Encouraging inpatients to self-manage diabetes

In 2010 the Joint British Diabetes Societies (JBDS) started publishing guidelines for managing inpatients with diabetes; the newest guidance in the series on self-management of diabetes in hospital has just been published (JBDS Inpatient Care Group, 2012). The guiding principle is that “people with diabetes manage their condition on a day-to-day basis when out of hospital, and should continue to self-manage during a hospital admission unless there is a specific reason why they cannot” (JBDS Inpatient Care Group, 2012). 

There are nine main recommendations:

• Provide written information explaining staff and patient responsibilities.
• Agree the circumstances of self-management, which is signed by both parties.
• Agree a preoperative care plan for elective surgical admissions.
• Regularly assess the person with diabetes’ clinical condition and ability to self-manage.
• Refer to the diabetes team where necessary.
• Encourage the self-monitoring of blood glucose and sharing of test results.
• Encourage people with diabetes to record their insulin doses on their drug charts.
• Ensure that appropriate meals are provided, including their timings.
• Ensure that there are ward facilities for safe insulin storage.

Disempowerment in hospital is a regular complaint among people with diabetes (Diabetes UK, 2007), so it is hoped that implementation will improve inpatient satisfaction and also lead to better glycaemic control and fewer insulin errors. 

It is important to note that self-management means that people with diabetes in hospital should administer their insulin and adjust doses appropriate to their blood glucose levels, activity levels and food consumed, while self-administration means that individuals give themselves their insulin on advice from medical staff. 

So what will be involved for diabetes teams? The guidance comes with a patient information leaflet, information for healthcare professionals and an agreement to sign. However, implementing other recommendations will be more involved. While it should be assumed that people managing diabetes at home are capable of doing so in hospital unless prohibited by their presenting condition, it is important for diabetes teams to ensure that healthcare professionals on the ward are capable of assessing this. This may mean increasing knowledge of insulin devices and dose adjustment among ward staff. 

It should also be made clear that self-management does not automatically preclude the need for a diabetes referral. People can fall into bad habits without realising. If a self-managing individual has erratic glycaemic control, it would provide an ideal opportunity for the diabetes inpatient specialist nurse (DISN) to review the individual’s management and address any educational needs. 

Self-monitoring of blood glucose could prove controversial because the recommendation is that people with diabetes should continue to use their meters, but most hospitals will have a contradictory policy stating that only hospital-approved, quality-controlled meters are used. It should be possible to overcome this, but it must be clarified that these individuals are taking responsibility for all their care. If glycaemic control deteriorates or they become unable to self-manage, staff should only use hospital meters. However this is overcome, the diabetes team must ensure there is agreement with existing point-of-care testing committees or biochemistry departments to ensure that all patient safety requirements have been fulfilled. 

Pharmacists play an integral role in successful implementation. They will no doubt want to take a lead role in ensuring that drug charts are suitable for people with diabetes to document insulin doses and that facilities are available for safe storage of insulin. Dietetic departments should be able to provide information on the carbohydrate content of hospital meals. Diabetes teams should engage all members of the multidisciplinary team at the beginning of the implementation process.

These new guidelines should prove useful for improving patient satisfaction and safety. DISNs should champion their implementation, remembering that success is likely to depend on the diabetes team’s ability to involve all other implicated hospital departments.