Quality Standards for Diabetes Care Toolkit

Follow-up

Follow-up for people admitted to hospital with diabetic ketoacidosis should take place within 30 days of discharge by a specialist diabetes team (National Institute for Health and Care Excellence [NICE] 2011a).

Introduction

The Joint British Societies for Inpatient Care Group (JBSICG) (2013) has published a comprehensive guideline for the management of diabetic ketoacidosis. It highlights the need for diabetes expertise in the inpatient setting and states the following:

‘Diabetic ketoacidosis (DKA), though preventable, remains a frequent and life threatening complication of type 1 diabetes. Unfortunately, errors in its management are not uncommon and importantly are associated with significant morbidity and mortality. Most acute hospitals have guidelines for the management of DKA but it is not unusual to find these out of date and at variance to those of other hospitals. Even when specific hospital guidelines are available audits have shown that adherence to and indeed the use of these is variable among the admitting teams. These teams infrequently refer early to the diabetes specialist team and it is not uncommon for the most junior member of the admitting team, who is least likely to be aware of the hospital guidance, to be given responsibility for the initial management of this complex and challenging condition’ (p 6).

‘Diabetic ketoacidosis is associated with increased mortality and morbidity. An improved understanding of the pathophysiology of DKA together with close monitoring and correction of electrolytes has resulted in a significant reduction in the overall mortality rate from this life-threatening condition. Mortality rates have fallen significantly in the last 20 years from 7.96% to 0.67%’ (p 8).
According to the JBSICG, the diabetes specialist team must always be involved in the care of those admitted to hospital with uncontrolled diabetes and in the assessment of precipitating factors, management, discharge and follow-up (Mills et al 2014). Their involvement shortens patient stays and improves safety (Cavan et al 2001; Davies et al 2001; Leveta et al 1995 [Koproski et al 1997]), leads to intensification of treatment during in-hospital stay, and reduces readmissions and post-discharge HbA1c levels (Wei et al 2013).
For patients admitted with DKA or HHNS, review by the specialist diabetes team should occur within 24 hours of admission. For these patients and those admitted with uncontrolled diabetes, specialist diabetes team input is important to allow re-education, to reduce the chance of recurrence, and to facilitate appropriate follow-up. There is good evidence of improvement in care and of reduced readmissions, with use of diabetes inpatient specialist nurses; however, few New Zealand district health boards provide adequate dedicated diabetes nurse specialist inpatient diabetes services (Diabetes Care Workforce Service Review Team 2011).