The Diabetes Specialist Nurse Team (DSNT) is well established in the Northern Devon Healthcare Trust (NDHT), delivering inpatient, outpatient and community support to patients with diabetes.
An Inpatient Diabetes Awareness (IDA) project commenced in 2015, as the existing link nurse model was ineffective. A 12-month programme was developed to enable the diabetes specialist team to audit different aspects of diabetes management and care on each ward. The aim was to highlight areas that were going well and review those that required education and improvement. Among the topics audited was insulin safety and wastage. Themes identified included: insulin safety (ward stock management); safe administration of insulin; patients’ own insulin (waste reduction); staff education and training; multidisciplinary team working; patient transfer/discharge; insulin wastage and patient experience. Since 2016 the project has improved inpatient diabetes care through increased staff knowledge and awareness, improved efficiency and money saving, reduced insulin omission and reduced incidents.
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The DSNT introduced an integrated model for insulin safety and diabetes management at ward level. In response to the findings from the IDA project, National Diabetes Inpatient Audit (NaDIA), NHS Outcomes Framework and Patient Safety Alerts, the DSNT introduced: targeted ward team education and support; patients’ own insulin review; patients’ own insulin kept with them; no pens or cartridges stored in fridge; reduction in the number of wards carrying insulin stock; only named insulin vials used for patients needing community nurse support on discharge; monthly ward audits of insulin stock; a monthly audit review with pharmacy team, and a quarterly review of insulin incidents with the medicines governance group. The project sought to change existing practice around the ordering and stock management of insulin vials and the storage of patients’ own insulin for all inpatients. This was a collaborative approach, involving the DSNT, pharmacy team and all ward staff. A strong link was established with pharmacy through mind mapping, meetings, sharing ideas and education sessions for pharmacy technicians. This broke down barriers, gave staff greater understanding of each other’s role and improved engagement. Open communication and rapport with ward staff were achieved through encouragement and feedback alongside face-to-face and blended learning sessions.
To provide a sustainable service, the aims of the project were to: promote patient safety; increase staff knowledge regarding the safe use of insulin; to reduce insulin waste and cost in the acute setting. The project methodology was based on quality improvement cycles, piloted on one ward, using Plan Do Study Act (PDSA) test cycles. The PDSA cycle tested the impact using outcome and process measures, before extending the learning to other areas. A monthly audit of ward insulin fridge stock was initiated, which identified a number of issues with established practices: patients’ own insulin was not being kept with them, to facilitate self-administration of insulin where appropriate; delayed timing of insulin administration; poor insulin stock management; unnecessary insulin waste caused by poor management by staff; insulin being drawn from insulin cartridges and pen devices, and lack of ward staff education. In response, monthly ward visits by the diabetes healthcare assistant were started, to collect data on stored insulin, ensuring each one was in date, dated and that no cartridges or pen devices were stored in the fridges. Out-of-date, undated, deceased and discharge/transferred patients’ stock was removed each month, returned to pharmacy and logged. Ward staff education sessions were delivered on wards to avoid disruption to clinical practice and encourage uptake. A staff feedback questionnaire and checklists were developed. Patients were consulted to ensure they agreed with their insulin being kept in their medication pods. Patients admitted to hospital with a large amount of insulin were encouraged to send the excess home. A database was designed to capture all insulin audit results. These results were shared with the pharmacy, medicines and ward management monthly and used to identify insulin ward stock management which enabled the DSNT to target insulin training and insulin stock review with input from the pharmacy/medicines management team. Insulin-related incident reports were monitored.
Over the last 12 months there have been notable improvements in inpatient safety, insulin cost reduction and waste. The first audit in 2016 highlighted a potential problem in the safe administration of insulin, a considerable wastage of insulin and accruing cost. In that single month insulin wastage across every ward amounted to £459.11, including £89.17 of unpreventable waste (out-of-date and deceased patients’ insulin). In May 2018 the cost was £135.84, including £82 of unpreventable waste (out-of-date insulin). Four main areas were audited at the start and re-audited throughout the year. The results showed: out-of-date insulin reduced by 61.5%; a 91.4% reduction in patients being discharged without their insulin;a 62% reduction in the date not being written on insulin vials when opened; the deceased patients’ data is an extrinsic factor. Working with pharmacy and ward staff on a regular basis maintains current practice. In addition to improved insulin stock management, reported insulin administration (medication) incidents (January 2015-May 2018), showed a reduction in harm over time (following an initial increase in reported incidents August 2015-January 2016), associated with education and training delivered to ward teams, and increased awareness of insulin safety issues.
Sustainability and Spread
This project did not require additional funding, but did, and will, require leadership from the DSNT to drive the audit and ward education programmes. An education and audit plan will need to be included in the DSNT strategy and work plan. The education programme could be focused most effectively on new staff and target teams specifically (identified and supported by the DSNT, ward managers or Trust Medicines Governance Group). The learning could be spread to other Trusts through publication, clinical networks and other publicity. A poster was designed and entered into the Nurse Celebration day held by the Trust.
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