Download for work to improve the quality of diabetes care in a district general

Storyboard Entry Form 2015
Main author:
Email:
Telephone:
Fiona Smeeton
[email protected]
01873 732432
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storyboard.
The word limit is 1500 words including references. Your storyboard will not be
accepted if you exceed the word limit.
1. Storyboard title: a clear concise title which describes the work
Improving the quality of diabetes care and reducing harm by establishing a Diabetes Inpatient Care
Team in a District General Hospital
2. Brief outline of context: where this improvement work was done; what sort of
unit/department; what staff/client groups were involved
This improvement work was done by identifying patients admitted as an emergency
with a diagnosis of diabetes. The majority of time diabetes is not the reason for
admission but a secondary diagnosis. Patients with diabetes are identified either on
the emergency assessment unit or on a medical ward. They are then proactively
reviewed by a member of the multi-disciplinary Diabetes Inpatient Care Team (DICT)
consisting of a Consultant Diabetologist, Specialty Doctor, Diabetes Specialist Nurses
and where necessary a Dietician or Podiatrist. An individualised treatment plan was
then made together with the patient during their hospital stay. This in-patient
diabetes service continues to date.
3. Brief outline of problem: statement of problem; how you set out to tackle it;
how it affected patient/client care
In 2010 there were aspects of care that we were aware could be improved but had
not quantified. The prevalence of diabetes amongst the in-patient population is
between 15 and 20%. Insulin is one of the top 3 medications associated with harm.
The team were aware of many critical incidents involving insulin and other diabetes
medications. Hypoglycaemia was sometimes unrecognised and inappropriately treated
or not treated at all. Patients were started on intravenous insulin infusions and left on
them for too long. Nearly all patients with diabetes did not have a documented foot
examination during the admission. Diabetic foot emergency admissions were not
being admitted to the diabetes ward. A significant proportion of in patients with
diabetes were not identified to the diabetes team. In addition the Joint British
Diabetes Societies (JBDS) had issued new guidelines on the management of diabetic
emergencies.
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These issues were discussed regularly by the team however we lacked a clear vision
or focus of how to tackle the problems which at times seemed insurmountable.
We agreed a number of interventions.
monitoring chart were introduced.
An insulin prescription and blood glucose
A “Hypobox” containing glucose tablets, drinks and glucogel was introduced to all
clinical areas in the Health Board with an accompanying treatment protocol.
New trust guidelines on the treatment of diabetic emergencies were created.
In 2012 we established the DICT providing a daily ward round Monday to Friday with
the principles based on the “Think Glucose” programme. This enabled those admitted
with a diabetes related emergency to be picked up early, some admissions related
directly to diabetes prevented, diabetes inpatient management can be optimised and
appropriate follow up provided.
4. Assessment of problem and analysis of its causes: quantified problem; staff
involvement; assessment of the cause of problem; solutions/changes needed to make
improvements
The process started in 2009 when we were involved in 1000 lives project looking at
insulin errors and improving the safety of prescribing and administering insulin. Out of
this came the use of the insulin prescription chart but also made us look at the wider
issues of inpatient diabetes management.
In 2010 and 2011 prior to the introduction of the DICT we wondered how we were
going to introduce and disseminate the new JBDS guidelines for diabetes emergencies
which proposed a change in existing practice. A baseline audit of existing
management had been conducted and the results quantified what we were all seeing
in day to day practice.
For 3 consecutive years a snapshot audit has taken place across the UK on the same
day looking at all aspects of inpatient diabetes care, providing individual results and
benchmarking against national results. The first National Diabetes Inpatient Audit
(NaDIA) results in 2011 proved the catalyst for identifying the need for further
change. Our results were disappointing and fell below the Welsh national average in
most categories.
We needed to be more closely involved in the day to day management of diabetes.
Proactively seeking patients with diabetes as close as possible to admission would
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maximise early diabetes specialist input. We could then deliver care to patients and
education to healthcare professionals that was both timely and relevant.
5. Strategy for change: how the proposed change was implemented; clear client or
staff group described; explain how you disseminated the results of the analysis and
plans for change to the groups involved with/affected by the planned change; include
a timetable for change
The initial change was the issue of new guidelines and charts in 2010 and 2011. We
are a large organisation so this presented a challenge in how to engage staff, raise
awareness and promote their use; this was achieved by e mail and a publicity
campaign. When the “Hypobox” was distributed to all clinical areas across the trust
our diabetes specialist nursing team provided local education to staff groups in all
clinical areas involved inpatient care.
In 2012 a six month pilot diabetes inpatient care project was started with the first
rounds conducted on the Emergency Assessment Unit. After three months the service
was then extended to all medical wards and the results audited at six months. We
identified unmet need across medicine and surgery. Later in 2013 we started
prioritising those patients in need of review by providing a virtual review of low risk
patients and formally seeing those who were high risk or with complex needs.
6. Measurement of improvement: details of how the effects of the planned
changes were measured
The results below are from both our own internal audits and NaDiA.
Diabetic Emergencies
Diabetic ketoacidosis (DKA)
One year of admissions with a diagnosis of DKA were audited in 2010 before
intervention and re-audited in 2013 after guidelines and proactive review. This
showed time from admission to iv fluids was similar, median time to insulin infusion
was 2.5 hours reduced to 1 hour, time on insulin infusion reduced from 35 to 21
hours, median time for DKA resolution 11 hours and a reduction in hypoglycaemia
from 47% (14/30) reduced to 13% (3/30) on intravenous insulin infusions.
Comparison Data: DKA Management
40
35
35
30
25
21
2012/13
20
2010
15
12 (47%)
10
5
3 (10%)
0
Hypoglycaemia
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Total time on IV insulin (hrs)
Hypoglycaemia
Internal audit data in 2010 (30 patients) showed 43% of hypoglycaemia including
severe hypoglycaemia went unrecognised and untreated. After the introduction of the
hypobox and education programme the recognition and appropriate treatment of
hypoglycaemia was improved to 97% in 2011, this was sustained on our re-audit in
2013.
Hypoglycaemia before and after intervention
30
25
20
Hypos 2010 pre hypobox
15
Hypos 2013 post hypobox
10
5
0
Not treated
treated innapropriately
treated appropriately
Diabetic foot emergencies
Before the project started only 1 in 4 were managed on the diabetes ward and 50%
seen within 24 hours of admission. In 2014 all were seen either within 24 hours if
admitted on a weekday or by the next working day if on the weekend. Ten patients
provided feedback, 9 out of 10 rated their care as excellent and one satisfactory. From
NaDIA data 0% were seen within 24 hours by the multidisciplinary foot team in 2011,
in 2013 this had improved to 100%.
Admission prevention
We avoid admission for an average of 7 patients per month.
Prevention of harm
Medication errors
These were reduced from 43% in 2011 to 28.9% in 2013 (NaDiA). We are able to
address prescription errors on review and provide education but there is still room for
improvement for admissions out of hours.
Foot care
Foot risk assessment was not documented in 83/95 of patients with diabetes at
admission in December 2013. All have a documented foot examination when seen by
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the team and podiatry intervention was required in 8/95 (8.4%) subsequent to this
assessment.
Treatment modification and patient education
Internal audit in the month of December 2013 showed a change in diabetes
management plan occurred in 69/95 (68%) and education was provided to 72% of
patients after review by the team.
7. Effects of changes: statement of the effects of the change; how far these
changes resolve the problem that triggered the work; how this improved patient/client
care; the problems encountered with the process of changes or with the changes
The changes have made a difference to the quality and safety of care for inpatients
with diabetes. They have not resolved all of the problems all of the time and there is a
continuing need to update health professionals and provide education and feedback.
8. Lessons learnt: statement of lessons learnt from the work; what would be done
differently next time
Agree beforehand which subgroups would benefit from review to enable us to target
those who would derive the most benefit from the involvement of the diabetes team.
With adequate resource we would have liked a structured education programme to
run in parallel for healthcare professionals involved in the care of patients with
diabetes. We would have liked a pharmacist to have been part of the team.
9. Message for others: statement of the main message you would like to convey to
others, based on the experience described
It has been hard work but rewarding. We function more effectively as a team. The use
of available resources have been maximised, mainly personnel. There wasn’t a “quick
fix” to the problems it required long term commitment. Issuing guidelines and
protocols on their own wasn’t a solution; education and continued updating for staff
working at all levels and across all specialties is required. Having the problems
quantified enabled us to focus on the areas where our input would make the most
difference.
10. Please summarise how your entry reflects the principles of prudent
healthcare:
you
can
find
out
more
about
prudent
healthcare
at
http://www.prudenthealthcare.org.uk/
We have shown a clinically significant improvement in the quality of inpatient diabetes
in Nevill Hall Hospital. We have reduced risk of harm and improved care for diabetic
emergencies. Opportunities for patient education have been created and we work in
partnership with patients to achieve this. We remodelled the way we worked as a
team to achieve change. We have learned how to identify and prioritise those patients
who need our specialist input to maximise the effectiveness of intervention.
www.1000livesi.wales.nhs.uk
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The NHS Wales Awards are organised by the 1000
Lives Improvement service in Public Health Wales.