Get ready for hospital Don’t let a hospital stay throw your diabetes management off track
Managing your diabetes in a hospital environment can be challenging. Type 1 blogger Melinda Seed explains how you can stay safe and in control
“I was pleading for insulin. They said I had to wait until after the ultrasound, but the ultrasound kept being delayed. Eventually I fell into a coma and I don’t remember what happened for the next few days.” As someone who has had type 1 diabetes since infancy, this story of another type 1’s experience in hospital encapsulates my worst fears. Difficulties accessing insulin and tools to manage diabetes when hospitalised for non-diabetes reasons are not uncommon. Anecdotes abound: the emergency doctor issuing instructions to withhold insulin for five days after a hypo, being denied access to a basal insulin dose because the type 1 patient isn’t eating, and type 2 patients not having access to blood glucose monitoring are just a few examples. Stories such as these from people with diabetes no longer surprise me.
What did surprise me is how well known and documented the problem is among diabetes healthcare professionals. The United Kingdom takes a snapshot of inpatients with diabetes every year. Despite some improvements over time, the latest report shows 40 per cent of patients on insulin had experienced an error in insulin administration, 1 in 4 people had a severe hypo and 1 in 25 developed ketoacidosis while hospitalised. Small studies in Australia indicate things are certainly no better here, with one Melbourne hospital finding 52 per cent of patients with diabetes experienced a medication error during their stay.
Speaking at the 2018 Australian Diabetes Congress, Professor Anthony Russell, director of Diabetes at the Princess Alexandra Hospital, attributed the problem to a lack of resourcing of hospital diabetes teams, such that diabetes care of inpatients was left almost exclusively to generalist interns or residents and “current nursing and intern education programmes can only do so much”. As many people with diabetes would agree, it seems inpatient diabetes care is being left in the hands of healthcare professionals with good intentions but insufficient knowledge of diabetes.
This should not be a problem for most people who successfully manage their diabetes every day. Sometimes you may be too ill or too medicated to manage your diabetes, but this is not the case for most people during the majority of their hospital stay. Unfortunately, expertise in self-management is neither recognised nor accommodated in most hospitals. Doctors and nurses are not used to patients administering their own medicines and testing their own blood, so their default position is to remove the option for self-management by controlling access to insulin and the means to deliver it.
Insulin treatment is highly individualised and complex.
The combination of stress, illness, fasting or hospital food with generalist doctors managing insulin does not bode well for keeping BGLs within your target range. ➤
1 IT’S NEVER TOO EARLY TO BE PREPARED
You may not have plans to be hospitalised, but there are things you can do now to make future hospital visits safer. At your next diabetes appointment, ask your team if they have any tips for what to do in the event of an unexpected hospitalisation for something not diabetes related. I have been told to ask for the ‘endocrine registrar on call’ if you are concerned about anything diabetes related while in hospital. If hospital staff are attempting to make changes to your diabetes treatment that you think are unwise, ask that approval comes from your endocrinologist prior to consenting to the treatment.
The Australian Safety and Quality Health Service Standards require all hospitals to maintain and publicise mechanisms for patients or carers to ask for a clinical review of their case.
Be aware that if you do end up with deteriorating diabetes control, such as high BGLs and ketones, you can ask for care to be ‘escalated’. If you feel your concerns aren’t being listened to, ask for a copy of the hospital’s escalation policy and follow the procedures outlined.
2 PLAN EARLY FOR SCHEDULED HOSPITAL STAYS
As soon as you know you have to have a medical procedure in hospital, speak to your diabetes team about whether changes to your medications will be required, particularly if you are required to fast. If you are type 2, then some oral medications may be changed or you may be asked to not take tablets for a day or two. If you use insulin, discuss changes to timing and dosages with your doctor.
You will need a medication plan for before, during and immediately after the surgery. Ask for the plan to be written down and include your regular basal insulin dose, insulin to carbohydrate ratio and correction factors.
Once you have sought advice from your diabetes team, speak to your surgeon and anaesthetist again, before admission to hospital, about how your diabetes is to be managed. Take the instructions from your diabetes team with you and get the plan written up in your notes. Bring a copy of the plan with you to hospital as well. If you are required to fast, ask how you should treat hypos, should they occur during this time. You should discuss any hypos and how you treat them during the fasting period with your anaesthetist and surgeon prior to the procedure.
Ask to be first on the surgical list for the day to ensure that your diabetes will suffer minimal disruption.
3 BRING AN ADVOCATE WITH YOU
If it’s at all possible, bring a family member or friend with you to the hospital. A significant other who understands your diabetes and knows how to advocate for you if you are too sick to do it for yourself is one of the best ways to ensure that you stay safe. Make sure this person knows your diabetes plan and has the contact details of your diabetes team and the hospital’s escalation policy.
So what can you do to keep yourself and your diabetes safe in hospital?
4 WHAT ELSE TO BRING
Make sure you bring all your own diabetes supplies: your own glucometer, plenty of test strips, all your regular medications in their original packaging, pump supplies, pen needles, syringes, insulin and hypo treatments. Not only will your own lancing device hurt less, but you can keep an eye on your BGLs instead of having to wait for the nurses to do tests.
Ensure you have a list of all your medications that records dosage and the time you take them. Also be sure to include any vitamins, herbal treatments or supplements on the list.
Bring the names and contact details of your diabetes care team. If you have an after hours contact number for your endocrinologist, bring it with you. Have an extra copy to give to your advocate.
With your hypo treatments, make sure they are in easy reach.
If you have type 1, take ketone testing strips, even if you hardly ever use them at home. Ketones and high BGLs indicate a serious diabetes problem and urgent action is required to bring down your BGL. Being able to monitor ketones yourself may help you get more timely access to care. Ask for an endocrine review or for your endocrinologist to be called if you have ketones. Insist on escalation of your care if you cannot access treatment for ketones urgently.
5 WHILE IN HOSPITAL
Make sure you advocate for yourself – speak up ASAP if something doesn’t feel right. You know yourself best, so don’t be afraid to ask questions and get help for any new symptoms, a worsening condition or diabetes problem.
It is not unheard of for generalist doctors and nurses to be unaware people with type 1 require basal insulin, even when they are not eating. If modifications to your insulin regimen need to be made by generalists, ensure you are clear you need basal insulin even if you are not eating and that your endocrinologist says his or her approval is required before altering your basal regime. Ask specifically how your basal insulin requirements are to be met if you are told not to inject yourself or they say your pump must be removed.
Remember, if hospital staff suggest deviations from your agreed diabetes care plan, you do not have to consent. You can also ask that your diabetes team be consulted about any changes to your diabetes regimen before giving your consent.
Keeping your BGLs as close to your target as possible promotes healing and assists in preventing infections or other illnesses. Do not be afraid to be assertive in using your knowledge and experience, and the support of your diabetes doctors and nurses, to stay safe. Hospitals are generally safe places in which staff do their very best to help their patients in stressful circumstances. In an ideal world, hospital diabetes care would be a seamless alliance of patient, specialist and generalist collaborating to achieve perfect control for each person. That ideal seems a way off yet, so in the meantime be prepared, use the expertise of your diabetes team, and be confident. You’re the expert on your diabetes.
Stress, illness and hospital food do not bode well for your BGLs