Enhancing inpatient diabetes care by developing a new Capillary Blood Glucose and ketone monitoring chart: a Quality Improvement Project (QIP)

Background The 2018 National Diabetes Inpatient Audit (NaDIA) reported that people with diabetes mellitus (DM) experienced substantially longer hospital stays, poor glucose control and frequent medication errors.1 Intercurrent illnesses can impact blood glucose readings;2 therefore, DM management may need to be tailored when people with diabetes are hospital inpatients to prevent dysglycaemia, which is associated with harm.1 There has been an increased number of admissions relating to diabetes during the pandemic.3 Hospital admission may be an opportunity to improve glycaemic control, to educate people and potentially to reduce future complications. People who are on glucose-lowering medication(s) should monitor their capillary blood glucose (CBG).4 It is very important to display CBG and ketone readings in a clear, interpretable manner and to document them in a timely fashion to enable pattern recognition and titrate diabetes medications effectively. This allows one to determine the impact of change too. Sharma D et al concluded that a colour-coded CBG chart led to more actions being recorded when dysglycaemia occurred and to reduced mortality.5 Our aspiration was to achieve the same result at Watford General Hospital (WGH). Prior to this project, most people with diabetes had their CBG checked four times a day, but this was not necessarily before meals. It was randomly conducted, which led to an increase in adverse events audited by NaDIA-Harms and an increased number of referrals to the diabetes team. This required urgent intervention from the diabetes team. There were no clear instructions for ward staff outlining when to check the patient’s CBG or ketones at WGH. It is difficult to establish a pattern of hypoglycaemia or hyperglycaemia using the current line graph, which makes titration of diabetes medications tough. Moreover, there were no sections for nursing staff to add notes for any interventions carried out for dysglycaemia. After reviewing charts used at different hospitals, the team decided to develop a new chart, which looks similar to the one that people with diabetes use at home. The new Joint British Diabetes Society guidelines (JBDS) promote self-management of diabetes as an inpatient;4 a familiar chart would promote this.