THE TRANSITION from medical student to fully qualified doctor with responsibility for patients is a major step. The fear that you might do something wrong that injures or kills someone is frequently present. Evidence shows that managing diabetes is one of the most likely ways in which that might happen and yet it is relatively straightforward to prescribe safely and effectively and improve care for patients with diabetes. Here are some facts and handy tips to help you to help your patients.
The size of the problem
Diabetes is a common long-term condition and is significantly over-represented in hospital patients. Whilst around 4 per cent of the UK population have diabetes, around 15 per cent of hospital inpatients are known to have diabetes. The vast majority (86.7 per cent) are admitted as an emergency and once they are admitted, the average length of stay is eight days, three days longer than the typical stay for all inpatients.
Patients may be admitted either as a direct consequence of diabetes complications, such as short-term glucose disturbances including ketoacidosis or hypoglycaemia, or due to long-term complications such as foot disease or renal failure, or for an unrelated matter with diabetes in the background. Therefore, diabetes patients can be found in every hospital specialty from neonates to geriatrics and surgery to psychiatry.
What goes wrong?
Whilst the management of diabetes with tablets can be fraught with pitfalls – such as the need to always stop metformin treatment before any contrast radiological procedure including CT scans or angiograms – it is insulin prescription and adjustment where the most significant problems tend to be found. According to a recent audit of inpatient diabetes care in England and Wales over one-third of inpatients with diabetes experienced at least one medication error during their admission. On closer inspection a quarter of their charts had prescription errors and a fifth had one or more medication management errors. Excess amounts of insulin can result in potentially fatal hypoglycaemic episodes (‘hypos’) and insufficient insulin can lead to diabetic ketoacidosis (DKA) which, if unrecognised and untreated, can also prove fatal.
The audit found that patients with medication errors had more than twice the rate of hypoglycaemia (18.1 vs 7.9 per cent) than those without definite prescription errors. Although the fact that nearly 8 per cent of patients had hypos in hospital with the “correct” insulin prescription is also a little alarming to us. Perhaps even more worryingly, 0.4 per cent of the inpatients surveyed developed DKA and 2.4 per cent had hypoglycaemia severe enough to require injectable treatment such as glucagon or IV dextrose (only ever use 5 or 10 per cent and never 50 per cent dextrose to treat hypoglycaemia).
What can we do to reduce these errors?
As an extension of the Scottish Patient Safety Programme, and the results of this audit, a new initiative, Think Glucose, is being piloted in a number of Scottish hospitals. The campaign aims to improve diabetes care in hospitals, particularly insulin management, delivering the right insulin to the right patient at the right time. It promotes the self-management of insulin by patients (when appropriate), reducing the likelihood of incorrect prescriptions by doctors, details the times when patients should and should not be referred to hospital diabetes teams, particularly diabetes specialist nurses, and includes clear accountability for monitoring of diabetes, ensuring that corrective measures are taken for inappropriately low or high blood glucose levels.
As the FY doctor you can do your part in a number of simple ways:
• Always ask the patient how much insulin they take for a given meal. Not every patient gets their diabetes right every time but they generally have more experience than you. However, beware of the patient with a high glycated haemoglobin result who claims to take a large insulin dose as they may not take this dose for every meal.
• If the patient is not self-managing then ensure that insulin doses are written up at least one meal in advance. That way it can be given at meal times so there is no delay that might increase the risk of glucose disturbance. There is no need to wait for the blood glucose level to prescribe insulin.
• If the glucose is low or high it is the corresponding dose that precedes the abnormal level on the next day that should be adjusted. This is particularly true for breakfast insulins which should always be prescribed by the end of the previous working day. If a glucose level is high or low find out why. Did the patient miss a meal for a diagnostic test or have they been eating or drinking inappropriate foods or drinks? If so, the insulin may not need to be adjusted at all but that situation remedied.
• Learn how to recognise and treat hypoglycaemia appropriately.
• Become familiar with commonly used insulin in your area and their time actions.
• Most hospitals have a diabetes specialist nurse who looks after inpatients with diabetes. Find out how to contact them and don’t be afraid to ask them for advice. Early referral to the diabetes nurse can aid earlier discharge.
• Follow the national DKA protocol and make sure patients on long-acting insulins still get them whilst on IV insulin infusions. Overall, simple steps can ensure that diabetes patients, particularly those on insulin, have a safer time in hospital, which also speeds recovery and reduces length of stay, improving everyone’s quality of life.
Dr Matthew Young, consultant in diabetes and acute medicine
Janet Barclay, diabetes specialist nurse, at the Royal Infirmary of Edinburgh