The Virtual Ward (VW) was initiated because of the high number of housebound patients with diabetes who required daily community nurse (CN) visits to administer insulin, but for whom diabetes control remained poor. North East Essex Diabetes Service (NEEDS) and Anglia Community Enterprise (ACE) worked collaboratively in the VW to review each patient’s individual needs, resulting in improved patient outcomes, quality of life and reduced CN visits, saving hundreds of hours of CN time, all of which have brought financial benefits to the local NHS. This project has also led to closer working relationships with the wider community team.
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The North East Essex (NEE) region has a higher-than-national-average prevalence of diabetes (5.6% compared to 4.1% nationally, Gadsby et al 2017). The prevalence of diabetes is even higher in the elderly population, increasing to 10% in those over 65 and peaking at around 25% in care home residents. The high incidence of diabetes is partly explained by the high percentage of the population being 65 years of age or older. This cohort of patients is often dependent on CNs to administer insulin daily, owing to physical or cognitive impairment. Many are unable to attend clinic appointments because of their co-morbidities and GP surgeries struggle to manage home visits to enable regular reviews of control. Historically this patient group has had poor diabetes control due to lack of support, and often only a once-yearly review. Prior to the VW there had been regular ambulance call-outs/admissions to hospital due to hypoglycaemia, recurrent foot ulcer infections and UTIs caused by hyperglycaemia. The diabetes service identified this cohort as needing improved care and safety. No replicable national case studies or successful models with similar service set-up were found, so a new plan was needed to manage this group without recruiting more staff. The main objectives were: to review, assess and optimise the diabetes control of those housebound patients that the CNs visited for insulin injections, improving quality of life; improving overall diabetes control so that they achieved an Hba1c of 53-64mmol/mol or, if cognitive impairment was involved, up to 70mmol/mol; a reduction in CN visits, and sharing of any important learnings nationally.
VW reviews are held once a month by a diabetes specialist nurse (DSN) and the diabetes link nurse for the CN locality, with access to a diabetologist consultant, if required. Taking a holistic approach to general diabetes control and making clinical decisions by reviewing/adjusting/changing medication and blood results leads to improved quality of life and mortality for the patients. Setting individual patient-specific blood glucose targets has improved patient care and reduced the numbers of visits needed by the CNs when they are already overstretched. The focus is on those patients with an Hba1c below 53mmols or above 64mmols, as these are the patients at high risk of short- and long-term health decline. The CNs were visiting these patients every day, sometimes twice daily, depending on insulin regime. They knew these patients well but were struggling to optimise diabetes control due to lack of diabetes knowledge and communication issues with GP surgeries. The diabetes VW has changed this, as now each CN area has a diabetes link nurse with advanced diabetes knowledge. The nurse flags when there is an issue with someone’s control and contacts the DSN direct, plus discussions are held in the VW meetings. Problems highlighted may be regular episodes of hypoglycaemia or hyperglycaemia, a change in general medical circumstances or even food intake, so blood glucose levels are assessed, medication is reviewed and changes are implemented to benefit the patient’s health.
The project originally reviewed only priority patients, but its effectiveness has led to the entire caseload of the insulin patients being reviewed. So far 145 of the 188 patients who rely on the CNs for insulin administration across NEE have been reviewed, with a constant stream of new patients requiring review. Those with an initial mean Hba1c of 75mmols saw this drop to 69mmols at the three-month follow-up, and at six months it had dropped to 65mmols, showing an average drop of 10mmols in six months with improved quality of life. Those with an initial mean Hba1c of 83mmols dropped to 73mmols at the three-month follow-up, achieving a reduction to 64mmols at six months, showing an average drop of 19mmols over six months, with decreased recurrent infections and improved quality of life. In just one month 86% of the patients reviewed had their medications changed, resulting in a reduction of 90 CN visits. Since the project started there have been over 1,446 visits saved, equating to over 241 hours of CN time. There has also been a significant decrease in the amount of people admitted to hospital with hypoglycaemia in this cohort.
Sustainability and Spread
The project is ongoing and integrated into NEEDS. There are new referrals to the VW all the time. As type 2 diabetes is a progressive condition, medication regimes change and people are regularly starting on insulin. Demand on CNs is only going to get greater, so there must be emphasis on ongoing reviews and improving long-term health. The diabetes link nurses are improving their knowledge all the time and becoming more proactive when there is an issue. Collaborative working is optimising diabetes control and improving patient outcomes effectively and efficiently. The VW is in its third year and remains unfunded, but it is proving financially viable. Other areas nationally are interested in rolling out the VW since the project’s outcomes were presented at the Diabetes UK conference. Outcomes will also be published in Diabetes Update and Diabetes Times. The VW approach is being duplicated for other areas of both NEEDS and ACE.
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