Rosemary Walker, BSc (Hons), RGN, FETC.
Partner, In Balance Healthcare UK, Suffolk
The recently published English National Service Framework for Diabetes (Department of Health, 2001; 2003) includes hospital care among its 12 standards to be achieved by the NHS by 2013: ‘All children, young people and adults with diabetes admitted to hospital for any reason will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes.’
The rationale for this is explained in the NSF standards document (DoH, 2001) and shown in Box 1.
For nurses, who have the responsibility for day-to-day management of people with diabetes in hospital, this standard is both a welcome spotlight on this area of diabetes care and a challenge to make diabetes care more effective.
Diabetes mellitus and aims of care
Type 1 diabetes occurs as a result of an auto-immune process that destroys the beta cells of the pancreas. This results in such limited insulin production that the only treatment is to replace it by daily injections.
In Type 2 diabetes insulin resistance and/or reduced beta cell function result in raised blood glucose levels. It is usually seen in conjunction with obesity, hypertension and hyperlipidaemia and, as a result, is thought of as a syndrome rather than a single condition (Williams and Pickup, 2000). Type 2 diabetes is primarily treated with attention to reducing calorie intake and increasing physical activity, with the eventual addition of oral hypoglycaemic medication and insulin, if necessary, to achieve good control. Type 2 diabetes is a progressive disease, eventually requiring several agents to control hyperglycaemia.
It is clear now that, in both types of diabetes, achieving good control prevents or delays the progression of the long-term complications of retinopathy, nephropathy and neuropathy (DCCT, 1993; UKPDS, 1998a). In Type 2 diabetes, maintenance of blood pressure at 140/80 or below significantly reduces the risk of heart attacks and strokes (UKPDS, 1998b).
Diabetes in hospital
People with diabetes occupy up to 16% of hospital beds, and diabetes treatment consumes approximately 9% of hospital costs (Audit Commission, 2000). Therefore nurses working in any hospital department will care for people with diabetes who have been admitted either for reasons directly connected to their diabetes or unrelated to it. Once diagnosed, diabetes is an inextricable part of a person’s life and must be taken into consideration along with their presenting condition. This is because diabetes control can be adversely affected by illness, stress and changes in food intake and activity levels (Williams and Pickup, 2000). Also, healing processes and well-being are promoted by normal blood glucose levels. Whatever the circumstances of a patient’s admission or attendance, the pursuit and maintenance of good diabetes control must always be a treatment goal.
The NSF states that people with diabetes are admitted more frequently and stay in hospital for longer than those without. Extended hospital stays are often due to the fact that their diabetes is not attended to because it was not the original reason for admission. Practical aspects of care can also delay discharge - for example, if a change in diabetes treatment is not reflected in medications the person is given to take home, causing last-minute delays. Discharge planning needs to include diabetes-related issues (see Box 2).
Although more research into the hospital care of people with diabetes is required (DoH, 2002), evidence already exists to show that hospital-based diabetes specialist nurses working with general nurses can significantly improve quality of care and reduce lengths of stay (Davies et al, 2001). The model suggested in the NSF is for hospital-wide protocols on the care of people with diabetes to be adopted and regularly audited. These protocols should include the care of people attending for day surgery and investigations, as well as those staying in hospital.
Principles of care for people with diabetes
Diabetes control - Evidence from the DCCT (1993) and UKPDS (1998a) shows that diabetes is optimally controlled when the HbA1c level - a measure of overall diabetes control - over the preceding six to eight weeks is around 7% and finger-prick capillary blood glucose levels are kept between 4 and 7mmol/l. Once the blood glucose level rises above 10mmol/l, platelet function is impaired, healing is compromised and an environment that encourages infection is created. In addition, hyperglycaemia will cause the person to experience uncomfortable symptoms of thirst, polyuria and blurred vision.
Illness, stress and inactivity all produce hyperglycaemia through the effects of counter-regulatory hormones, so these levels can be difficult to achieve in hospital. This means that medication may need to be introduced or adjusted to compensate and to keep blood glucose levels down. For example, someone with Type 2 diabetes normally controlled on oral hypoglycaemic agents who has been admitted with an acute infection may need an intravenous infusion of insulin to maintain normal blood glucose levels. Whatever the reason for admission, diabetes control must be optimised.
Monitoring diabetes control - In hospital clinical areas the most common means of monitoring diabetes is by capillary blood glucose monitoring (CBGM) using a small meter. The equipment used for testing should be properly maintained and operated only by staff who have received suitable training, in conjunction with manufacturers’ instructions and within a hospital policy.
The reason for testing in this way is that the results are used to adjust or maintain treatment to achieve good diabetes control. If adjustments are never made on the basis of CBGM, the tests are rendered useless. In acute situations, such as the management of ketoacidosis, monitoring may need to be done hourly. In less acute circumstances, such as on a long-stay ward for rehabilitation after a stroke, testing daily at different times may be sufficient.
Regular testing will enable the nurse to detect trends in blood glucose levels, which then need to be acted upon. Diabetes control can also be monitored by laboratory tests - for example, fasting blood glucose levels - or by HbA1c if an overall picture of blood glucose control is required.
Tablets and insulin - Most people with diabetes require some form of medication to help them control it. People with Type 1 diabetes need insulin therapy, and those with Type 2 diabetes may be on one or more of the following oral hypoglycaemic agents: sulphonylureas (gliclazide, glimepiride, repaglinide), biguanide (metformin), alphaglucosidase inhibitor (acarbose) and thiazolidinediones (rosiglitazone, pioglitazone). These classes of drugs have different actions and so are often used in combination with each other according to licence and National Institute for Clinical Excellence guidelines (NICE, 2002). People with Type 2 diabetes may also take insulin to supplement their oral medication. During their hospital stay, increased doses of insulin or tablets may be needed to overcome poor control as a result of their presenting complaint. It is important to remember that it may be necessary to reduce the dose again once they recover.
Timing of insulin and oral hypoglycaemic drugs is important to optimise diabetes control.
With two exceptions, insulin given more than once daily and tablets must precede food to ensure there is enough circulating insulin in the bloodstream to utilise glucose from the meal. The exceptions are metformin, which should be taken after food to limit possible gastric side-effects, and rapid-acting insulins and their mixtures, such as insulin lispro or insulin aspart, which can be given up to 15 minutes after eating (BMA/RPSGB, 2003). People with Type 2 diabetes often have a daily injection of intermediate or long-acting insulin at bedtime to limit overnight release of glucose from the liver and thus help prevent fasting hyperglycaemia. This may not need to be taken with food.
In the hospital environment insulin may be given via an intravenous infusion, either alone or in combination with a dextrose infusion and managed via a sliding scale in which insulin rate is titrated according to frequent CBGM. The most common indication for this is if the person is not able to eat or drink - for example, because of acute illness, unconsciousness or surgery. Box 3 lists tips for management of an insulin sliding scale.
Food and drink - People on insulin or sulphonylurea tablets are at risk of hypoglycaemia if they are not able to eat regularly. Eating on time, even in hospital, is therefore an important principle for this group. Those on other oral hypoglycaemics alone are not at risk of hypoglycaemia, but the regularity and amount of carbohydrate intake is still important, in order to keep blood glucose levels even. A small amount of food during the day and a large evening meal will ensure a high blood glucose the next morning. Extra consideration should be given to people requiring nutritional support, those who have a poor appetite or are underweight, for whom healthy eating guidelines would not apply.
The principles of food management for people with diabetes can be summarised as follows:
- Eat regular meals with carbohydrate making up approximately 50% of meals
- Limit intake of foods high in fat, salt and sugar
- Try to increase fruit and vegetable intake
- Nothing is ‘banned’, but some foods may need to be eaten less regularly than others.
A dietitian can help to explain these principles to both ward staff and people with diabetes - particularly those who are newly diagnosed during their hospital stay (Diabetes UK, 2003).
Promoting self-management in hospital
People who have had diabetes for some time are usually experienced in dealing with their condition and may find it hard to hand over its day-to-day management to hospital staff. While it is often necessary for changes to be made during a hospital visit or stay, the NSF (DoH, 2001) suggests that such people should be offered the chance to contribute to decision-making about their diabetes. This not only enables them to learn more about the condition but will also promote better self-care once discharged. In some circumstances, especially where the admission is for a long period and is not related to diabetes, patients may be able to maintain their own testing, tablet and insulin-taking much as they do at home and document this for the necessary hospital records. This concept of empowerment and mastery of the condition is increasingly promoted as a model of supporting people with chronic conditions such as diabetes (Walker, 2003).
Every nurse in every hospital department will have some contact with people with diabetes. Illness and stress can interact with the condition and cause blood glucose control to deteriorate. This in turn can delay recovery and may produce complications such as infection. Attention to maintaining good diabetes control is thus essential. Nurses can play a significant role in promoting this by providing up-to-date and evidence-based care and support.
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Davies, M., Dixon, S., Currie, C.J. et al. (2001)Evaluation of a hospital-based diabetes specialist nursing service. A randomised controlled trial. Diabetic Medicine 18: 301-307.
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Walker, R. (2003)How the NSF can promote the use of an empowerment model in practice. Diabetes Digest 2: 2, A7.
Williams, G., Pickup, J.C. (2000)Handbook of Diabetes (2nd edn). Oxford: Blackwell Science.