The 2016 National Diabetes Inpatient Audit (NaDIA) identified a number of management, clinical and patient safety issues, resulting in harm. A Diabetes Inpatient Nurse Team quality improvement project was initiated to improve quality and safety for adult diabetes inpatient care, focusing on key issues. The team worked across organisational boundaries, systems and teams, delivering significant improvements to diabetes inpatient care and safety. Substantial funding has been secured for the team to continue to improve and drive diabetes inpatient care and safety.
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The vision was to improve diabetes inpatient care and safety within the Royal Cornwall Hospital (RCH). The Lead Diabetes Specialist Nurse (DSN) worked with Kernow CCG, RCH and Cornwall Foundation Trust to identify specific goals and milestones based on the shortfalls within the NaDIA benchmark. A 12-month initial timeline was established, with the aim of identifying four areas with the highest patient safety issues. The patient safety quality improvement outcome objectives were: a 10% reduction in medication/insulin/prescribing errors; a 10% increase in the numbers of patients self-managing in hospital; a 10% improvement in the management of hypoglycaemia; ward-based diabetes education for staff; a reduction in length of stay of half a day, plus patient friends and family tests. The Diabetes In-Patient Service (DISN) team developed and reviewed electronic patient reporting systems in collaboration with the RCH Electronic Prescribing team (EPMA). A daily report listed all the diabetes inpatients and their prescribed medications. A range of prescribing and administration errors were identified and highlighted each day for each individual patient on the daily reports. The EPMA team produced a monthly report of the numbers of patients self-injecting their insulin. Furthermore, a daily blood glucose report was set up. This was developed from the Trust connective blood glucose monitoring system in collaboration with the point of care team and the meter company. It generated a daily report of all episodes of hypoglycaemia < 4 mmol/l and hyperglycaemia > 15 mmol/l, identifying the high-risk patient groups. The team also undertook an initial baseline audit to identify four wards with the most elevated incidents of medication/insulin prescribing/management errors/episodes of hypoglycaemia/self-monitoring. These wards were focused on for a minimum of six months.
The DISN team actioned a range of measures. First there was an initial safety brief on all the project wards. The ward managers had to be engaged from the outset as incident reporting was necessary to inform the ward team of the themes and to identify learning needs. Daily clinical patient reviews were undertaken, covering all the safety factors on the project wards. These were identified by review of the daily report and blood glucose alerts, and direct referrals. Education and training were ‘bitesize’ and focused on four topic areas initially: types of diabetes, hypoglycaemia, medications and insulin. As the project expanded, further topics and longer sessions were added, such as pre-assessment and the management of diabetes during surgery. At first, education was for nursing staff, but grew to encompass medical staff and allied HCPs (pharmacists, medical/nursing students, pre-registration pharmacy students and the Trust’s non-medical prescribing group). Evening education sessions away from the ward were provided and a variety of visual teaching aids/ games were developed. These included fact sheets, medication body puzzles, diabetes timelines and diabetes safety flash cards. Staff were supported to make changes in situ through ward-based thematic structured education, on-the-spot learning, case discussion and making prescribing decisions and changes. Daily data collection from the project wards was input onto a central data base. Ward-based pharmacists helped with the daily report and promotion of self-management in hospital. In addition, there was a system of incident reporting and review, and patient satisfaction surveys were carried out. A plan-do-study-act (PDSA) approach facilitated changes to working practice throughout the project. These measures resulted in a reduction in prescribing errors of 72%, a reduction in administrative errors of 99%, an increase in self-management in hospital of 65%, as well as a reduction in hypoglycaemic events of 77%. A hypoglycaemia care action label, that had been introduced in response to a clinical incident prior to the project’s initiation, was rolled out to the project wards. It demonstrated a sustained improvement in the treatment and documentation of hypoglycaemia and has been implemented across the Trust. A further finding was that length of hospital stay reduced from 5.6 in 2015-16 to 5.2 in 2018-19.
Sustainability and Spread
This approach facilitates patient care across NHS boundaries, as well as integration between disciplines and organisations, and is a sustainable plan. It overcomes some of the traditional barriers to patient care, flow and patient follow up. The DISN team changed working practices significantly to encompass technological approaches to the planning and management of inpatient diabetes care, by identifying and prioritising patients based on clinical safety factors, going beyond general referrals and follow-ups. Changes to working practice within the team are sustainable. These include: proactive patient identification; proactive caseload management; virtual reviews; daily EPMA reports and alerts, and bitesize timely education and teaching. The DISN team reviewed every inpatient with diabetes in the hospital, face to face or remotely during the project. Educational resources were funded from educational budgets and are reusable and adaptable. The project, and transferable working practices, like the daily EPMA reports and hypoglycaemia care label, have been shared regionally via the NHSE cardiovascular diabetes network and used in other areas.
The provision of funding for a DISN position to continue this work demonstrates the viability of the project.
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