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HOSPITALS are not designed to empower patients with diabetes to continue to manage their own disease, a situation that can lead to iatrogenic harms such as under- and overdosing with insulin, say experts.
Professor Greg Johnson, CEO of Diabetes Australia, told InSight+ that people who have a good handle on their diabetes should be empowered to play a crucial role in managing it in hospital.
“But often our hospitals aren’t designed that way. They take things away from people and just do things to people,” he said.
“Diabetes is something that people manage themselves at home. They administer their insulin, adjust their dose each day according to their diet and exercise. You go into hospital and all of that is taken away. It’s very challenging.”
Professor Johnson was responding to research published in the MJA, which found that diabetes is often poorly managed in Queensland hospitals, although as much as a quarter of admitted patients have the disease.
The Queensland Inpatient Diabetes Survey (QuIDS) found management deficits that included “high rates of hospital-acquired diabetic ketoacidosis (8%), hypoglycaemia (9.5%; 6.0 episodes per 100 patient-days), and diabetes medication errors (32%), and low rates of achieving glycaemic targets (59 good diabetes days per 100 patient-days), particularly in patients treated with insulin”.
The research was undertaken in 2019 and included 27 of 115 public hospitals that provide acute inpatient services. There were three components to the audit: hospital characteristics, a bedside audit, and a patient experience survey.
One of the study authors, Dr Peter Donovan, was not surprised by the results.
“We know that when people with diabetes are hospitalised, it’s a high risk time for them,” he said.
“If they’re unwell or their meals are being missed because they’re unwell or the meals are different, then their sugar control will not be as good.”
Australia is not alone with these challenges. Many of the results were similar to audits in England and Wales during the National Diabetes Inpatient Audit (NaDIA).
“The proportions of patients subject to diabetes medication prescription and management errors were similar (NaDIA, 31%; QuIDS, 32%), with similar rates of prescription and glucose management errors. However, we identified a substantially higher proportion of patients with insulin errors (NaDIA, 18%; QuIDS, 137 patients, 39%),” the authors wrote.
The insulin dosing errors were of particular concern, according to Professor Johnson.
“Right now, we have around 460 000 people in Australia who use insulin every day. Those people are using technologies like insulin pumps, continuous glucose monitoring devices, insulin pen needles – new, smart ways to deliver insulin. When they get admitted to hospital, often their ability to use those devices and to administer their own insulin is taken away from them.”
Many patients with diabetes aren’t in hospital because of their disease and are there for another health issue. As a result, the medical practitioners in charge of their care are experts in their own field, but not necessarily in diabetes.
The researchers suggest a solution to this is to expand the accessibility of specialist diabetes teams working with patients with diabetes while they are in hospital.
Dr Donovan said some studies have found specialist diabetes team in hospitals can reduce complications.
“There aren’t any specialist diabetes teams in Queensland that deal with inpatients like this. That might be a step forward, although they are an expensive resource.”
Diabetes teams are interdisciplinary, with specialists including an endocrinologist, allied health and nursing staff trained in diabetes management and mental health support.
Professor Johnson said specialist teams were a good solution.
“The specialist team needs to be consulted and called in to make sure the diabetes management is not disrupted, so we don’t get overdosing or underdosing of insulin and the problems that come with that.
“We don’t want to do harm in hospital,” he said.
A statement from Queensland Health said the department was committed to providing better support for people living with chronic conditions such as diabetes. They acknowledged that specialist diabetes teams were one way of providing better care.
“Team care from clinicians experienced in diabetes care is one aspect that can enhance the lives of people with chronic diseases including diabetes,” the spokesperson wrote.
There has been some excellent work from individual hospitals across the country, said Professor Johnson.
“I can say confidently in every state, we’ve seen really good examples of individual hospitals and services that have done great work in recognising these problems and trying to improve them.
“The issue with that is it’s not across every hospital, it’s not systematised. From a public perspective and a system perspective, we want to get it scaled up,” Professor Johnson said.
If the hospitals could even just cater for the diet. I have just been given apple juice on a CF diet only and refused broth.
The community are ultimately the funders and the beneficiaries of our healthcare system. They deserve a system that works with and for them. In the community > 95% of diabetes care is self management, supported by healthcare providers. Yes, care in hospital is often complex and needs greater health provider input, but out of respect for the fact that those affected by diabetes have insight into their own care preferences and needs, this should still be about partnership between those with diabetes and those providing their care.
It is the very multifactorial nature of influences on blood sugar level of ill inpatients in hospital which demands the more widespread use of continuous blood glucose monitors during this period.
And dare I mention the elimination of unnecessary sugar from the hospital menu – specifically offering our diabetic patients ice cream and commercial fruit juice.
It’s somewhat disappointing to read dichotomous representations of inpatient diabetes care as either entirely the physician’s domain or entirely the patient’s. I would have thought the last half century has lead us to an understanding that the best possible medical care can come from collaborative decision-making where the best elements of the physician’s expertise and the patient’s self-experience can come together to optimise diabetes care. Of course the intubated unconscious patient relies entirely upon the physician’s judgement regarding their BG management but by the same token I defy a physician without diabetes to carbohydrate count more accurately than an engaged person with type 1 diabetes who does this multiple times per day.
Inpatient diabetes care, just like outpatient care, does not and should not be an all-or-nothing phenomenon.
What a load of rubbish! Of course glycemic control is worse when people are sick, fasted, in pain, stressed, and not in their own home environment.
Rather than a specialist diabetes inpatient team, perhaps our Level 4 service could have a diabetes educator and an endocrinologist?
It’s certainly true that “admission for stabilisation” can be counterproductive – in the absence of an acute cause. Hopefully, this is no longer happening. There is also a lot more than tweaking medications in T2DM management – lifestyle coaching, including overall diet (not just sugars and fats) and physical activity should be emphasised in a community environment.
For the acutely unwell diabetic, or those undergoing surgery, however, Greg is correct – there are too many influences on BSL and too many interacting factors.
Patients may be very skilled at managing their diabetes when they are well, but do not have formal medical or diabetic training. In hospital, they may be fasted for x-rays, procedures or operations, they may have superimposed reactive hyperglycemia due to pain, fever or corticosteroids, and they may be receiving medications such as narcotics or anesthetics which can impact on their clarity of thought. Also, their renal or liver function can change acutely when they are unwell and impact on the safety of their usual oral hypoglycemic drug therapy. That is why it is unsafe to allow patients to self-manage their diabetes in hospital. Every patient, at the point of hospital admission, should have a decision made as to which doctor or clinical team is going to supervise their inpatient diabetic care.
Empower them ? Sure, like actually bothering to take their meds at all ? Or bother to check their blood sugars?
A 2019 Diabetes Case for Change in NSW found that only 5% of people being treated in NSW Hospitals have diabetes as a primary diagnosis. A significant number of people are admitted to hospital for the complications of diabetes (circulatory, digestive, kidney, eye, foot and respiratory system issues) or for other care (surgery, birthing, etc).
While specialist diabetes teams are an important feature of care for people with diabetes, the number of people in our hospitals with diabetes requires that more clinicians than just this (often) small specialist diabetes team are confident in the management of diabetes, insulin and other treatments.
As part of the Leading Better Value Care program in NSW Health, the Agency for Clinical Innovation and NSW Diabetes Taskforce have developed Thinksulin, a clinical decision support app that supports junior medical officers (JMOs) to deliver best practice insulin management. But the use of such decision support tools need not just be targeted at JMOs.
Any clinician responsible for the prescription and administration of insulin can access information and decision support on blood glucose level targets, hypoglycaemia management, blood glucose monitoring, basal-bolus insulin regimen calculations, charting and dose review.
As silos exist between services and across settings, there are opportunities such as Thinksulin that help to integrate care modalities, that are interdisciplinary and can be delivered across care settings.