Rising to the challenge of inpatient care

In September 2009, over 200 acute Trusts took part in the first ever National Diabetes Inpatient Audit arranged by NHS Diabetes. This was an arduous task, and involved a good deal of organisation and communication with the staff involved (both in the diabetes team and ward-based staff). At Aintree Hospitals NHS Trust we rose to the challenge and organised (in an almost military style!) a group of enthusiastic members of the diabetes team supported by a group of unsuspecting medical students.

The audit took most of the day and staff gave up their time around clinical commitments. We revealed a 16.4% (125 patients) incidence of diabetes across the Trust. This is a rise from 7.1% in 1990 (Masson et al, 1992) and 11.1% in 2003 (Wallymahmed et al, 2005). The audit highlighted several areas of concern: inappropriate use of glucose–potassium–insulin regimens, poor management (or no management) of hypo- and hyperglycaemia and inappropriate capillary blood glucose monitoring. However, areas of good practice were also identified, and we will pass on this good practice.

On the day of the audit our inpatient DSNs were aware of only 25 (20%) of the 125 patients identified as having diabetes, and many of those not known to the service had been in hospital for several days and were in need of specialist advice and intervention according to our referral criteria. Despite our concerns, however, inpatients with diabetes appeared to be generally satisfied with their hospital care on the day of the audit.

Admission to hospital can be a stressful experience, and often people do not know what to expect. In December 2009, Diabetes UK published a new information booklet containing comprehensive information on what care people with diabetes should expect before, during and after a stay in hospital. The document highlights the importance of individual care planning before an elective admission and during an emergency admission. The care plan should be available to hospital staff and the person with diabetes, and should include the following:

• An explanation of planned investigations and procedures.
• How to contact the diabetes team.
• How hypo- and hyperglycaemia will be managed.
• How blood glucose levels will be managed.
• Information about self-care, dietary and cultural needs.

People with diabetes are encouraged to be involved in their own care (where appropriate), and this includes self-management of hypo- and hyperglycaemia. Detailed information is given on self-monitoring of blood glucose, access and timing of food, and the document even includes a checklist and record card.

In this issue of the journal, Javed et al (page 56) describe the problems associated with inpatient diabetes management in their local area – many of these issues are common to acute Trusts throughout the UK. It is disturbing and, unfortunately, not surprising, that 45% of people with diabetes on medical wards did not have a blood glucose (venous or capillary) measurement recorded on admission, and in 42% of patients, hyperglycaemia did not prompt a change of treatment. The authors have now implemented a number of changes and plan to reassess on an annual basis.

Diabetes teams need to use the Diabetes UK patient information booklet and the results of the audit (to be presented at the Diabetes UK conference in March this year) as drivers to improve inpatient care. However, there will be resource implications – not only in terms of availability of specialist teams to review inpatients, but also, for example, in assisting pre-admission assessment teams in developing individualised care plans for people with diabetes. Once again we will endeavour to rise to the challenge!