Speeding discharge: The role of the inpatient DSN

The author has been a DSN for 12 years. She initially worked at Wycombe General Hospital and Amersham General Hospital before it merged with Stoke Mandeville Hospital to become Buckinghamshire NHS Hospitals Trust in 2005. There are approximately 500 acute hospital beds across the three sites. Her role is now primarily in inpatient diabetes care, striving to improve quality of care and patient safety. 

Patients with diabetes are referred by all members of the multidisciplinary team for assessment by the inpatient DSN, and sometimes by the individuals themselves. Referrals are made regarding education, sliding scale transfer and insulin initiation for individuals with poor glycaemic control, and also regarding other discharge difficulties related to diabetes (Box 1). The patient is assessed, a plan implemented, and a review then made on an individual basis. Follow-up care is also planned post-discharge. 

Non-medical prescribing is an important competency to ensure effective delivery of care. The author typically sees 10–16 individuals daily. Some of these will be initial assessments and some of them will be review. The Trust includes the National Spinal Injuries Unit as part of its remit and, therefore, inpatient stay can be lengthy and complex. 

The role of the inpatient DSN has evolved and developed significantly in the past few years since the appointment of the first one in the early 1980s. Evidence from a national audit in 2006 (Sampson et al) shows that DSNs are still not available in all hospitals, despite the recommendations of standard 8 of the National Service Framework for diabetes (Department of Health [DH], 2001). This framework and NHS Diabetes both focus on specific parameters that need to be targeted to achieve these aims (National Diabetes Support Team, 2005). 

There is no doubt that the introduction of non-medical prescribing has had a significant impact on diabetes inpatient care, which supports the DH’s (2001) vision that this introduction would provide easier access for people requiring medication at the point of care, reducing delays in treatment changes and optimising the use of trained nurse skills, especially in the care of a long-term condition such as diabetes. 

Much has been written in the literature about the impact of the inpatient DSN’s input on reducing length of stay (Cavan et al, 2001; Sampson et al, 2006). There is now evidence that non-medical prescribing for inpatients can also help reduce length of stay (Courtney et al, 2007). The author’s diabetes team has developed the “Quick Access to the Community” (QAC) discharge scheme, which aims to get people with diabetes home and visited by the community DSN within 24 hours of discharge. Poor glycaemic control should not be a reason to delay discharge once the appropriate medical team has assessed the individual as medically fit for discharge.

Non-medical prescribing
The introduction of non-medical prescribing in 2001 has had a significant effect on enabling effective, appropriate and timely prescribing for people with diabetes at the point of care. However, the fact that it was originally introduced within the confines of a clinical management plan caused problems. This involved arranging a three-way agreement between DSN (the supplementary prescriber), the doctor or dentist (the independent prescriber) and the patient. A doctor’s signature was required to support the nurse (supplementary) prescriber, and made it virtually impossible to make changes to in-patient prescription charts without a lengthy process. As James (2005) states: “as nurses, we found it frustrating as we felt we had the confidence and competence to prescribe in our own right”. 

Among the benefits for people with diabetes, James (2006) demonstrated that non-medical prescribing resulted in “fewer delays in treatment, prompt treatment changes, fewer prescribing errors and an enhanced role for people with the condition in the decision-making process”. Supplementary prescribing was implemented with the aim of achieving these benefits, but it was unwieldy and inadequate in its execution. 

Independent prescribing
In 2006, independent prescribing was introduced and suitably qualified inpatient DSNs could now prescribe appropriate oral antidiabetes agents and insulin therapy for patients (as well as other medications related to their diabetes). It also supported the DH’s (2006) requirements of an initial patient assessment, interpretation of that assessment, a decision on safe and appropriate therapy and a process for ongoing monitoring.

DSNs could now prescribe in a timely manner in the ward environment – using the right people, with the right skills at the right time. It also supported the DH (2000) initiative for “one stop care”. DSNs could now prescribe for patients after a thorough assessment of medical, psychosocial and socioeconomic factors on an individual basis. A suitable plan for therapy could be initiated and therapy changed as necessary. The advent of non-medical prescribing also contributed towards achieving standard 8 of the National Service Framework for diabetes (DH, 2001). 

There is evidence that people with diabetes do not always receive appropriate care in hospital, and insulin therapy in particular (Flanagan and Baggott, 2008). These authors also recognised the need for meal and insulin injection timing to be coordinated. More disturbing is the misunderstanding of the importance of good glycaemic control (Penfold et al, 2008), and the lack of confidence in modifying diabetes pharmacotherapy in the TOPDOC study (George and McKay, 2009). 

The National “Think Glucose” campaign is striving to improve diabetes care for inpatients, and states that “it should be no more acceptable for acute Trusts to be lacking an effective glycaemic control policy than it is for infection control or patient consent”. The campaign specifically targets insulin administration as a major cause for concern. Furthermore, insulin prescribing errors have been identified at Parliamentary level, and June 2009 saw the Westminster Health Forum Keynote Seminar Diabetes: Quality of Care and Patient Safety (awaiting publication).

Length of stay
Length of stay in hospital for people with diabetes is an area for concern. It is well-recognised that people with diabetes are twice as likely to be admitted to hospital than those without the condition, and stay twice as long as those without diabetes. 

One in ten patients in an acute hospital is likely to have diabetes (DH, 2001). As the number of people with diabetes continues to increase, it is apparent that the inpatient population with a diagnosis of diabetes will also get larger. 

Buckinghamshire Hospitals NHS Trust encompasses three district hospitals, and a local inpatient audit performed from 25 February to 21 March 2008 identified 17% (n=119) and 11% (n=132) of patients as having diabetes as a primary or secondary diagnosis, respectively. There is evidence, however, that independent prescribing by the inpatient DSN can reduce length of stay of these individuals, as well as reduce insulin and oral hypoglycaemic agent prescribing errors (Courtney et al, 2007).

Quick Access to the Community scheme
Evidence of the reduction of length of stay when inpatient DSNs intervene is well supported (Cavan et al, 2001; Sampson et al, 2007), as has the impact of independent nurse prescribing (Courtney et al, 2007). 

The QAC referral pathway developed in the author’s locality enables early discharge to the community DSN. The ability of the inpatient DSN to assess, implement and follow-up treatment changes means patients are prescribed therapy on an individual basis. 

Follow-up after discharge is undertaken by the community DSN rather than the district nurse. Reducing the need for referral to district nurses is important, as their workload has increased dramatically in recent years. It also ensures timely and coordinated specialist diabetes nursing support. 

In the author’s area, the community DSNs have been part of the secondary care diabetes team, which has promoted good communication and liaison across primary and secondary care. Despite being the inpatient DSN, the author is able to undertake domiciliary visits for those individuals with diabetes who have been recently discharged, if the need arises.

Conclusion
Inpatient diabetes care continues to be both challenging and rewarding. As the number of patients with diabetes continues to increase, the role of the inpatient DSN continues to be key in helping to deliver high-quality care. Non-medical prescribing enables appropriate and safe therapy adjustment by the inpatient DSN, which can enhance the patient’s experience and result in a shorter journey from admission to discharge. The local QAC pathway supports this care, and the Think Glucose campaign should further promote good diabetes inpatient care.