Getting insulin care right, one step at a time

For people with diabetes in regional and rural Australia, hospital stays can be challenging. You’re away from home, unwell, your routine is disrupted, and you’re relying on a busy team to manage your insulin.

Lori, a Credentialled Diabetes Nurse Educator (and endorsed nurse practitioner) at Echuca Regional Health in rural Victoria, says: “I was approached by concerned pharmacists, doctors and nursing staff, in addition to some of the patients I was being referred to. There were clear opportunities to improve care for insulin-requiring patients in our hospital.

“With a rising prevalence of rural people with insulin-requiring diabetes, so too is the number of admitted patients on insulin. Hospital stays can impact a person’s glucose level, including through pain, disruption to food and fluid intake, surgery, decreased mobility and stress. Expert management of a person’s glycaemia is required to avoid situations related to high and low glucose levels resulting in the patient becoming critically unwell.”

When Lori reviewed records over three months, there were instances of low and high blood glucose fluctuations where follow-up ketone or glucose testing was not always completed as per best practice. Instead, follow-up tests were often conducted when resources were available. Lori suspected this practice may also be impacted by their hospital not having clear instructions embedded into current systems for staff to act upon.

Lori identified a nationally recognised charting tool for Echuca Regional Health staff to use to guide their practice, including insulin dosing charting. The tool was developed by the Australian Commission on Safety and Quality in Health Care, which gave Lori confidence to introduce and implement it with support from the hospital’s “Medication Safety” committee.

Kellie, an Echuca Regional Health medical ward Nurse Unit Manager, told us: “Like any new process, there were some difficulties. Our hospital uses a hybrid system where medications are prescribed electronically, while all other charts, forms, and notes remain paper-based. Moving insulin prescribing away from the electronic system created challenges.

“One advantage of the electronic charting was that doctors could prescribe remotely without needing access to bedside charts. Staff reported doctors often overlooked the requirement to prescribe insulin on the new charting tool during ward rounds, which could delay discharge prescriptions. Staff also found the charting tool busy and cluttered.”

Lori collected staff feedback before and after the tool’s implementation and used this information to shape the charting tool to suit their service’s practice context.

“It was always going to be a challenge making alterations to a long-used system. However, we first needed to implement the nationally recognised chart in its original form for insulin prescription. Following a subsequent audit, we were then able to make impactful changes to the chart and adapt to what best suited our hospital, staff and patients.”

Policies have now been updated, staff trained, and key learnings shared.

Kellie said: “We were very keen to adopt evidence-based best practices in our hospital. However, we found the new charting tool did not integrate well within our hybrid system. We subsequently pivoted and adaptions were developed collaboratively.

“The revised charts proved far more user-friendly and provided clearer guidance for escalation of care. Importantly, we observed improvements in glucose management outcomes, which gave staff a strong sense of satisfaction and ownership over the change in practice.”

People in rural and remote areas often face extra barriers to good health. When they come into hospital, care must be safe, consistent, and responsive. This project is a reminder that improving health care doesn’t always mean big, flashy changes. Sometimes, it’s about paying attention to details, listening to staff, and being willing to try, learn, and adjust.

Add a Comment Cancel reply