Diabetes: A hospital perspective

Diabetes affects 7% of adults in the UK. Among hospital inpatients it is much more common. Adult hospital bed occupancy for people with diabetes varies with population and case mix. Percentages are often in the mid-teens and may exceed 20%.¹ Length of stay (LoS) for people with diabetes greatly exceeds that of non-diabetic patients as do emergency readmissions. Day case admissions are fewer. (Please see the National Diabetes Information Service website for details.²) Many admissions are preventable. Patient and healthcare professional education with specialist diabetes team support reduces emergencies and prevents escalation if any occur.³

People with diabetes report bad experiences in hospital (Box 1).⁴ People who manage their own condition find themselves forbidden to do so. Most illnesses or operations affect glucose balance, as can drugs and fasting. Hospital diabetes care is challenging, requiring expert specialist care. Yet patients are often managed by doctors and nurses with little knowledge of diabetes or awareness of the dangers. Patients, if not confused or too unwell, are usually better than staff at controlling their diabetes in hospital and should be allowed to. The National Patient Safety Agency has issued a mandatory alert ‘Safer administration of insulin.’ It states ‘a training programme should be put in place for all healthcare staf…expected to prescribe, prepare and administer insulin.’ See the NHS Diabetes training site.⁵

Box 1.

Comments from people with diabetes. Reproduced from the Diabetes UK survey.⁴

‘People with diabetes in hospital need the right expertise at the right time from a trained ward team supported by the diabetes specialist team.’ Diabetic inpatient specialist nurses reduce admissions from accident and emergency, reduce clinical incidents, shorten LoS and improve patient experience.³ Every acute hospital should have prompt access to a diabetes inpatient specialist team with dedicated inpatient sessions and access to all diabetic inpatients on all units. The Think Glucose programme to improve the care of people with diabetes in hospital, is available from the NHS Institute for Innovation and Improvement.⁶

People with diabetes are at risk of a wide range of complications in hospital many of which can be reduced by meticulous care (Box 2).⁷ On admission, or preoperatively check for complications, for example heart, kidney, neuropathy, foot, skin, eyes, infection. Promptly refer diabetic foot problems to the specialist diabetic foot team (see Putting Feet First).⁸

Box 2.

Risks for people with diabetes in hospital. Adapted from Reference 7.

Glucose control is important. Higher glucose levels (on admission or perioperatively) are associated with more complications. An early study showed benefits from intensive glucose control in critically ill patients but meta-analysis showed that this increased the risk of mortality and hypoglycaemia.⁹ Until clearer evidence is available the American Diabetes Association 2010 guidance¹⁰ is helpful: start insulin in critically ill patients with persistent glucose levels >10 mmol/l aiming for 7.8–10 mmol/l. For non-critically ill patients aim for pre-meal glucose of 4–7.8 mmol/l and a random level of 4–10 mmol/l. Avoid hypoglycaemia at all costs.

Other important measures are:

• ensure appropriate nutrition. Seek dieticians' advice

• check feet and heels daily. Use pressure prevention measures⁸

• wash hands

• insert cannulae cleanly. Check daily

• use dressing packs and gloves to view ulcers/wounds. Debride and dress them properly

• use the right antibiotic for appropriate duration.

• avoid methicillin-resistant Staphylococcus aureus or Clostridium difficile.

In summary, hospitals should have an inpatient diabetes specialist team, train all staff about diabetes, monitor and reduce insulin errors and ensure that glucose control and complications are checked on admission and throughout. Poor inpatient diabetes care is distressing, disabling and costly to all concerned. Much can be done to improve it.

• Royal College of Physicians