Inpatient diabetes care: first do no harm?

The Hippocratic oath is one of the oldest binding documents in history. Medical practitioners traditionally took the oath to safeguard the interests of those whom they treated – a key element being to “prescribe treatments for the good of my patients according to the best of my ability and my judgement and never to do harm, nor give a lethal drug to anyone…” In this article we ask just how well does inpatient diabetes care match to the aspirations of Hippocrates. Inpatient care of patients with diabetes accounts for around 9% of annual NHS hospital expenditure. This is likely to be an underestimate, as the diagnosis of diabetes is omitted from around 1 in 5 discharge summaries1 and, moreover, there is considerable variation in the “depth” of coding between different acute Trusts.2 The latest QoF data for 2006-07 gives a diabetes prevalence of 3.75% for England (which probably underestimates the true prevalence by up to 50%). Meanwhile, the prevalence of both Type 1 and Type 2 diabetes has been increasing and is expected to continue to do so.3 The proportion of hospital inpatients having diabetes is thus now around 12-15% in our own Trust. Despite the high prevalence of diabetes in the western world and the significant increase in hospital admissions, it remains poorly understood by non-diabetic specialist hospital staff.1,4 Both hospital admission rates and length of hospital stay are substantially greater for people with diabetes.5 This may, in part, be inherent to the condition itself – for example, people with diabetes develop more extensive myocardial damage, with more complications, following myocardial infarction.6 However, suboptimal management of diabetes on non-specialist wards may also be a contributing factor. In one study the introduction of care pathway prompting appropriate referrals to the diabetes specialist team resulted in shorter length of hospital stay.7 Most inpatients with diabetes are not admitted as a result of their diabetes and will not be cared for by clinicians with specialist diabetes expertise. Analysis of completed consultant episodes for diabetes in Newcastle upon Tyne Hospitals for 2007-8 identified that only 41.1% of these were in medical, elderly care, cardiology, respiratory and renal wards. Thus, even taking the most generous interpretation of which clinicians have the skills to deliver inpatient diabetes care, the majority of patients do not routinely receive even this level of specialist clinical oversight. As the disease prevalence continues to grow, demands on inpatient care for patients with diabetes will have a significant impact on overall cost which is estimated at 3.5 billion per year to the National Health Service.1 Streamlining the delivery of care within individual acute Trusts will need to be recognised. Although diabetes is a chronic condition, its management in hospital affects every part of the organisation, with implications for patient experience, governance, efficacy and outcomes.

‘For the good of my patient’

The 2007 Healthcare Commission National Survey of People with Diabetes questionnaire challenges the notion that we are “doing good” for hospital inpatients with diabetes. It identified they are often unhappy about the management of their diabetes while in hospital. Some 30% reported that staff were unaware of their condition and 10% complain they get no help with diabetes care in hospital. Only 24% reported that they had access to the diabetes team.8 Diabetic inpatients often know more about managing their condition than the staff looking after them, and a manifest lack of understanding of their condition evidenced by hospital staff may lead to patients losing confidence in their overall care. A review of our Trust’s patient safety and incident data involving the care of diabetes patients for 2007-08 indicated that 85% of reported errors involved insulin prescribing. These include wrong doses, confusion with insulin types, poor documentation and failure to follow protocol. This is not unique to our Trust and has been replicated in other centres.9,10 Fifty-eight per cent of reported incidents came from the surgical wards and/or during peri-operative care. The medical wards accounted for 20% of reported incidents. The remainder of errors occurred in the maternity and paediatric wards. The majority of these incidents could be addressed by improving the understanding of diabetes care by staff caring for these patients. A significant proportion of these incidents could also have been avoided had specialist input been requested earlier. A recent national survey in the UK reflected on the high levels of clinical risk inherent in the management of inpatient diabetes care and acknowledged the important contribution made by the diabetes specialist team to inpatient care.11