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Empowering inpatients with diabetes: how to improve safety and reduce errors

Enabling self-administration of insulin recognises patients as experts in their own care

Enabling self-administration of insulin recognises patients as experts in their own care

  • National Diabetes Inpatient Audit shows 260,000 people with diabetes experienced medication errors in hospital in 2017
  • Better support in hospitals for people to take ownership of their diabetes is crucial to improvements in patient safety, says charity Diabetes UK
  • You don't need specialist knowledge to assess whether a patient can manage their diabetes - one trust's on-the-spot training takes only five minutes
Ilustration highlighting he elements involved in day-to-day management of diabetes
Picture: iStock

Being admitted to hospital can be a frightening prospect for people with diabetes, with research showing high numbers of medication errors with the potential for serious harm or even death.

The charity Diabetes UK says that better support in hospitals to allow people to take ownership of their diabetes is crucial to improving patient safety.

This includes being able to self-administer insulin in hospital, where appropriate.

‘We’d had negative feedback about patients’ sense of disempowerment... They would be managing normally at home and then come into hospital, we take over and mess it up’

Nicola Davies, lead diabetes specialist nurse, North Bristol NHS Trust

Its report Making Hospitals Safe for People with Diabetes, published in October 2018, says patients expressed 'fear' over not being able to self-manage their condition while in hospital and having their insulin taken away from them on admission: 'On too many occasions they felt those caring for them did not understand their needs and that they weren’t listened to.’ 

One patient commented: ‘I was not given the ability to make my own decisions about my insulin and was made to follow instructions given by healthcare professionals who did not specialise in diabetes.’

Diabetes in the UK: the figures

  • Inpatient diabetes care costs the NHS £2.5 billion, according to the charity Diabetes UK
  • One in six hospital beds is occupied by someone with diabetes – this is predicted to rise to one in four by 2030
  • More than one million patients with diabetes were admitted to hospitals in England in 2017, but for 92% it wasn’t because of their diabetes
  • People with diabetes have longer-length hospital stays – 1-3 days more than those who don't have the condition. Mortality is also 6.4% higher
  • More than one fifth of hospitals in England and Wales have no diabetes inpatient specialist nurses, despite the fact that inpatient staffing levels for almost all diabetes professions are increasing, says the National Diabetes Inpatient Audit (NaDIA) 2018, published in May 2019. Running since 2009, NaDIA measures the quality of diabetes care provided to people with diabetes while in hospital for any reason. Data is collected and submitted by hospital staff in England and Wales
  • In 2017, 260,000 people with diabetes experienced a medication error in hospital that could have resulted in serious harm or even death, according to the NaDIA audit from that year, which asked additional questions about patient experiences
  • The same year, 58,000 people with diabetes who were admitted to hospital had an episode of severe hypoglycaemia, and an estimated 9,600 needed rescue treatment after falling into a coma
  • One in 25 people with type 1 diabetes experienced hospital-induced diabetes ketoacidosis, as a result of under-treatment with insulin, the audit found. ‘This should not happen in hospital,’ the Diabetes UK report Making Hospitals Safe for People with Diabetes says. ‘Diabetes inpatient teams have expressed grave concerns that little is being done to address diabetes errors because, put simply, patients don’t always die’

 

Trusting patients’ competence to self-administer

Specialist pharmacist Victoria Ruszala, who has type 1 diabetes, works with North Bristol NHS Trust diabetes and endocrinology team. As part of a project that began at the trust in 2015, she has worked closely with lead diabetes specialist nurse Nicola Davies and other members of the nursing team to implement major changes, enabling patients to self-administer unless there were compelling reasons why they shouln’t.

‘The main premise is we assume competence,’ says Ms Ruszala. 

Previous policies on self-administering medications were rigid, with patients needing to prove they knew what they were taking, and nurses observing them counting out doses.

‘My feeling, as a patient and a professional, was that it was never done, because it made everyone’s lives so miserable and was far too complicated,’ she says. ‘Here the question is: are you competent or are you not?’ 

This approach is based on guidance produced by the Joint British Diabetes Societies for Inpatient Care Group, called Self-management of Diabetes in Hospital. It says: ‘People with diabetes manage their condition on a day-to-day basis when out of hospital, and should continue to self-manage during a hospital admission, unless there is a specific reason why they cannot. 

‘The choice to continue to self-manage during admission, if well enough to do so, should be the patient’s.’

Inpatients with diabetes who meet the criteria for the programme are able to self-administer insulin with a pen device
Inpatients with diabetes who meet the trust’s criteria are able to self-administer insulin
with a pen device Picture: Science Photo Library

Backing from senior nurses from the outset

After clarifying nurses’ responsibilities with the Nursing and Midwifery Council, Ms Ruszala took the idea to the trust’s senior nurses first, to gain their support from the outset. 

‘Because we’d done our homework, the conversation was simple,’ Ms Ruszala recalls. ‘They were happy and could recognise the benefits for their teams. 

‘We know that insulin can be given badly and there are lots of errors. Anything that could lead to a reduction in those mistakes, and improve the patient experience, was in line with the trust’s priorities.’

Exclusions from self-administering

In day-to-day practice, the trust has two criteria that exclude patients from self-administering. The first includes those who do not do it at home and may have come into hospital for a reason related to their diabetes, and those who have severe co-morbidities that prevent them from self-managing their diabetes. 

There may also be a temporary exclusion for someone admitted due to trauma, undergoing surgery or newly diagnosed and in need of more support. 

‘If you don’t fit in either of these categories, you should be allowed to do it,’ says Ms Ruszala.

Steps to improve safety in diabetes care

Based on conversations with diabetes inpatient teams, healthcare professionals working in hospitals, hospital managers and people with diabetes, Diabetes UK recommends the following steps and requirements to ensure that people with diabetes are safe in hospital:

  • Establish multidisciplinary diabetes inpatient teams in all hospitals Estimates show that investing £5 million in diabetes inpatient specialist nursing services in 54 trusts could save around £14 million a year, according to the charity’s report
  • Improve support in hospitals for people to take ownership of their diabetes, with support to self-manage where appropriate
  • Create better access to systems and technology, with all hospitals able to identify on admission patients with a diabetes diagnosis
  • Increase support to help hospitals learn from mistakes
  • Strong clinical leadership from diabetes inpatient teams
  • Invest in knowledgeable healthcare professionals who understand diabetes, with training provided to all nursing students and trainee doctors on the important aspects of inpatient diabetes care

 

Pilot study and concerns over storage of insulin

After gaining senior nurse support, the team carried out a pilot study with patients at a renal centre, giving them a concentrated cohort. ‘They had never been allowed to self-administer before, so initially they were quite bemused,’ says Ms Ruszala. But it proved highly successful, with patients welcoming the initiative.

‘Trying to make sure that everyone had heard the message was a big part of introducing it’

Victoria Ruszala, specialist pharmacist in North Bristol NHS Trust’s diabetes and endocrinology team

Among the early sticking points was whether or not insulin would be allowed to be stored in a patient’s bedside locker, with suggestions that the Care Quality Commission (CQC) would insist all medicines must be locked away securely. The team sought advice from other trusts and discovered that this was not the case, providing risk assessments had been done and there was a specific local policy. 

‘We asked the CQC to confirm this and they did,’ says Ms Ruszala. ‘We managed to fix this, simply by speaking to the right person.’

Simplifying their processes was also crucial to the project’s success. This included removing vials and insulin syringes for the most part, with the pharmacy supplying insulin pen devices instead, cutting down on variability. This change also helped nurses to remember that insulin stays in the patient’s own locker. 

‘You can say to nurses, put the vial the patient is using in their locker, but in reality everyone puts them in the fridge,’ says Ms Ruszala. ‘Changing to a pen device made it the patient’s pen, so it stayed with them.’

Training and assessments to administer the new initiative 

Training a large number of people working shifts across various locations was another challenge. ‘Trying to make sure that everyone had heard the message was a big part of introducing it,’ says Ms Ruszala.

Some nurses were worried that they would be expected to become experts in managing diabetes. Ms Ruszala explained that the assessment they were being asked to make was like many others they made as a matter of course – it did not require specialist knowledge.

‘We all know the patients who can dress themselves and those who definitely can’t – and if someone starts putting their pants on their head, then you need to call for help,’ she says. ‘Nurses soon realised they weren’t in charge of diabetes, but simply assessing whether their patient was safe to manage themselves. It overcame their fears that they didn’t know enough about diabetes to do this – we’d faced a lot of that.’

Patients carry the insulin pen with them, removing the need for staff to ensure they are kept securely
The insulin pen stays with the patient, removing the need for staff to ensure their medication
is kept securely in a locker Picture: iStock

In time-pressured environments, they were conscious that information must be delivered quickly and to the point. ‘Our on-the-spot training is five minutes max,’ says Ms Davies. ‘Nurses don’t have time for more than a few minutes and you have to be realistic and nurse-friendly. We concentrated on what’s the key message, what do we want them to understand, and what do we want them to do.’

In addition, they made use of the trust’s link nurses, training them first and then asking them to cascade information to staff in specific clinical areas. It is also a mandatory aspect of induction for new staff joining the trust.

Making change management work

  • Start with the process, say Victoria Ruszala, specialist pharmacist in North Bristol NHS Trust’s diabetes and endocrinology team. ‘By working out what happens and following the patient, you can immediately identify where the issues might be before you do anything else. It saves a lot of time’
  • Do things in stages, rather than trying to bring in everything in one big effort. ‘That made a massive difference,’ says North Bristol NHS Trust lead diabetes specialist nurse Nicola Davies. ‘Otherwise it’s overwhelming and too many things can go wrong’  
  • Make each stage a project in its own right ‘It stops you trying to go too fast,’ says Ms Ruszala. ‘You will address each appropriately, rather than if it’s one small step in a big project where you can fall over, because you’re not paying enough attention’ 
  • Gain support from those at the top at the outset ‘We took it to the heads of nursing first and once they were convinced, it meant there couldn’t be pushback from those lower down,’ says Ms Ruszala
  • Do your research first, identifying how you can overcome stumbling blocks. ‘We looked at all the things that might prevent it from working well in practice at a nurse level,’ says Ms Davies
  • Don’t reinvent the wheel ‘Our work followed on from what had happened in Southampton and Sheffield trusts,’ says Ms Ruszala. ‘There was a lot of shared practice’
  • Work with colleagues from other disciplines, who will have contacts you may not know. ‘In a big trust like ours, you can talk to 20 different people before you get to the right one,’ says Ms Davies

 

Positive reactions to the change of procedure

For patients, the impact has been overwhelmingly positive. ‘We’d had negative feedback about their sense of disempowerment and feeling uninvolved in their own care,’ says Ms Davies. ‘In extreme circumstances, some even felt a little bit insulted.

‘They would be managing normally at home and then come into hospital, we take over and mess it up. Now I get lovely cards and emails saying, ‘wow, what a difference’.’

Nurses too have warmly welcomed the change. ‘They can see it’s one less thing they have to do,’ says Ms Davies. ‘It works far better for us, as patients are happier and it reduces risk. Their only concern is if the patient does something wrong and there’s a problem.’ 

To allay any fears, while there is no requirement to supervise patients on their first injection, in practice nurses tend to watch them a couple of times until they are satisfied all is well.

Working in a multidisciplinary way has also brought many benefits. ‘We have shared goals and passion and that’s important,’ says Ms Ruszala. ‘But we come at it from different angles. As a project, it means it’s holistic because we’re doing different aspects – and it usually means we’ve covered all of them.’ 


Lynne Pearce is a health journalist


Find out more

Improving inpatient care for people with diabetes (Diabetes UK)

Self-management of Diabetes in Hospital (Joint British Diabetes Societies for Inpatient Care Group)

National Diabetes Inpatient Audit (NaDIA) 2017

National Diabetes Inpatient Audit (NaDIA) 2018

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