This month’s inpatient blog is written by Christina Lange, a Diabetes Specialist Nurse working in Hereford County Hospital since 2013. Christina leads the diabetes specialist nursing team which covers both the acute and community in Herefordshire. In 2019 Christina won the prestigious National Institute for Health Research (NIHR) 2019 Internship Pre-Doctoral Silver Scholar Award at the University of Nottingham.
I have always felt passionately about the importance of insulin safety, particularly in the hospital setting. It does not sit comfortably with me that it is an area where so much patient harm happens; when we should be supporting and caring for people with diabetes in a safe environment.
Sadly, over the years, I have heard concerning comments from both patients and clinicians regarding insulin therapy. Patients have told me: “They don’t listen to me. I told them I didn’t need so much insulin but they gave it to me and then I had a hypo.” And “I am so glad to see you. They don’t know what they are doing. I am scared to fall asleep and not be involved in my insulin decisions."
...And from clinicians: “Insulin scares me!” and “I don’t know much about insulin”. Whilst these experiences are alarming, there are also examples of good practices in hospital, and many clinicians who are confident and capable managing insulin therapy.
It is key that professionals working with insulin, from prescription to administration to dispensing, all feel competent and knowledgeable. However, we know the national picture shows we have many more improvements to make to ensure safe use of insulin in hospital.
Year on year, the National Diabetes Inpatient Audit (NADIA) highlights significant problems with medication errors experienced by inpatients with diabetes in particular. In 2017 almost 1 in 3 inpatients experienced such errors, and 1 in 25 inpatients with type 1 diabetes developed diabetic ketoacidosis during their hospital stay. This is a potentially life-threatening condition, and statistically the likelihood of developing it in hospital is greater than in the community, for patients with type 1 diabetes (NHS Digital, 2018). I find that such a shocking statistic – surely we can do better for these patients.
The inpatient team at Diabetes UK have asked me to share my top tips for healthcare professionals looking to improve insulin safety, with a focus on the inpatient setting. I’ve taken on that challenge and here they are:
1. Listen to your patient.
It’s likely they manage their insulin regime at home and know a lot more about it than you. If they are able and well enough to self-manage their insulin therapy then this should be supported and encouraged – find out your local policy on this.
2. Learn and remember the 6 Rs of insulin therapy:
Right patient, right insulin, right dose, right time, right device and right way.
3. Never omit the basal insulin and know your diabetes types.
We should not be using terminology such as insulin dependent diabetes as that does not tell us which type of diabetes the person has. In type 1 diabetes insulin omissions or delays can quickly lead to development of ketones and risk of diabetic ketoacidosis (DKA).
4. Get the basics right:
a. Glucose monitoring – this is key in insulin management. Understand what your patient’s glucose target range is and escalate glucose out of range appropriately and in a timely manner. Know the appropriate frequency of glucose monitoring – this will be different depending on the clinical scenario (eg sc insulin/IV insulin). Know when to consider checking for ketones.
b. Hypoglycaemia – we know hypos can happen, we want to prevent them as much as we can but treat them appropriately when they happen. Do you know your local hypo protocol? Do you know where the hypo boxes are kept? Are you ensuring the patient’s treatment is reviewed post hypo to prevent recurrent hypoglycaemia?
c. Diet – another really important part of diabetes management. Are we supporting patients to make the best dietary choices for them in hospital? Are we providing them with the carb content of meals for those that carb count for their insulin management? Are we thinking they may need extra snacks to prevent hypo?
d. Diabetes kit – there’s lots of it out there and increasingly more technology. From different insulin pens to insulin pumps to different glucose monitoring equipment: glucometers to flash and continuous glucose monitoring. Find out more about this and what can be used when. Also, if you are administering insulin to a patient – you must use safety needles.
5. Get to know who is in your local diabetes team:
When are they available, and how can you refer? We love early referrals and enjoy supporting you with your questions. We are all in this together for safer diabetes care in hospital.