Inpatient Diabetes Management

The Diabetes, Obesity, and Nutrition Strategic Clinical Network (DON SCN) is leading a provincial initiative: with the goal of improving and standardizing how patients with diabetes are cared for in Alberta’s hospitals.

This is a multipronged quality improvement initiative, in collaboration with AHS provincial Pharmacy, AHS provincial Nutrition and Food Services, and the Zone operational areas. It involves a multidisciplinary approach (with many different health care providers) to diabetes management, with the patient and family as key team members.

• initiative overview diagram

1 in 5 adult patients admitted to hospital in Alberta has diabetes. When compared to their non-diabetic counterparts, patients with diabetes have longer hospital stays. Provincially, the average length of stay among patients with diabetes was 5 days, which is two days longer than the average length of stay among non-diabetics.

The inpatient diabetes management initiative is a priority for the DON SCN because hyperglycemia continues to be common in hospitals and increases the risk of complications including: post-operative infections, pneumonia, diabetic ketoacidosis (DKA), and delays wound healing.

Literature suggests that patients with diabetes experience hyperglycemia (high blood sugar) 38 per cent of the time they are in hospital. Alberta data is consistent with this figure.

Improving blood sugar control in hospital has been associated with shorter length of stay in hospital and decreased rates of readmission. National Guidelines recommend blood glucose targets of 5-10 mmol/L for most patients with diabetes in hospital. Blood glucose targets of 5-12 mmol/L are recommended in the frail elderly, those with limited life expectancy and those at risk for severe hypoglycemia (e.g. hypoglycemia unawareness). See more information in the Diabetes Canada (previously the Canadian Diabetes Association) Clinical Practice Guidelines (CPGs) for In-Hospital Management of Diabetes.

One of the initial priorities of the overall initiative is the implementation of Basal Bolus Insulin Therapy (BBIT), building upon work started in the province, and also implemented in other hospitals across the country.

The Safe Management of Insulin Pump Therapy (IPT) in Hospitals is another priority of the initiative.

Other areas of focus include:

• Glycemic management policy with procedures for hyperglycemia management and hypoglycemia management. Learn more
• Pharmacy Initiatives – simplified formulary and patient specific delivery of insulin (more information available on Insite, the AHS staff intranet, by searching Diabetes Management) – reducing errors associated with the use of insulin: consistently one of the top 3 causes of medication errors in hospitals
• Nutrition and Food Services Initiative – labelling carbohydrate (CHO) content (led by Nutrition and Food Services)
• Better coordination of meal availability and medication administration
• Transition from and back to community care
• Self-Management – supporting patients to self-manage their diabetes where appropriate
• Peri-procedural / Peri-operative care guidelines
• Diabetic Ketoacidosis (DKA) guidelines – spread and scale of work done by the Emergency SCN and Chief Medical Information Office

The following assessments of current state were conducted to help guide our direction and priorities:

1. Provider Survey - 72 providers across 24 Alberta acute care site were interviewed. We found that there is a wide variation in practice, and that sliding scale insulin is commonly used
2. Patient Survey - sent to 2800 patients that had diabetes coded in their chart, and were discharged from an Alberta hospital in June 2014. Abstracted summary of survey
3. E-Scan of other Health care jurisdictions across the country to learn how they are managing diabetes in their hospitals, to collaborate, and to gain insights.