VOL: 98, ISSUE: 19, PAGE NO: 51
A.C. Felix Burden, MD, FRCP, is consultant diabetologist, Heart of Birmingham Teaching Primary Care TrustDiabetes UK receives many calls and complaints from people with diabetes about their inpatient stay. The Audit Commission was also concerned about this issue (Audit Commission, 2000). People with diabetes appreciate the help and care received on specialist wards but are often worried if they are admitted to non-diabetes wards. Their concerns lie with the perception that the nurses and doctors caring for them lack knowledge of diabetes.
Diabetes UK receives many calls and complaints from people with diabetes about their inpatient stay. The Audit Commission was also concerned about this issue (Audit Commission, 2000). People with diabetes appreciate the help and care received on specialist wards but are often worried if they are admitted to non-diabetes wards. Their concerns lie with the perception that the nurses and doctors caring for them lack knowledge of diabetes.
What sorts of problems are reported? First, nurses may take over diabetes care entirely so that patients are not allowed to undertake their own blood glucose testing, to self-inject and to make appropriate adjustments to their treatment. Postoperatively, patients may wake to find that they are on a sliding scale of insulin, apparently designed to keep their sugars high, with no routine review of insulin requirements and adjustment of the system. Their wishes are frequently not explored and they are often given little information about the plan of management.
There have been several attempts to try and improve the situation. One of the first was by Diabetes UK, which produced standards for inpatient care. The latest, What Diabetes Care to Expect (Diabetes UK, 1999), is available from their website at www.diabetes.org.uk, as are leaflets for patients.
These make a useful audit tool as well as informing both patients and health care workers. Issues are divided into routine diabetes care (outpatient care) and care while in hospital (Fig 1). There are also other specific inpatient issues that need to be addressed (Fig 2).
Audit of care
Each of the points listed in Fig 1 can be audited. Some should be easy to achieve. Others may be outside the control of a ward or group of wards - such as blood glucose-monitoring quality assurance systems. If they are not adequate, requests to improve them should be made by involving the laboratory and diabetes service.
A recent audit on pressure care highlighted the continuing problem that people with diabetes face, with insufficient nursing care given in hospital to prevent problems (Jackson et al, 2001). This is partly due to the lack of simple neurology testing or not realising the effect of neuropathy. Guidelines in print form may easily be lost - many hospitals therefore keep theirs online. They still require to be updated, however, at least yearly.
Methods to try and improve the situation
Diabetes UK has tried to improve care by patient empowerment - the development and distribution of What Diabetes Care to Provide is a direct attempt to do this. Other methods that have been tried include the following:
At least one nurse per ward should be educated to act as a link nurse. This can include formal seminars as well as informal meetings. There is no doubt that such systems can improve knowledge (Burden and Burden, 1993), but there are some difficulties with the link nurse philosophy. There may be a rapid turnover of staff, and link nurses must pass on the knowledge and information gained to other members of the team rather than just retain it for themselves.
In-patient diabetes nurse
Another system that has been tried and subjected to randomised control trial (Davies et al, 2001) and prospective audit (Cavan et al, 2001) is appointing a diabetes specialist nurse dedicated to the inpatient service. They work within set protocols, similar to those for outpatient insulin adjustment and provide education and back-up to the ward staff about particular patient requirements.
The first study (Davies et al, 2001) was a prospective, open, randomised controlled trial of standard inpatient care for adults with diabetes, with and without the intervention of a diabetes specialist nursing (DSN) service. Its aim was to evaluate the effectiveness and cost implications of a hospital diabetes specialist nursing service. Those studied were randomised patients referred to the hospital DSN service.
The primary outcome measures were length of hospital stay and patterns of readmission. Secondary outcome measures were subjects' diabetes-related quality of life, a diabetes knowledge score, satisfaction with treatment, GP and community care contacts following discharge and costs. The results are shown in Table 1 - only length of stay was significantly reduced.
In the second study (Cavan et al, 2001), the effect of a routine review by a diabetes nurse adviser was determined by the length of stay for medical and surgical inpatients with diabetes. This used a prospective cross-sectional observational technique with a historical control. Inpatients with diabetes were identified prospectively from January 1997 until December 1998 (792 in 1997 and 819 in 1998). A new post of diabetes nurse adviser was introduced in January 1998. The length of stay was calculated retrospectively from hospital computer records.
The results showed that the median length of stay was reduced by three days on medical and surgical wards (P <0.001). the="" bed="" occupancy="" by="" patients="" with="" diabetes="" fell="" from="" 6.8="" to="" 4.0%.="" at="" the="" same="" time="" the="" mean="" length="" of="" stay="" across="" the="" hospital="" remained="" unchanged.="">0.001).>
Diabetes specialist nurses are potentially cost-saving as they reduce hospital length of stay. There was no evidence of an adverse effect of reduced length of stay on readmissions, use of community resources or patient perception of quality of care.
The evidence from the health economics of this trial (Davies et al, 2001) suggested that, for a district general hospital, about £250,000 can be saved in terms of bed numbers, because of a quicker turnover.
Although the second study (Cavan et al, 2001) was not a randomised controlled trial and used historical controls, the conclusions support the first study (Davies et al, 2001). It is highly likely that inpatient length of stay, and hence costs, can be reduced by such a service. What was not clear was if the quality of care had improved. In any randomised controlled trial an issue such as quality of care may be masked by contamination of control subjects by nurses who have become more knowledgeable due to the intervention.
The dedicated diabetes specialist nurse can also act as a focus to training link nurses and the ward staff. However, holidays, absence due to sickness and study leave may pose a problem if only one nurse is given the task. It may be better to incorporate this function within the the secondary care diabetes specialist nurse's work.
What Diabetes Care to Expect can provide a framework for a structured questionnaire that a suitably trained diabetes adviser can use to question people with diabetes as to whether they need extra assistance. This is the system we have recently used with a nursing auxiliary acting as a diabetes adviser. She reviews people with diabetes who have routinely been referred, using an electronic template. If there are problems the nursing auxiliary cannot address she contacts the diabetes specialist nurse to see the patient.
The inpatient diabetes specialist nurse is on a development DSN programme because of the high likelihood of assistance being readily available from other diabetes specialist nurses and diabetes physicians if required. This also gives the trainee an opportunity to become familiar and more skilled with the acute problems likely to be faced.
All nurses should be comfortable dealing with people with diabetes because it is a common disease - affecting about 10% of elderly white people (Croxson et al, 1991), more of Indo-Asian and black descent, and the disadvantaged (Riste et al, 2001).
Care needs to be given when patients are unable to care for themselves, but then control must be given back to them at the appropriate time. This can also be an excellent opportunity for opportunistic education.
The way forward
It is hoped that the Diabetes National Service Framework (www.doh.gov.uk/nsf/diabetes/) will recommend a complete package incorporating the aspects I have described. All nurses should have the opportunity to be updated about diabetes, using the link nurse system, but with additional teaching, when needed, from the diabetes inpatient team - including a diabetes adviser.
If nurses were allowed to prescribe insulin and modify sliding scales in accordance with protocols this would improve care even more. Each hospital will have a quality-assured blood glucose monitoring system with audit and regular checks to ensure that the information gained through blood testing is used appropriately.
People with diabetes will be allowed to self-adjust treatments, self-test if they so wish and equally, will be (at their request) able to have the test performed for them.