Overview of In-Hospital Diabetes Management: Audit of Patients Attending a Rural Hospital in Queensland, Australia

Context: The Australian Institute of Health and Welfare (AIHW) health survey in 2018 demonstrated that mortality rates from diabetes in remote and very remote areas were twice as high compared to those in the urban regions. Moreover, diabetic patients in the lowest socioeconomic areas were more than twice as likely to die from the disease and its associated complications than those living in the highest socioeconomic areas (77 and 33 per 10,000 respectively) ([1]). These health disparities prompted a closer look into the quality of local inpatient diabetes management in order to identify the changes required to improve diabetes care in a rural community. Methods: A retrospective audit assessing all adult patients (aged over 18) with diabetes between August and October 2019 who attended treatment in one rural health centre in Queensland, Australia was conducted. Information was obtained from paper based patient records, especially the state-wide insulin subcutaneous order and blood glucose chart. Results: There were 122 diabetic inpatients during the study period. 9 were excluded due to poor documentation on the details of diabetes or insulin management. Men comprised 62% (n = 75) of the patients and the chronicity of diabetes in the majority of the patients was either unknown or undocumented (n = 90). Type 2 diabetes represented 87% (n = 106) of the hospitalisations. There were 64 hospitalisations with diabetes or diabetic related complications as the principal diagnoses. Among these, 7% (n = 8) were due to diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) or severe hyperglycaemia with ketosis, while 2 patients (1.7%) presented with hypoglycaemia. The majority (32%, n = 36) of the diabetic related complications were due to an underlying infection. Throughout inpatient stay, half (50.4%, n = 57) of the patients experienced one or more hyperglycaemic episodes and 14% (n = 16) experienced at least one hypoglycaemic events. The prevalence of inappropriate management of hyperglycaemia during this period was observed to be 21%. This was due to prescription errors i.e. usual insulin not prescribed (n = 7), erroneous insulin type (n = 3) and unsigned order (n = 4). Persistent hyperglycaemia, defined locally by blood glucose level (BGL) > 12 mmol/L was not managed ideally in 10 patients due to either lack of communication between staffs and physicians or failure to make changes when notifications were relayed. Patients were followed up until the discharge phase. Nearly half (41.8%, n = 51) of the patients were found to have no clearly documented follow up plans albeit the limitations of paper based clinical records should be taken into account. Conclusion: The management of diabetes in the rural communities can be challenging. Communication between the different layers of healthcare providers is imperative to ensure hyperglycaemia among hospitalised patients is not mismanaged. Clear documentation of insulin doses and BGL levels on paper records as well as regular education and shared clinical experience on insulin titration in response to abnormal BGL levels by clinicians are strategies to improve diabetes care. Reference: 1. Australian Institute of Health and Welfare. 2021. Diabetes, Type 2 Diabetes - Australian Institute Of Health And Welfare. [online] Available at: <https://www.aihw.gov.au/reports/diabetes/diabetes/contents/hospital-care-for-diabetes/type-2-diabetes> [Accessed 6 January 2021].