Cornwall has a diabetes population of 28,000, with a high in-patient
diabetes prevalence of 16.4%. Diabetes healthcare is increasing in
complexity and, with changing team dynamics and restructuring of
healthcare organisations, comes a need to provide high quality safe
clinical practice in diabetes management. Cornwall Partnership NHS
Foundation Trust's DISN team created a Hypoglycaemia Simulation
Training programme following three Serious Untoward Incidents (SUIs) of hypoglycaemia, two of which
resulted in deaths. The programme enabled teaching of the management of hypoglycaemia according to the
Trust guideline within the ward situation, at the point of care. Following the session, participants undertake
a structured team de-brief that analyses learning points, response to the event, team communication and
working integration, appropriate and timely use of ward and hypoglycaemia resources. Open and interactive
discussion provides feedback for development and any remedial measures are identified and actioned.
The hospital had experienced three hypoglycaemia management SUIs - despite an up-to-date Trust wide
hypoglycaemia guideline, the introduction of hypoglycaemia ward boxes, regular face to face training
and access to national e-learning modules. These educational methods alone appeared to be ineffective.
Simulation training, widely used by the aviation industry, has received significant endorsement by the
Department of Health and the General Medical Council and it was decided to develop a Hypoglycaemia
Simulation module designed to be delivered at the POC. The idea was that challenging human factors
in the work environment allows the multi-disciplinary team to learn together, improving performance,
with consequent delivery of safer patient care, better outcomes and improved productivity.
To address failings in the clinical area following hypoglycaemia SUI and reduce their occurrence. Also, to
improve management of hypoglycaemia within the hospital and develop effective multi-disciplinary teams.
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