Reducing hospital admissions for people with diabetes: What can be done?

It is a well-established fact that people with diabetes are more likely to be admitted to hospital than the general population and, once admitted, length of stay is increased. In England, approximately 16% of all hospital beds are occupied by a person with diabetes, although prevalence rates can be as high as 25% (Health and Social Care Information Centre [HSCIC], 2013). On the day of the National Diabetes Inpatient Audit in 2013, only around 8–9% of hospital admissions of people with diabetes were specifically for the management of diabetes (HSCIC, 2013). This is encouraging as it indicates that the majority of people with diabetes are able to manage blood glucose problems themselves or with the help of their diabetes care team; however, it is estimated that over £2 billion per year is spent on inpatient care for people with diabetes and this represents about 11% of the NHS England inpatient expenditure (Kerr, 2011).

Once people with diabetes are admitted to hospital, every effort should be made to ensure that their hospital stay is as short and as safe as possible. The National Diabetes Inpatient Audit in 2013 reported that 37% of inpatients with diabetes experienced at least one medication error during their hospital stay (HSCIC, 2013).

Admissions to hospital can be avoided by easy access to advice from DSNs (Evans et al, 2012). In this 12-month prospective study, the authors responded to 5703 telephone consultations, including 235 calls for sick-day advice (103 with ketonuria) and 304 calls for advice and education about hypoglycaemia. The group report huge potential savings from admission avoidance. Many of us offer a similar service but we do not always have the same level of data to support avoidance of hospital admissions as this group.

In December 2013, the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) published a document, Admissions avoidance and diabetes: guidance for clinical commissioning groups and clinical teams. This document is aimed at clinical commissioning groups and senior management in UK acute trusts and stresses the importance of integrated diabetes care. The document includes 16 recommendations covering a wide range of diabetes care, including:

• Commissioning a service model based on adequate diabetes inpatient nurses and diabetes specialist sessional time to improve various aspects of diabetes care, including elective procedures and “front door” care in accident and emergency departments.
• Commissioning a diabetes service that identifies individuals who are frequently re-admitted with diabetes-specific problems and supporting them with intensive education and access.
• Commissioning a service that is associated with a lower rate of admissions with diabetic ketoacidosis.  Such a service includes: access to collaborative pathways; access to structured education and  intensive education on insulin management; and access to specialist advice, blood ketone testing and an open access phone line.
• Commissioning an adolescent and transitional service that identifies high risk individuals with type 1 diabetes.
• Commissioning a hypoglycaemia management pathway in collaboration with ambulance trusts.

This document is useful reading and presents many challenges, including access to 24-hour advice for people with diabetes. The Journal of Diabetes Nursing is keen to hear from any services that are funded to provide a 24/7 advice line for people with diabetes.

This education section focuses on two important areas of diabetes care: hyperosmolar hyperglycaemic state (HHS) and self-administration of insulin in hospital. Joy Williams and Anne Claydon discuss the Joint British Diabetes Societies (JBDS) 2012 guidelines on HHS, which is a life-threatening condition, often poorly understood. In addition, in an article from my own Trust, we discuss the challenges involved in introducing a training programme to support self-administration of insulin. Please do get in touch if your centre has implemented a similar programme.