Being admitted to hospital can be a worrying time for many people.
Being admitted to hospital and having diabetes can sometimes complicate things, but this does not have to be the case, as Dr Mayank Patel, Consultant Physician in Diabetes at the University Hospital Southampton NHS Foundation Trust explains.
Before a 'planned' admission
Knowing that an admission to hospital is planned (elective) means that there is time to prepare. If this is the case, it is worth ensuring that a few simple measures are taken to help make aspects of diabetes related care one less thing to worry about. Firstly ensure your diabetes control is the best it can be before hospital admission and seek help if needed to achieve this. It is also important that you have a good knowledge of how your treatment is supposed to help you. There may also be a pre-assessment visit to hospital before admission, which can be a time to mention diabetes.
Before being admitted to hospital, it is worth ensuring your packed bag contains up to date information on your medications (with the doses taken clearly stated) and GP details. If insulin is being used, it is advised that a week's supply is brought in, with doses clearly documented and the correct insulin pen or syringe is also packed. Why not take a picture of your insulin packaging with its name and your current doses clearly printed using your camera phone? As there are many different types of insulin used in hospital, it is essential that the correct one is prescribed for the correct person. It is also suggested that whilst treatment for hypoglycaemia is readily available in hospital, people may wish to bring in their personally preferred sugar based snacks from home to take if needed in hospital. People who use a personal insulin pump for their diabetes control should inform their specialist team when and where they are going to be admitted, so an appropriate diabetes review can take place in hospital. Good footwear is also advised to help avoid the need of having to walk barefoot and risking damage to feet.
On arrival at hospital
It is essential ward staff are made aware of your diabetes, with some people electing to wear medic-alert jewellery for instance (like the DRWF necklace available free of charge here).
DRWF provides a Diabetes Awareness Necklace free of charge for people with diabetes to alert healthcare professionals that they have the condition in an emergency
Other associated relevant issues, such as dietary preferences and medication timings should also be made clear to staff. Information on the carbohydrate content of meals can be made available.
The nature of any treatment that is to be undertaken should be fully explained to you and if anything is unclear, always seek clarification. It is worth asking about any possible impact of the treatment on usual diabetes control so steps can be taken to address this as necessary.
Sometimes, the nature of a procedure or an operation requires that people need to be 'nil by mouth'. In diabetes, special instructions may have been provided beforehand, advising of the need to either withhold certain diabetes tablets or reduce insulin doses. There is also an occasional need to keep diabetes control stable in hospital by using intravenous (within the vein) glucose-based fluids and an insulin drip for a short time. Usual diabetes care may therefore pass to the medical team looking after you until you are able to resume self-management. Your insulin is likely to be stored in a safe place away from the bedside.
The accepted range for blood glucose levels to run at may be higher than people are used to at home (e.g. 6-12 mmol/L), as the hospital environment is an unpredictable one. As medical interventions, altered dietary habits and recovery from operations and procedures can affect glucose levels on a daily basis, there is likely to be an increased frequency of blood glucose testing in hospital.
The 'unplanned' admission
On some occasions, things may happen without warning and people suddenly become very unwell, which can result in an emergency admission to hospital. In this situation, there may not have been time to properly prepare from a diabetes point of view.
Emergency diabetes kit - may be prepared in advance of any hospital stay
To be safe, some people with diabetes elect to have an emergency diabetes kit (pictured above) at home that contains the essentials (medication list, sugar based snacks, as well as insulin needles and blood glucose testing strips where applicable) that can be brought in. Some people also store some of their medical information and next of kin information on their mobile phones. People have also been encouraged to add 'ICE' ('In Case of Emergency') to their mobile contacts, as a means for medical personnel to know who to contact. Family and friends are also often made aware of someone's diabetes situation, so they can help with giving relevant information to medical staff for instance.
The stress on the body of being unwell and reduced physical activity as a result can mean blood glucose levels climb to very high levels, as the body tries to release more glucose to be used for energy to help fight illness. Often in cases of acute illness with diabetes, there is not enough insulin produced to bring this high glucose level down without additional support. It is not unusual for people who have very high blood glucose levels therefore to either be switched from their usual diabetes tablet based treatment to insulin injections, or to an intravenous insulin based drip to help get these levels down promptly, whilst in hospital.
People who are usually on insulin should not be surprised to find that their usual doses sometimes need to be doubled during acute illness, even if they are eating less than usual. This is particularly relevant for people with type 1 diabetes who must never stop taking insulin under any circumstance. The nature of the treatment of certain illnesses can involve the use of steroid-based therapies, which are well known to upset diabetes control by making the body less sensitive to insulin, so blood glucose levels can increase.
Ensuring that blood glucose levels are kept in a safe range can increase the rate of recovery from illness, promote good wound healing and reduce the length of stay in hospital. Keeping well hydrated and avoiding constipation can also help stabilise glucose levels.
Involvement of the Specialist Diabetes Team
Whether an elective or an emergency admission, being hospitalised can provide an opportunity to reassess overall diabetes care. People can request a bedside review from their hospital diabetes team or be referred to them by the ward team should blood glucose levels be persistently higher or lower than deemed appropriate. Attention can then be given to relevant aspects of diabetes to promote good health and wellbeing, such as in supporting people to stop smoking, improving blood pressure or blood glucose control as needed. Educational updates with supporting literature, such as patient information leaflets, to take home can also be provided. It is important that people understand any proposed treatment changes and are happy to undertake them. For instance, if it is deemed necessary for a person to be discharged home on insulin treatment, having never used it before, they, or their next of kin, must be trained in insulin self-administration and monitoring of their blood glucose levels. Follow-up with an appropriate healthcare professional should be arranged before leaving hospital. Discharge related paperwork should also make reference to important diabetes treatment changes for GPs to be aware of.
Healthcare professionals in hospital aim to give people with diabetes the best care possible during their stay, with special attention to any needs their condition requires
Improving diabetes care in hospital
The last few years has seen a raised awareness of the impact of diabetes on hospital patients. The vast majority of UK hospitals now ensure that appropriate processes and guidelines proposed by national diabetes medical societies are in place for non-specialist staff to support diabetes care effectively. In our hospital for instance, in addition to supporting people admitted with diabetes, the education and training of medical, nursing, dietitians and pharmacy staff is a big priority for the diabetes team, who run regular study days and ward-based training sessions for staff to improve their competence and confidence in providing diabetes-related care.
People should always be vocal if there are aspects of diabetes care in hospital that they are unhappy with. They have the right to be reviewed by the hospital diabetes team. Issues around meal choices and insulin related issues are particular themes where people can feel let down. Where possible, most hospitals endeavour to allow people with type 1 diabetes to take insulin themselves, but people should appreciate that there are occasional circumstances when this is not possible. There is no desire among healthcare professionals to disempower people from self-managing their diabetes.
Knowing that you are going to hospital gives plenty of time for diabetes to be reviewed if necessary, which can go a long way in helping the hospital stay to go more smoothly. Knowing what to do about diabetes if you feel unwell is also important, as following suggested advice can sometimes prevent the need for admission to hospital if unwell (more on this can be found in the DRWF leaflet Managing diabetes when you are ill).
After getting home, if you feel able, do let the hospital know how they did in managing your diabetes care. Patient feedback, either positive or negative, is one of the best ways in which staff can learn about and review their diabetes related care processes.
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The DRWF leaflet Managing diabetes when you are ill is available to download here
Author thanks: I would like to formally acknowledge some invaluable insights from a friend with diabetes who spent time in hospital and shared some thoughts on being prepared for an admission.