Friday, 20 July 2012


Regular pattern made by a sculpted white garden wall
Garden wall, Royal Tunbridge Wells, May 2012
I've been trying to squeeze in some personal development time alongside the demands of the wards and my clinic, in the specific area of diabetes. So far there have been three opportunities. The first was observing part of a session of 'structured education' aimed at people with Type 1 diabetes, then I sat in on part of a specialist diabetes clinic with a Dietitian, and the last was part of our clinical supervision in the department.

The National Institute for Health and Clinical Excellence (NICE) publishes guidance describing good practice for various health conditions, including diabetes. One of the elements of good practice for diabetes is 'structured education', where people with either Type 1 or Type 2 can attend tailored programmes covering the important aspects of the medical condition, its treatment, and best management by healthcare staff and the patients themselves. The programme for Type 1 diabetes has been developed locally, comprising four full days delivered once a week over four weeks to a group of up to eight people. I attended the start of Day 2.

Since the first session on the previous week, participants were supposed to check their blood sugar at least four times a day (before breakfast, lunch, dinner and bed) and bring the readings along to the second session along with what was eaten that day and any activity within the day. Looking at highs and lows through daily readings over a week can allow better adjustment of insulin: basal (background) dosage of long-acting insulin, bolus 'ratios' of short-acting insulin to match carbohydrate intake, and adjustments for out-of-range high or low readings, activity, stress or illness.

I've seen this type of activity before, so I'm getting more familiar with the 'basal-bolus' regimen of insulin management. The learning points for me at this type of session were more about ways to work with the people involved. The reason they have been invited onto the course, and the reason that they agree to attend, is usually because of 'less than ideal' blood glucose management, so it is fascinating to see the issues they bring to the session. Most straightforward are the ones who just haven't been given the information before, so didn't know how insulin could be matched to carbohydrate intake and activity. They suck up the lessons on carb counting, and off they go. The interesting ones are those who have already been given the tools and knowledge, but aren't carrying it through to daily life. That's what guided most of my questions to the Dietitian later - how do you deal with knowing that your input may make no difference? How do you manage your own frustrations?

The same sort of questions arose in the clinic, where I sat in on three consultations. It is a sobering thought  that diabetes doesn't distinguish between people who are educated and numerate and those who live chaotic lives and can barely carry out the calculations required to keep them healthy. Timings of injections, blood sugar readings, calculating carbohydrate per portion multiplied by the ratio of insulin to carbohydrate or working out how much carbohydrate to eat based on a fixed insulin regime - these are not easy or straightforward decisions. Even knowing which foods have carbohydrate and why it matters is quite challenging for many. Add to the mix the range of lifestyles that exist in all the various strata of society, and the unpleasant and life-threatening consequences of getting it wrong - it seems to me that sometimes the Dietitian just has to work out what the most important single piece of information is, because not much more can be done in some cases.

In clinical supervision the basic grade Dietitians get together each month with a more senior Dietitian, and talk about a topic. We had a short Q&A with one of the diabetes Dietitians and a Clinical Nurse Specialist in Diabetes. This was much more relevant to everyday life on the wards, and related mostly to enteral feeding. If someone on insulin is being fed via a pump at 100 ml/h for 15 hours, when should they be given their insulin, and what type should it be? The answer is generally half of their dosage of short-medium acting insulin at the start and half in the middle of the feed, and the background dosage consistently at the same time each day (it is not critical when this time should be). The dose halfway through the feed may be at a time like 3 a.m. if the pump is running overnight, so it may be worth reconsidering the timing - and the hundreds of other considerations that might affect things - medication, hydration, how likely the nurses are to give the right amount of insulin at the right time, and so on.

People with diabetes in hospital wards have a lot to contend with, especially if they are not allowed to manage their own medications. Hospital food may not turn up when it should, it may not be what was expected, it might be very difficult to judge the carbohydrate content, their appetite may be variable, and blood sugar control is notoriously difficult when the body is stressed, even without additional factors like vomiting. If the nurses are administering insulin, then they should be very aware of whether food has been eaten or not, and what it consisted of, but it is hard to imagine that every nurse would take all these factors into account. There is a 'nurse-friendly' option of 'sliding scale' administration (or VRII, variable rate insulin infusion) whereby blood glucose is measured hourly and short-acting insulin is given based on the reading obtained. While this is likely to prevent severe blood glucose highs or lows, it isn't very patient-friendly, demanding many blood tests a day and preventing any prophylactic control of blood sugars. On VRII, even if you know you've eaten four scoops of mashed potatoes, you can't anticipate the increase in blood glucose, but have to wait until it happens and then treat it.

There has been a campaign on the wards to raise the profile of diabetes and its management in hospital, but whether the principles are always put into practice is doubtful, given the multitude of competing priorities that the nursing staff have to deal with. And the reality of where each patient was coming from. I was asked by one nurse to see a diabetic patient who was 'always eating the wrong things', resulting in higher than desirable blood sugar levels. When I reviewed the patient's notes, it turned out that he was over 80 and had had some previous bad experience with hypos. At that age, the short-term risk of dying from a hypo far outweighs the long term risk of organ damage from high blood sugars, so I told the nurse that I would behave in much the same way as the patient if I were in his shoes and left him alone.

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