Over a million people with diabetes were admitted to hospital in England in 2017. 92% of them were not admitted because of their diabetes. A hospital stay for a person with diabetes can be a frightening experience and it is easy to understand why. In 2017, an estimated 9,600 people required rescue treatment following a severe hypoglycaemic attack. 2,200 people suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin . We can and must do better for people with diabetes in hospital.
We need to stop working alone and start learning from each other. Below are examples of good practice in diabetes inpatient care from across the UK.
Use the following resources and tools to improve inpatient and hospital care for people with diabetes:
- Making hospitals safe for people with diabetes (October 2018) (PDF, 1074KB)
- Self-assessment checklist (October 2018) (PDF, 509KB)
Our report has been developed through conversations with people with diabetes, diabetes inpatient teams, healthcare professionals working in hospitals and hospital managers. It highlights the challenges facing diabetes inpatient services and shows what should be in place in all hospitals. We know fully resources, proactive diabetes inpatient teams and an educated inpatient workforce lead to improved patient satisfaction and shorter lengths of stay. We also know that when proper systems are in place, healthcare professionals can manage their workload better and make sure they are prioritising those most in need. Change can be difficult but with the right support and team structures it is possible.
- Adapting the Ipswich Touch Test to increase foot risk assessments at the Royal Free Hospital, Diabetes UK (August 2016) (PDF, 173KB)
This bright idea describes how the Royal Free Hospital created a foot risk assessment tool based on the Ipswich Touch Test. Since introduction of the tool, the percentage of people with diabetes who received a foot risk assessment on admission increased from 6.5 per cent in 2013 to 40 per cent in 2015.
Download the tool featured in the bright idea (PDF, 42KB).
- Joint British Diabetes Society: guidelines for inpatient care, Diabetes UK website
- NHS Digital: National diabetes inpatient audit results, NHS Digital website
- Diabetes Think, Check, Act resources, Health Improvement Scotland website
- Inpatient care for people with diabetes: The economic case for change (PDF, 10,597KB)
- The NHS Getting it Right First Time (GIRFT) programme website
- All Party Parliamentary Group (APPG) website: The future of diabetes inpatient care report
- NHS RightCare pathway: Diabetes
- Diabetes Quality in Care website: award winners
- Example business case for diabetes team (PDF, 557KB)
- NCEPOD report- Perioperative Diabetes: Highs and Lows
Shared practice examples
Engaging and training frontline staff
Ruth Miller, Diabetes UK Clinical Champion, developed a training programme when she observed that many diabetes inpatients have their care delivered by non-specialists. Since introduction of the training at Poole Hospital, medication errors have reduced from 46.9 percent in 2015 to 26.7 percent in 2016.
DiAppbetes provides concise guidance notes that cover a wide variety of key themes. The app can be downloaded and edited for different hospitals.
Diabetes back to the floor involves periodic diabetes care quality review at ward level followed by formative feedback to staff.
- Inpatient diabetes education tool for doctors in training (INDIE), Leicester Diabetes Centre website
INDIE forms the basis for a blended inpatient diabetes educational tool which includes a web based educational resource (including knowledge survey, links to educational material and guidance.)
Inpatient Diabetes Education through Animation – (IDEA) involves a series of short cartoons based on real life scenarios, developed by trainee doctor, Sowmya Gururaj.
West Suffolk NHS Foundation Trust have incorporated simulations into their training for frontline staff to consolidate their knowledge and skills around hypoglycaemia.
E-learning training modules
- Diabetes in healthcare (free, log in required) – an introductory diabetes education tool for healthcare professionals covering Type 1 and Type 2 diabetes
- Six steps to insulin safety (free, log in required) – an essential module for all those prescribing, managing or administering insulin, with the overall aim of reducing insulin errors in clinical practice
- Think, Check, Act e-learning modules, NHS Scotland quality improvement hub website (free, login required)
- Secondary care, education for general staff, diabetes education Scotland website (free)
Managing DKA and Hypoglycaemia
Dr Parijat De, Consultant in diabetes and endocrinology and Diabetes UK Clinical Champion, piloted a condensed version of the original DKA management and monitoring chart developed by the JBDS-IP committee.
This factsheet has been designed by Southampton Hospital for patients experiencing DKA.
- Innovative use of ward glucose systems to reduce inpatient hypoglycaemia, Ipswich Hospital (Word, 27KB)
The DICE (diabetes inpatient care and education) team optimised use of their blood glucose monitors to identify trends in hypoglycaemia and introduced new initiatives to reduce levels.
Pocket medic and Diabetes UK Clinical Champion, Dr Sam Rice, have created a video to help health care professionals recognise and treat hypoglycaemia.
Insulin safety, electronic prescribing and improving self administration
- Self-administration of insulin in hospital: a guide to support Trusts through the implementation process, Wessex Academic Health Science Network website
This guide supports Trusts through the process of setting up safe and robust arrangements for routine self-administration of insulin. Part 1 helps Trusts to make a case for change and Part 2 provides step by step guidance on how to implement and measure self-administration of insulin throughout a hospital.
- Insulin self-administration: Development of an assessment tool to empower hospital inpatients with diabetes
At University Hospital Southampton, an electronic review process has been developed to assess whether patients are able to self-administer insulin and to ensure that their suitability is continually reviewed. This process has been piloted in four wards with great success and is due to be rolled out across the Trust.
- Patient assessment flowchart (PDF, 200KB)
- Patient information sheet for self-administration (PDF, 199KB)
This project aims to improve the experiences of patients on insulin in hospitals, the education of Foundation Doctors who write most of their insulin prescriptions, and the appropriateness of the prescriptions they write. It uses the SMAC2 reflective tool to help insulin prescribers develop 'situation awareness'. SMAC2 empowers prescribers to acknowledge when they are uncertain. It encourages them to seek information and supplement their personal resources by involving patients, fellow professionals, and seniors.
- Improving the management of inpatients on insulin, Harrogate and District NHS Foundation Trust (PDF, 23KB)
A multi-disciplinary group was created to develop a programme of work to improve the safe use of insulin.
- Derby inpatient improvement project (DIPS) (PDF, 407KB)
The Derby Insulin Safety Group introduced change at multiple levels to improve the standards of all aspects of diabetes care in the hospital.
To improve patient care and safety the diabetes team trialled a new way of working in the Clinical Decision Unit.
In Sheffield, the pharmacy team led a series of projects to increase the number of people able to self-manage in hospital. This resulted in a change of policy permitting patients to keep insulin in their possession and to continue self care
This guide developed by the Health Innovation Network (HIN) sets out recommendations using validated tools to help improve insulin safety on discharge
- Improving in-hospital awareness of different insulins – insulin profile sheet, Lister Hospital (JPEG, 3.28MB)
- Insulin Profile poster, University Hospital of Leicester NHS Trust (PDF, 257KB)
- NHS Improvement, Risk of severe harm and death due to withdrawing insulin from pen devices. Patient safety alert, NHS Improvement website
Seven day working
- A seven day diabetes service for inpatients and the emergency department in an acute hospital setting, Future Hospital Journal Website
This case study describes how the East and North Herts Diabetes Outreach Team (DOT) introduced seven day a week access to diabetes specialists for inpatients.