On Wednesday 19 April, the All-Party Parliamentary Group for Diabetes had a meeting on The Future of Inpatient Diabetes Care. The meeting was chaired by the Rt Hon Keith Vaz MP and had the presence of Jim Shannon MP and Mary Glindon MP.
Right now, one in six hospital beds is occupied by a person with diabetes. Because of poor management and a lack of training for staff about how to care for people with diabetes, a large number of these patients develop complications whilst in hospital that can lead to a longer length of stay. Despite areas of improvement, medication errors are still common and there is a need to improve staffing levels and patient experiences.
The APPG heard from experts in the field on why change is needed, the challenges remaining and potential solutions to improve inpatient diabetes care. The meeting focused on the measures hospitals should adopt to improve the experience of people with diabetes in hospital.
1. Lesley Doherty, patient voice, Cheshire (East)
Lesley has Type 1 Diabetes and she shared the positive and negative experiences she has had with inpatient diabetes care. She has been admitted twice at the same hospital, once for colon surgery and another for orthopaedic surgery, and experienced a varied range of quality of inpatient diabetes care.
For her colon surgery, she stated the pre-assessment was excellent. The nurse contacted the Diabetes Specialist Nurse (DSN) for advice on insulin and its effects on anaesthetics. Lesley was fully informed about insulin management prior to the operation, on what to expect during the post op and after the discharge. She was given a direct line for emergency care and advice, received dietary management on how to optimise her dietary intake post and after surgery, and received guidance on the procedures for admission and recovery at the general ward.
This was the opposite of what happened during pre-assessment for her orthopaedic surgery. The operative procedures were discussed, however the nurse was unable to offer any advice on diabetes care, the DSN was not available and she was not offered a contact number.
“I was shocked that the same hospital could get care so right in one department but so wrong in another. If this had been my first experience of hospital care I would be very afraid.”
Gladly, Lesley stated that for both times the care during surgery was excellent. She was allowed to store her medication and food/drink supplies at an accessible place, her blood glucose (BG) was checked and the insulin infusion drip adjusted accordingly. She was questioned about her feet and any bed sores.
“I felt confident in the hospital team. Confident that all my healthcare needs were fully understood and I would be well cared both during and after the operation. I also felt confident that if surgery presented any complications these would be satisfactory managed and I would be kept safe.”
Unfortunately, the same excellent care was not continued during the night or the weekend. In one evening, she started feeling her BG levels dropping and could hear the alarm on the insulin infusion drip, but was unable to find a nurse to help her. By the time a competent nurse reached her, her BG levels were down to 1.7 and she was in need of rescue. This was fixed during the morning by removing the insulin infusion drip and allowing her to self-manage her own diabetes. However, during the weekend, the ward was staffed and the only nurse was often not available. She asked her consultant if she could be discharged as she was worried about what would happen to her if she suffered another hypo. “I felt fearful for any future long term hospital stays and frustrated that a medical emergency could easily been avoided”, said Lesley.
2. Prof Mike Sampson, Chair, JBDS-IP
Prof Mike Sampson started by covering the role and plans of the UK Joint British Diabetes Societies for Inpatient diabetes care (JBDS-IP), which he chairs. The JBDS-IP started in 2011 as a collaboration between Diabetes UK, the UK Diabetes Inpatient specialist nurse (DISN) group, the UK diabetes specialist diabetologist group (ABCD) and colleagues with the objective of supporting the development of safe and effective inpatient diabetes services.
He complimented the work of the National Diabetes Inpatient Audit (NaDIA) in providing clear recognition of the scale of the problem with inpatient diabetes care, but wondered: “how this knowledge can be translated into improvements?” He raised the issue of Acute Trusts and how they need to be persuaded of the scale of the inpatient diabetes problem and convinced to take it seriously.
In order to address this, he shared how since 2014 JBDS has had multiple discussions with the Care Quality Commission (CQC) national leadership. As a result, in 2015/2016 inpatient diabetes became recognised as one of the few disease specific areas in a CQC Acute Trust inspection and inpatient diabetes is integrated into most stages of a CQC Acute Trust inspection.
“The process may nudge Acute Trusts to focus more on inpatient diabetes care, remove obstacles to better care, and may identify Trusts where there is as particular problem with inpatient care. The CQC has a key role in highlighting inpatient diabetes.”
The next steps for JBDS will be to build on the current inclusion by ensuring the current inpatient diabetes inspection framework works well and to develop an additional service inspection framework for focused CQC inspections, which can be used for a specific trust where CQC have concerns.
3. Gerry Rayman, Lead, National Inpatient Diabetes Audit
Gerry Rayman spoke next about the National Inpatient Diabetes Audit (NaDIA). Gerry shared how he came up with the idea of NaDIA in 2008 due to the need to know what was going on with inpatient diabetes care. When he proposed it, a lot of people told him it would not be possible. However, with an extraordinary commitment from inpatient diabetes teams, the audit is now a success.
He started by sharing the findings of the 2016 audit. There has been some encouraging improvements over previous years, but it clear there is still a big problem, especially with people on insulin. He talked about how 2% of inpatients with diabetes have suffered a severe hypoglycaemia and were in need to be rescued due to high management errors. He explained how despite prevalence of hypoglycaemic episodes declining in hospitals, Diabetes KetoAcidosis (DKA) still happens as 140,000 hypo events every year. Sadly, it is still dangerous going to hospital if you have diabetes. The other area of harm Gerry has focused on were on inpatients with diabetes acquiring foot disease while in hospital. There are 200 cases a year of foot disease.
“It is too much. Because of bad care, people with diabetes can die in hospital.”
Gerry said the way forward involves investing on the people who deliver the care. He talked about the importance of dedicated diabetes inpatient teams and the need for these teams to work together with hospital management to implement hospital-wide safety practices. He stated that inpatient diabetes care needs to be a safety issue.
“We need a commitment and a concerted effort made now, across all hospitals, driven forward by hospital leaders including both managers and clinicians, to provide a high level of care for inpatients with diabetes.”
4. Dr Mayank Patel, Consultant Diabetologist, University Hospital Southampton
Dr Mayank Patel spoke next on the novel inpatient initiatives being used to improve and transform inpatient care in Southampton. Each day, 1 in 5 adult inpatients in his trust has diabetes (200 patients). He shared how the Multidisciplinary Diabetes Outreach Team (doctors, specialist nurses, dieticians and a pharmacist) is not able to review all patients daily; also, as the vast majority of these patients have not been admitted primarily due to diabetes, they are not under the care of a specialist diabetes team.
To address this, his team developed in 2011 a series of processes to support the care for patients with diabetes. The processes involve the development of a hospital menu (with carbohydrate content), a Diabetic KetoAcidosis (DKA) careplan booklet, plus different strategies in education and technology integration to support their staff in providing effective diabetes care.
“In our trust, as nationally, many staff do not feel confident in managing diabetes. Part of my team’s role is in delivering staff training. All members of the team contribute.”
Some of the educational examples include a Diabetes Education evening for junior doctors, an Inpatient Diabetes study day for nursing staff, and diabetes ward rounds for final year medical students. After a healthcare professional is involved in insulin errors, they also conduct a reflective meeting. All strategies exceled in increasing confidence in doctors and nurses.
His team has also developed an inpatient diabetes e-learning tool and uses smartphones applications to support clinical diabetes care, either through the development of a free app (DiAppbetes) that works as a pocket book of diabetes advice, or another app (Southampton Tool for Action on Glucose), which acts as a decision support tool. Together, this has contributed to reducing clinical diabetes errors, reducing length of stay and increased patient and staff satisfaction with diabetes care.
Moreover, he spoke on the importance of commitment from the medical and nursing ward staff towards patients with diabetes. It is important patients with diabetes are easily identifiable, have their feet assessed within 24 hours, are immediately treated for hypoglycaemia or hyperglycaemia before referring to the specialist team and be supported to self-manage if appropriate.
However, they are not alone in this. Dr Patel highlighted how the diabetes inpatient team must have the commitment to support staff with reviews, material, education and plans. He also shared how a patient also must inform the staff if they need diabetes support, as the patient is better positioned to know what is best for them.
“The patient needs to be listened to and encouraged to speak.”
5. Dr Kath Higgins, Consultant in Diabetes Medicine, University Hospital of Leicester NHS Trust
Dr Kath Higgins spoke next on the initiatives being used to improve and transform care in Leicester. She started by stating there seems to be a widespread institutional acceptance of poor care that needs to be changed. Staff are lacking in knowledge and competence in managing inpatient diabetes care. Patients are often denied the opportunity to manage their own diabetes whilst in hospital. Inpatients with diabetes are at risk of harm.
“For years these issues have been seen as ‘diabetes team problems’ but they are not. This is a whole Trust problem and we will not be able to tackle the harm associated with inpatient diabetes care without engaging whole Trust buy-in.”
Dr Higgins shared how her team in Leicester has approached this issue to achieve change in inpatient diabetes care. It all starts with creating a strategy that is embedded in hospital. For this, her team has developed a Diabetes Inpatient Safety Committee, wrote a strategy document for the safe use of insulin and present it to the Trust executive team. As a result, her team was able to engage the executive team and develop a Trustwide strategy for the safe use of insulin, which is now embedded in the Trust Safety agenda.
She then explained what the strategy for safe use of insulin entails, and it focuses on: education and leadership, improving patient experience, and patient safety.
The strategy to educate healthcare professionals and develop core competencies for staff is about developing influencers of good care, fostering an ethos of championing good practice and challenging poor practice. Dr Higgins said the responsibility for safe and high quality care for inpatients with diabetes falls under each CMG leadership team to implement and monitor, with the support and input of the diabetes team.
To improve patient safety, Kath’s team adopted a systematic approach focused on empowering staff to recognise, challenge and take action to resolve poor practice or patient experience. One of the strategies were through a robust pathway for reviewing diabetes (REACT diabetes) and ‘rapid response’ targeted education with shared learning.
Another strategy was to integrate technology. Her team is looking at developing systems to monitor diabetes harms continuously. One of the systems the Trust has invested in is the NerveCentre, an electronic task management system on to which patient observations can be uploaded electronically. The system can be used for instant messaging of HCP, automatic task generation, immediate alerts, cascading escalations and overdue reminders. It also provides an audit trail with respect to actions taken in response to abnormal parameters. By designing condition specific recommendations and escalations they hope to develop automated algorithms in response to specific scenario, such as hypos or hyperglycaemia.
“As we move forward we are working with the Trust to procure networked blood glucose meters and link these to the NerveCentre system. With this we aim to develop an electronic Inpatient Diabetes Dashboard to allow continuous monitoring and feedback to clinical areas.”
Dr Higgins shared how her next steps will be to ensure this change can occur nationally. She spoke about the need of a national campaign, similar to previous work done in sepsis, with standards all trusts have to sign up to and internal monitoring with feedback to allow interventions and actions to improve care. She mentioned the need to explore a campaign to empower and inform patients, as well as tackling education and upskilling the ever changing junior medical workforce.
“There is no quick fix here. The work is complex, requires time and buy-in from the whole Trust”.
6. Dr Partha Kar, Associate National Clinical Director, Diabetes, NHS England
Finally, Dr Partha Kar provided an update on the NHS England perspective regarding inpatient diabetes care. He focused on the topics of safety and leadership.
He started talking about ‘Getting it right the first time’ (GIRFT), a programme designed to improve clinical quality and efficiency within the NHS by identifying differences in service delivery and encouraging sharing of best practice. He explained diabetes is a newly added speciality area and how the focus of the programme is primarily safety and good patient outcomes. He stated that improving safety and inpatient diabetes in hospital is a priority for the NHS. He mentioned the transformation fund that was available to those interested in improving inpatient diabetes errors, and hoped the announcement includes many quality inpatient care programs. However, for Dr Par this is not enough.
“How can you keep inpatient diabetes patients safe? There’s no amount of money that will improve diabetes in hospital. It takes leadership and help from the people on the ground.”
He complimented the National Diabetes Inpatient Audit (NaDIA) and Gerry Rayman for helping the NHS to get the data of what actually goes in hospitals. He spoke on how, despite improvements and commitment from the NHS, inpatient diabetes issues continue to be a major issue to tackle. About 1 in 25 patients with Type 1 diabetes go into DKA while in hospitals because of not being given insulin. “This must and will change”, he said.
Dr Kar said every acute hospital in England should have an inpatient diabetes team, especially a Diabetes Inpatient Specialist Nurse (DISN), in order to improve inpatient diabetes care. He talked about the role of the inpatient diabetes specialist as an educator and support for other staff, whether the specialist concerned is a doctor or nurse. He also said specialists are spokespersons for patients. Partha said that there is a need for a relationship between CCGs, primary and specialists. For Dr Kar, this collaboration on the ground between specialist and generalist teams will be the key to change. When that relationship is there, good inpatient diabetes care happens.
To Dr Kar, it is possible to deliver care for all people with diabetes in a more effective and cost-effective way. But to do it, it requires strong clinical leadership and he complimented the work of Dr Patel and Dr Higgins in doing just that. He said it takes good leadership and a desire to improve on what we have, not rely on others to do so.
7. Questions and Group Discussion
After the speeches, Mr. Vaz opened the floor for questions. First to raise an issue was Jim Shannon MP. Mr Shannon spoke about the need for a United Kingdom strategy to fight diabetes. He shared how Ireland has the largest prevalence of Type 1 diabetes and said it is time all nations come together. He stated he wants to work better together with England on a national strategy for education and awareness raising.
Dr Jonathan Valabhji spoke next on the importance to reflect on the positive improvements in inpatient diabetes as well. He explained how while there are more people, and older people with diabetes in hospital, this is partly explained by the fact people with diabetes are being able to live longer lives. He said not every change will happen immediately or tomorrow, but the NHS is doing what they can.
Mr. Vaz finished the meeting by thanking all the guests and speakers. He said our expertise is the envy of the work and commented how all the evidence received orally and in written form will be part of a report to be published soon.