A multidisciplinary inpatient diabetes service (IPDS) model was developed to improve inpatient diabetescare. Thiscomprised a succession of interventions in service delivery, systemicchanges and staffing levels, implemented over 18 months. The aim was to amplify outcomes via the augmentative effects of each single intervention. Outcome data demonstrated significant success in supporting staff, protecting at-risk patient groups, empowering patients via education and preventing glycaemic harms. The qualitive improvement outcome, cost-effectiveness and sustainability were acknowledged by significant additional funding to expand the IPDS team. Data from this work supported the recent JBDS-IP national guideline on Diabetes Inpatient Specialist Nurses (DISN).
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Quality Improvement methodologies were used to implement interventions and monitor outcomes. The following key primary drivers, secondary drivers, and project goals were identified. The primary drivers were: meeting national recommendations on a good, fit-for-purpose inpatient diabetes service; increasing coverage for hospitalised patients with diabetes; modernising service delivery. The secondary drivers were: focusing on at-risk hospitalised patient cohorts; increasing educational and preventative measures for staff and patients; sustainable funding and resources for IPDS team. The project goals were: supporting staff; protecting at-risk patient groups; empowering patients via education and preventing glycaemic harms. The principal outcomes measured were in clinical productivity, encompassing the quantity and quality of each patient care encounter. The following index activity data were meticulously recorded for each patient encounter: Insulin initiation, titration, education, and support; intravenous insulin infusion support; diabetes oral medication initiation, adjustment, and support; Hypoglycaemia; DKA; HHS; enteral and parenteral feeding in hospitalised patients with diabetes and/or hyperglycaemias; inpatient diabetes dietetic input; patient demographic; time spent with each patient; plus first bedside visit, or follow-up visit(s). Successive implementations of interventions were made over the 18-month period from January 2018.
Clinical productivity data were analysed on (i) patient care encounter episodes and (ii) index activities over the half-year intervals JanuaryJune 2018; July-December 2018 and January-June 2019. These data were compared against those in the half-year from July-December 2017. Statistical analysis was used to ensure the achieved changes had not happened by chance. Measures to help staff included successively increasing both the quantity and quality of diabetes in-reach support for staff and hospitalised patients with diabetes. The number of patient care encounter episodes increased from 1,541 to 2,281 per half-year (an increase of 50%); the number of index activities also increased from 2,033 to 2,960 per half-year (up 45%). This represents an increase in the proportion of patients covered, from 30% to above 50%, considering that the Trust has approximately 4,500 hospitalised patients with diabetes per every half-year interval. Diabetes support was increased significantly for elderly and surgical patients, who are recognised as being at risk of increased morbidity and mortality during hospital stays. Of the total number of patients cared for by the team, the proportion of elderly patients increased from 10% to 16% and the proportion of surgical patients increased from 28% to 31%. The service took a more empowering, educational approach with enhanced continuity for hospitalised patients with diabetes. Intensive follow-up activity rose from 50% to 53-57% and included support on medicinal initiation, adjustment, bedside and remote virtual follow-up. Dedicated educational activity increased from 5% to 12% and covered support on glucose monitoring, insulin self-administration, sick-day rules, hypoglycaemia advice and dietetic support, among others. A significant reduction was noted in severe glycaemia harms (severe hypoglycaemia, DKA, HHS, and inappropriate intravenous insulin infusion usage) requiring intervention, lowering from 16% of total index activity to almost 10%. This was despite the implementation of obligatory referral and automatic detection systems. Improvement in hypoglycaemia prevention appears to be the biggest contributor to such changes.
Sustainability and Spread
This NIPDS initiative began with a long term, substantial Trust and CCG commitment of £210,000 per annum. All positions within the enhanced inpatient diabetes service team are substantial posts. All interventions implemented during the 18-month period are permanent, with a view to long-term service redesign from the outset. There was commitment from all stakeholders, with the local authority providing significant additional support for the expansion of the IPDS team (3.0 whole-time-equivalent DISN), totalling approximately £120,000 per year of further funding. Sustainability, integration and compatibility were demonstrated by the outcome data over the 18-month period; they also demonstrated how individuals, speciality teams and hospital systems could be brought together collaboratively and efficiently. The long-term data collection system proved both accurate and efficient, in terms of clinical activity data capturing, repeat interval evaluation, and setting of further milestones. The team paid special attention to understanding the needs of individual staff, clinical teams and hospital management teams. Extra efforts were made to share the vision of the NIPDS project to gain support for improved IT infrastructure. The many interventions and networking helped to minimise disruption from the COVID-19 pandemic. The service was adapted according to the requirements for infection control, the health-risk category of each team member, in-reach care support and front-door diabetes admission management. Dissemination to colleagues was made via peer-reviewed professional meetings and networks (regional and national), including East of England Inpatient Diabetes Care Group, East of England Diabetes Clinical Network, DISN UK Group, ABCD and Diabetes UK. Outcome data were peer-reviewed, accepted and presented at the most recent Diabetes UK professional conference. The plan is to submit the same data to a diabetes journal in the coming months. Data from this work also helped to shape the recent JBDS-IP national guidelines on hypoglycaemia and DISN staffing levels. Ongoing quality improvement work is shared with patients and the public through face-to-face diabetes campaigning events and social media.
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