Inpatient Management of Diabetes Mellitus
Diabetes is a chronic condition marked by high levels of glucose in the blood. It is caused either by the inability to produce insulin (a hormone produced by the pancreas to control blood glucose levels) or by the body not being able to use insulin effectively. Diabetes can lead to acute and chronic complications. In an acute hospital setting, high blood sugar (hyperglycaemia) can increase risk of infection and other adverse outcomes. Chronic high blood glucose levels are associated with long-term damage, dysfunction and failure of virtually every organ, especially the heart and blood vessels, eyes, kidneys and nerves.
One in 11 people aged over 16 in NSW has diabetes. A 2014 Australian hospital audit of point prevalence data demonstrated that one in four inpatients had self-reported diabetes. Diabetes accounts for 11% of all NSW public hospital hospitalisations with an average length of stay of 6 days (3 days longer than a person who does not have diabetes), which may be related to an increased risk of infection or other adverse outcomes consequent to inpatient hyperglycaemia or hypoglycaemia. Type 2 diabetes accounts for about 85-90% of diabetes hospitalisations in NSW.
What clinical processes need to change?
The ACI Endocrine Network and NSW Diabetes Taskforce identified the need to implement a state-wide approach to improve glucose management for patients with diabetes in hospital in order to improve patient experience; reduce adverse events and hospital length of stay; and avoid failed hospital discharge.
Glycaemic instability is commonly observed among inpatients with diabetes. Patients with diabetes are frequently admitted to hospital for treatment of conditions other than the diabetes. Therefore, insulin orders, administration and glycaemia management is the responsibility of general ward clinicians (including nursing staff and Junior Medical Officers), not just endocrinologists or in-hospital diabetes services. Additionally, access to specialist services and staff (including Endocrinologists and Diabetes Educators) is variable across geographical regions in NSW.
Insulin is a high risk medication. Error rates with insulin are not necessarily higher than with other medicines, but when problems do occur the consequences can be severe. The ACI Endocrine Network’s NSW Subcutaneous Insulin Prescribing Chart aims to enable standardisation of insulin management across NSW. However, a 2015 evaluation of the chart in four LHDs showed a “lack of awareness and understanding about components of current best practice in the management of people with diabetes outside of specialist endocrinology units”, suggesting that best practice insulin management is not occurring in NSW hospitals.
A NSW hospital found the introduction of the chart, with increased education of Junior Medical Officer and nursing staff, made a positive impact on the glycaemic management of inpatients with diabetes who were on subcutaneous insulin therapy in a tertiary hospital.
How LHDs achieve best practice with insulin management should encompass standardised elements, while also being flexible and based on local needs. Implementation options would require consideration of resourcing to support local implementation and service delivery. ACI is developing tools to support:
- Continuous improvement in inpatient diabetes care, such as local clinical audit cycles and a mechanism to benchmark key performance indicators across NSW.
- Enhanced the capability and/or capacity of general ward staff in the care of patients with diabetes.
- Timely and appropriate access to inpatient diabetes management teams for people with diabetes.
- Implementation of procedures for the safe and effective transfers of care for people with diabetes within hospital wards and across settings, which may include criteria-led discharge.
- Standardised identification and screening processes for patients with diabetes on presentation to hospital.
ACI support model
The following will be offered to support Local Health Districts with implementation of the change:
- Program of capability development to support staff in the provision of best practice care, specifically targeted toward Junior Medical Officers and general nursing staff, which will include resources for local implementation.
- Support to conduct local audits in partnership with sites, including provision of feedback.
- Change management support for teams implementing a quality improvement process, which may be linked to results of local audit.
 Centre for Epidemiology and Evidence, Health Statistics NSW (NSW), Sydney: NSW Ministry of Health. Available at: www.healthstats.nsw.gov.au. Accessed (8 December 2015). NSW Population Health Survey (self-reported).
 Bach LA, Ekinci EI, Engler D, Gillfillan C, Hamblin SP, MacIsaac RJ, Soldatos G, Steele C, Ward GM and Wyatt S (2014), The high burden of inpatient diabetes mellitus: the Melbourne public hospitals diabetes audit, The Medical Journal of Australia, 201(6), 334-338.
 NSW Admitted Patient Data Collection, presented by ACI Health Economics and Evaluation Team to NSW Endocrine Network (25 October 2016).
 Wong VW, Ho A, Fiakos E, Lau NS & Russell H (2016) Introduction of New South Wales adult subcutaneous insulin chart in a tertiary hospital: its impact on inpatient glycaemic control, Internal Medicine Journal, 1323-1328.
 Clinical Excellence Commission, Medication Safety and Quality: High Risk Medications. Available at: http://cec.health.nsw.gov.au/patient-safety-programs/medication-safety/high-risk-medicines. Accessed (16 January 2016).
 O’Connell Advisory (2015), Agency for Clinical Innovation Evaluation of the Subcutaneous Insulin Prescribing Chart in Four Local Health Districts, Final Report.