Education: Initiatives to further improve diabetes care

I have recently been reflecting on my career in diabetes nursing, a career that now spans over 24 years; during this time there have been many changes in the way diabetes care is organised and delivered. When I first started working in diabetes, the management of glycaemic control in type 2 diabetes was far less complex than it is today; initial treatment was basically sulphonylureas (specifically glibenclamide at that time) for normal-weight individuals and metformin for those with a body mass index >25 kg/m². Insulin was kept in reserve only for those with the poorest control, with many viewing it as the “last resort”. DSNs focused only on glycaemic control, and much of my time was spent seeing individuals in their own homes.

Nowadays the role of the DSN has expanded to areas such as the management of cardiovascular and renal disease, pump therapy and painful neuropathy. While there is no doubt that home visits are resource-intensive, their value cannot be dismissed as much can be gained by seeing individuals in their own home environment. My heart sinks when I hear that some services are “not allowed” to do home visits; thankfully, in our service we still have the capacity to offer home visits when the need arises.

Another major change in diabetes care has been the relatively recent focus on the care of hospital inpatients with diabetes. The major impetus for this appears to have been the publication of the National Service Framework for Diabetes (NSF; Department of Health, 2001), which includes two standards specifically aimed at inpatient diabetes: managing diabetes-related emergencies and providing effective care while in hospital (standards 7 and 8). Following publication of the NSF, the number of inpatient diabetes nurses has increased, and the role has emerged as a subspecialty in its own right.

The annual National Diabetes Inpatients Audit is now well-established (Health and Social Care Information Centre, 2012), and in 2011 the audit involved approximately 12 000 inpatients with diabetes from 230 hospitals across England and Wales. Approximately 15% of all hospital beds audited were occupied by a person with diabetes, with approximately 10% of these being admitted to hospital specifically for the management of their diabetes. Thankfully, compared with the 2010 audit, there were improvements in all domains related to medication errors, including prescribing the incorrectly named insulin (6.4% in 2012 versus 10.7% in 2010) and the use of the abbreviation “u” for units (7.6% in 2012 versus 13.4% in 2010). These improvements may be as a result of initiatives such as “The safe use of insulin” education module, which is mandatory in some trusts, and possibly wider use of electronic prescribing, which eliminates the need to include units. However, there is no room for complacency as approximately one-third of individuals included in the audit experienced at least one medication error while in hospital.

By August of this year acute trusts and PCTs have to implement the “insulin passport” (National Patient Safety Agency, 2011). The aim of the passport is to provide individuals and healthcare professionals with important, up-to-date information about insulin prescriptions; the accompanying patient information leaflet alerts individuals to issues related to insulin safety (available from www.diabetes.nhs.uk). Thus increasing awareness of the potential problems related to insulin injections and facilitating self-administration (where appropriate) may lead to a reduction in insulin errors.

This supplement includes two articles focusing on the importance of diabetes education. Samantha Davies and David Coppini share their experience of developing an information leaflet for individuals with neuropathic pain, an often under-reported and under-treated complication of diabetes. They stress the importance of reporting symptoms and discussing realistic expectations of treatment. The management of hypoglycaemia is often a challenge for hospital staff; in their article, Jackie Mac Mahon Tone and Diarmuid Smith discuss the introduction of a “hypo box” and highlight the need for ongoing education following the introduction of any new initiative.