Author: Marina Davis
In leading the work of the NSW Diabetes Taskforce*, I’ve heard both positive and negative patient stories of care, visited many services across NSW, and consulted with a range of clinicians (from Endocrinologists and Diabetes Educators; to general nursing staff and Junior Medical Officers).
Unfortunately, Joan’s story highlights a not-so-good experience:
Joan** is a 74 year old woman who lives alone and presents to emergency in the middle of the night with shortness of breath.
Joan has Type 2 diabetes (requiring insulin) and a number of other comorbidities. She is assessed and admitted to the ward under a General Physician for further investigation.
While in hospital, Joan experiences many more episodes of hyper- and hypoglycaemia than she usually does at home and senses that her care team lack the knowledge and confidence to manage her diabetes and insulin requirements. Her experience of care is poor. She watches people come and go, and wonders when it will be her turn to leave the hospital.
When she is discharged she is confused by all of the information she has received, including medication changes for her diabetes.
Joan ends up staying in hospital for eight days. She is deconditioned and not feeling her usual self. She continues to have ups and downs and has difficulty with her day to day activities.
Like Joan, most patients with diabetes will present to hospital for a reason not directly related to their diabetes. When we don’t consider how we care for a person with diabetes the admission can become complicated, leading to poorer patient outcomes and more time spent in hospital.
Put simply, how a person’s diabetes is managed while they are in hospital really matters. It matters to the person receiving care and their family; it matters to the people that work in hospitals providing care; and it matters to the health system more broadly.
We know from studies that as many as one in four patients have diabetes. Many patients will require insulin. Insulin is a high risk medication meaning that when errors do occur the consequences can be severe.
While this post mainly focuses on care provided ‘on the wards’, I was recently reminded by a member of our Taskforce that most of the care a person receives for their diabetes is at home, by the person themselves. Regardless of the part of the health system we work in, I encourage all of us to take the time to consider the role we can play to enable this.
The health system in which we work is currently moving from traditionally-measured volume aspects of care, to one that measures value – value in terms of the experience and outcomes that matter to patients. As a health change manager, I’m excited by the current opportunity we have to make a real difference to the outcomes and experience of people living with diabetes, including (but definitely not limited to), hospital care.
We (patients, clinicians, and managers) have agreed that change needs to happen, and we have developed an approach for this to occur. By following these principles, we can encourage care to be delivered in a way that supports patients:
- Standardise approaches to identify and screen patients with diabetes, to better understand who is a higher risk of glycaemic instability during their inpatient stay.
- Identify high risk patients, to better facilitate timely access to specialist care, including education
- Recognise that not all patients with diabetes will require specialist care. If we can enhance the capability of the workforce (including Junior Medical Officers) in best practice diabetes management, we can reduce errors and other acute complications, further improving patient experience
- Aim to safely and effectively transfer care back to community, which will allow us to keep care closer to a person’s home
- By implementing continuous improvement processes, we can monitor and measure the ongoing effectiveness of our care strategies and determine where changes need to be made
If you have a role in caring for people with diabetes, you have an important role in this change, and the Agency for Clinical Innovation via the NSW Diabetes Taskforce can support you.
In caring for a person with diabetes, some of your responsibilities will include: taking history; prescribing medication, including insulin; adjusting insulin doses; managing hypoglycaemic and hyperglycaemic episodes; and listening to the patient as an expert in their own care.
One of the Taskforce’s aims is to help you feel that you have the knowledge and confidence to effectively manage a person’s diabetes in line with best practice. The Taskforce’s In-Hospital Working Group and Education Reference Group (made up of a number of Junior Medical Officers) are currently developing a suite of tools and resources to assist in the delivery of best practice diabetes care.
A quick overview of these tools includes:
1. A Point-of-Care Clinical Decision Support Tool (Smart Phone App)
This will provide information and decision support to JMOs on blood glucose level targets, hypoglycaemia management, blood glucose monitoring, basal-bolus dose calculations, and charting and reviewing doses.
Once developed, the app will be available for download on Google Play and the App Store.
2. eLearning Program
The eLearning Program will include a series of videos and accompanying (not too long) modules with knowledge checks. The initial topics that will be covered include: insulin basics, managing hypoglycaemia; and safely prescribing and administering insulin. Each module will work through patient scenarios and be available on desktop, tablet and smartphone via My Health Learning (for NSW Health staff), and ACI Moodle (for non-NSW Health staff).
3. Q-Stream Solution
Q-stream uses game design and game components to engage Junior Medical Officers in learning. The Q-Stream solution will include short scenario-based questions with text and images via the Q-stream application. These questions will be designed to reinforce key messages from the eLearning Program.
Q-Stream will be available to those Junior Medical Officers who complete the eLearning Program.
Let’s think about Joan again, and how her experience and health outcomes could have been different, if we understood and considered the management of her diabetes and felt confident to do so!
The theme of Diabetes Awareness Week this year is ‘it’s about time’ – think about what this means for you on the wards…
- Timely identification?
- Timely referral?
- Timely access to care?
- Less time spent in hospital?
- Time to reduce insulin dose errors?
From where I sit, and for others in the ACI Networks and Taskforce, it’s time for change – we all play a role and I encourage you to join us.
If you would like to learn more about the activities of the NSW Diabetes Taskforce, or would like to join an ACI Network, contact Marina via email [email protected].
*The NSW Diabetes Taskforce is a partnership between the ACI Endocrine and Chronic Care Networks.
**Joan’s story is a representative scenario.
Type 2 diabetes with Professor Ian Caterson
Diagnosing diabetic ketoacidosis (DKA) with Dr Barbara Depczynski
Perioperative management of diabetic patients with Dr Barbara Depczynski
Obesity with Professor Ian Caterson
BSL Management with Associate Professor Glynis Ross
Perioperative management of insulin dependent diabetes with Dr Sara de Menezes