Part of the reason it’s so difficult to become a CDE is that the criteria is set up to protect the public and ensure people are being taught diabetes education according to the current standards of care for diabetes management and education,” said Pamela Scarborough, PT, DPT, MS, CDE, CWS, a wound care provider with experience in acute and long-term care, outpatient services, and home health who earned her educator credential nearly 20 years ago. “What one does as a wound care specialist when educating people living with diabetes and wounds or a diabetic foot issue does not count toward the hours needed to be eligible to sit for CDE examination.”   Though she values the prestige that is inherent with the CDE and stands by the increased knowledge one gains through earning the credential, Scarborough admits the challenge to obtain the CDE today may be more than the requirements intend them to be.   “It is a problem,” said Scarborough, who has been able to maintain her previously acquired certification through one of the mandated processes for renewal, which includes passing the board certification exam and acquiring 75 hours of continuing education related to diabetes management and education every five years. “If I had to get my CDE today, I don’t know how I would do it because I don’t want to be a full-time diabetes educator — I want to do clinical wound care and teach wound prevention, wound care, and diabetes management, especially in the context of chronic, nonhealing wounds, to my colleagues who are proving care. One of the big drawbacks for wound clinicians trying to attain this credential is the fact that it’s very difficult to find a setting that will allow them the opportunity to accrue the required 1,000 hours. So, here we are in this diabetes epidemic and the CDE credential has become more difficult to acquire.”   With the requirements for CDE unlikely to significantly change any time soon, Scarborough said any possible solutions to this dilemma aren’t on the near horizon. “What we really need, and I’ve been saying this for years, is another credential related to diabetes care competency for clinicians who have an interest in elevating their diabetes-care practices, regardless of the kind of clinical care one provides,” she continued. “Wound care clinicians need to be knowledgeable and competent in both diabetes-care practices and have a working knowledge of DSME to be able to provide quality wound care and communicate with their wound care patients. This clinical diabetes credential that I’m fantasizing about should be across the disciplines, where you can say that you have advanced training in diabetes care, yet you’re not a CDE or an endocrinologist. The question is, ‘How do we fix this without offending people like endocrinologists, other physician disciplines, or diabetes educators?’ How the industry will do something like this, I don’t know, but providers need some advanced training in general diabetes management beyond what we get in school.”

The Mission Continues

  All wound care clinicians are in a unique position to provide consistent, ongoing, and relevant education to a rather captive audience. But what real information do we have for our patients? While there is readily available research on the prevalence of diabetic foot ulcers, the data regarding the association between other types of chronic wounds and diabetes is scarce. Even more difficult to find are data related to the education of patients regarding their diabetes as given by their wound care providers.   Not to be deterred in my desire to strengthen my knowledge base and become more equipped to share patient-focused education, I decided to take a different avenue and look at specific wound care certification related to diabetes. According to the Wound Care Education Institute and the National Alliance of Wound Care, the week-long Diabetic Wound Certified (DWC) certification class focuses on “… overall diabetic wound care and promotion of an optimal wound healing environment including prevention, therapeutic, and rehabilitative interventions …”.^5,6 Additionally, the definition for DWC scope of practice aligns with the wound care provider: “The DWC provides direct patient care, necessary patient education, and prevention measures through comprehensive assessment, referrals, and continuing evaluation of high-risk diabetic patients and all types of diabetic wounds.”⁶   This is not a blind endorsement of any program, as I am still undecided on how I will move forward. It falls heavily on all providers to do their own research regarding available resources; however, if there is ever a push in the wound care community regarding the importance of diabetes education due to the obvious opportunity wound care clinicians have to provide it, the change can begin to be made toward more education and certification in this area by those providers who chose to investigate available options.   While Scarborough admits the time commitment needed to earn the CDE can be very daunting to many wound care clinicians, she insists the CDE benefits are evident. “Anyone who has certification by an accredited board knows what that means,” she said. “Part of the quality that you have as a CDE is the problem-solving component for people with glucose issues. If a person comes into my clinic in the morning with a blood glucose of 175 after eight hours of sleep when their glucose was 125 at bedtime, I know their medication is not covering them through the night for their gluconeogenesis and that they need to go back to their primary care physician. Also, in order to get reimbursed by Medicare and many insurance companies for diabetes education, the patient has to have been educated by a CDE in a recognized diabetes self-management education program.”   Regardless of the path taken, it would seem that wounds and diabetes education could one day become a standard pairing. Jill Henneberg is on staff at St. Mary’s Hospital, Grand Junction, CO. Joe Darrah, managing editor of TWC, contributed to this article.

References

1. National Diabetes Fact Sheet, 2011. CDC. Accessed online: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. 2. Eligibility Requirements. National Certification Board of Diabetes Educators. Accessed online: www.ncbde.org/certification_info/eligibility-requirements. 3. Diabetes Report Card 2012. CDC. Accessed online: www.cdc.gov/diabetes/pubs/pdf/DiabetesReportCard.pdf. 4. Professional Practice Experience. National Certification Board of Diabetes Educators. Accessed online: www.ncbde.org/certification_info/professional-practice-experience. 5. Diabetic Wound Management Course Information. Wound Care Education Institute. Accessed online: www.wcei.net/dwc_courseinfo. 6. DWC Certification. National Alliance of Wound Care. Accessed online: www.nawccb.org/page.asp?id=95.