Quality Standards for Diabetes Care Toolkit

Clinical appropriateness to self-monitor and manage own insulin

People with diabetes admitted to hospital should be given the choice of self-monitoring and managing their own insulin as appropriate to the person with diabetes. Patients who are alert and demonstrate accurate insulin self-administration and glucose monitoring should be allowed to self-manage insulin as an adjunct to standard nurse-delivered diabetes management (Riethof et al 2012).

Introduction

The Quality Improvement Plan (Ministry of Health 2008) identified that people with diabetes tend to have more hospital admissions, stay longer and are more likely to be readmitted than those without diabetes. Inpatient costs for diabetes are high. For example, in the 2005/06 financial year there were 778 hospital admissions for diabetic ketoacidosis (DKA), which cost over $2 million. DKA admissions had increased by 25% over the five previous years (Diabetes Care Workforce Service Review Team 2011).
Patients with diabetes comorbidities and complications should have access to teams of multidisciplinary experts in diabetes. In the real world, however, teams are rare. An individual nurse or outpatient nurse specialist is often the only resource, and the contribution of the inpatient diabetes nurse to patient management and quality assurance has not been universally appreciated. A good system of care, including patient assessment and education, can be maintained through multidisciplinary cooperation, inpatient diabetes resources, and common goals. Tools and supporting education can be and have been the responsibility of dedicated inpatient diabetes nurses and dietician specialists. Care pathways, standardised assessment tools, and readily available teaching materials can provide guidance in practice (Nettles 2005).
There are three general hospital models to diabetes management:

1. A consultant approach, where the specialised diabetes services are invited by the admitting team to assist with the specific patient’s diabetes management.

2. A systematic hospital-wide diabetes programme that improves the identification of inpatients with diabetes and enhances the diabetes management skills of all staff through education and implementation of guidelines. The responsibility of managing the inpatient with diabetes remains with the admitting team.

3. Through a multidisciplinary team approach, with the role of the inpatient diabetes team varying from an advisory role to active management of the patient’s diabetes for all people with diabetes, and commences at the time of the patient’s admission.

The third model has been shown to reduce the average length of stay and medical costs following intervention by an inpatient diabetes management team that primarily involves a specialist diabetes nurse (Australian Diabetes Society 2012).
The UK Diabetes Inpatient audit revealed people with diabetes did not receive timely input from a diabetes specialist team and only 54.4% of inpatients with diabetes were seen by an expert team that should have been seen (National Health Service [NHS] 2011). The National Inpatient Diabetes Audit (NaDIA) examines data about inpatients with diabetes collected by hospital teams in England and Wales on a nominated day in a defined week in September. It covers issues such as staffing levels, medication errors, patient harm and patient experience. The 2013 audit involved 14,198 patients with diabetes in 142 trusts in England and six local health boards in Wales. In 2014 the repeated audit shows large gaps in care remain:

Over a fifth (22.0%) of patients with diabetes in hospital would have experienced a largely avoidable hypoglycaemic episode in hospital within the previous seven days.

One in 10 (9.3%) would have experienced a severe hypoglycaemic episode.

One in 50 (2.2%) required injectable treatment due to the severity of the hypoglycaemia.

This is despite the fact that only 8.1% of respondents had been admitted for their diabetes or a diabetic complication.

More than a third (37.0%) of patients with diabetes experienced a medication error, down from 39.9% in 2011.

Patients who had experienced a medication error were more than twice as likely to suffer a severe hypoglycaemic episode (15.3%) compared to those with no error in their medication (6.8%).
For more information: www.hscic.gov.uk/4806.
As well as providing expert clinical input to the care of people with diabetes whilst in hospital, clinical nurse specialists should be available for the education of general nurses and medical staff (Brooks et al 2013). Delayed involvement of specialist diabetes services, along with inappropriate diabetes management and poor blood glucose control are factors that all contribute to increased lengths of stay and poorer outcomes for the inpatient with diabetes (Australian Diabetes Society 2012).
The literature clearly demonstrates cost savings and reduced lengths of stay for inpatients with diabetes who had access to diabetes specialist inpatient service versus no access or traditional models of care (Australian Diabetes Society 2012; Davies et al 2001). The diabetes specialist team can play a pivotal role through teaching, training and support, to ensure that other members of staff are able to facilitate the pathway. Any increased costs associated with resourcing specialist teams to provide inpatient care, are offset by the savings through reduced lengths of stay, reduced rates of complications and overall reduced health care costs associated with inpatient care (Kerr 2011; NHS 2011).
A dedicated inpatient diabetes team raises the quality of care for patients, enhances patient and professional education and lowers the incidence of prescription and management errors (Brooks et al 2011). Pharmacist input prior to discharge improves adherence to medications (Shah et al 2013).
Resulting conclusions drawn from preliminary analysis of data from the Diabetes InPatient Length of Stay (DipLoS) study undertaken in three New Zealand District Health Boards (Auckland, MidCentral Health and Lakes) found the following:

Diabetes in patients admitted to hospital is even more common than recognised previously.

The Virtual Diabetes Register is far more complete, sensitive and accurate than previous admission coding for diabetes.

There is a major unmet need for inpatient advice, at least in Mid-Central and Auckland. The interventions were perceived as excellent but unsustainable by the nursing teams.

Diabetes is associated with (but not necessarily causative of) increased lengths of stay.

Delay in initial referral to diabetes teams is potentially a major cause of delay in discharge.

Simple prioritisation of inpatient work is ineffective.

Automated referral methods, without waiting for manual referrals, are effective in reducing delays in seeing patients and may prove effective in reducing the length of stay (Drury 2011).