The ongoing challenge of inpatient diabetes

People with diabetes are admitted to hospital twice as often and stay twice as long as those without diabetes. At least 10% of all hospital beds in the UK are occupied by someone with diabetes (Currie et al, 1996), and many of these individuals are unhappy with the standard of diabetes care they receive (National Diabetes Support Team [NDST], 2008). Major concerns are loss of self-management, insulin and blood glucose testing equipment being taken away, concerns about the knowledge and skills of healthcare professionals and poor access to the diabetes team (NDST, 2008). 

The National Service Framework for diabetes (Department of Health, 2001) highlighted the importance of caring for people with diabetes when they are ill and in hospital, and tasked acute Trusts to develop protocols for the management of diabetic emergencies, and to educate healthcare professionals. Inpatient DSNs were seen as key to the process. However, 7 years later, some Trusts still do not have a dedicated inpatient DSN, and the management of inpatients with diabetes remains a challenge. 

More recently, NHS Diabetes developed a care pathway for people with diabetes requiring hospital admission (NDST, 2008). This pathway identifies seven characteristics of good diabetes care:

• A clear focus on the patient experience: providing information on what care to expect, encouraging self-care and early discharge planning.
• Early identification of people with existing diabetes and those newly diagnosed with the condition: a system of flagging people with known diabetes and those with abnormal blood glucose results, close liaison with pre-assessment services to avoid unnecessary cancellation of procedures. 
• Assessment: comprehensive and standardised assessment of patients’ diabetes needs, including documentation of current medication, individualised care plans and appropriate referral to the diabetes team.
• Development of clear care pathways, particularly for the management of hypoglycaemia, hyperglycaemia and insulin. 
• Effective use of the inpatient diabetes team, including appropriate referral of people, and easy access to the team for ward and community-based staff. 
• Staff education: this may include encouraging reflective practice and ward-based coaching. 
• Commissioning and planning: diabetes specialist teams need to be involved in strategic development.

Achieving all of this is a hefty task, and for many diabetes specialist teams will involve the development of new skills and knowledge – particularly when working with commissioners. 

At Aintree University Hospitals NHS Foundation Trust, we currently have over 800 beds. Therefore, on any one day there are likely to be, at a conservative estimate, about 80 people with diabetes occupying beds. With 1.8 WTE inpatient DSNs, this is a heavy workload. Our link nurse project has been reasonably successful, with 20–30 nurses attending the sessions every 4 months. In addition, we have recently set up our own “Think Glucose” group, with the aim of identifying where the gaps in our service are, reviewing existing guidelines, developing new guidelines and working closely with other departments such as the medical assessment unit and cardiology. We are on our way but there is still much to be done. 

In this issue, Amanda Veall and Kim Bull describe a competency-based education project for nurses in acute Trusts. The project involves the use of self-directed learning packs and self-assessed competency. The project proved to be a success; however, the team do not have any protected time to develop the project any further. NHS Diabetes acknowledges that if staff education is to be successful, organisations need to commit to protected time and auditing effectiveness.   

In September of this year, NHS Diabetes are planning a national audit day. The audit aims to raise awareness of inpatient activity, identify gaps and empower the diabetes team to lead change locally. I would encourage as many acute Trusts as possible to take part. Further information can be found on www.diabetes.nhs.uk.