Summary
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.
Results
Mis-managed hypoglycaemia incidents on the ward where the SUI had occurred were reduced by 100% following training. Anecdotal evidence of correct hypoglycaemia management obtained from DISN patient clinical ward reviews, along with verbal feedback imparted from staff, verified that knowledge and confidence had increased and improved. A post-simulation report was formulated and sent to the ward manager and medical governance lead, copying in the DISN team, outlining recommendations from the training. This was actioned and formally reported back to the Trust governance board.
Challenge
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.
Objectives
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.
Solution
The DISN team met with the hospital Simulation team to collaboratively work with and write a Hypoglycaemia Simulation module based on the key points within one of the recent SUIs. The ward manager and governance lead within the area the SUI occurred agreed to the training which established engagement from all major stakeholders. The ward manager, Simulation team and DISN team agreed training dates. The ward manager took responsibility for advertising the training and ensuring availability of staff, and allocation of bed space. The ward team had to respond within real time to the event using the ward resources available, with minimal instruction enabling staff to independently make decisions - thus exposing any system and process errors or latent safety issues. A structured formal team debrief was undertaken, promoting reflection and transfer of knowledge for application to real clinical situations.
Learnings
Prevalence of SUIs and reported incidents of mismanaged hypoglycaemia throughout the Trust was subsequently reviewed one year on and had significantly decreased. Incidences of both mild and severe hypos throughout the Trust had decreased following initiation of the rolling Hypoglycaemia Simulation programme as per NaDIA results 2015. Staff knowledge and confidence in diabetes management has increased, with 75.2% of patients reporting that all or most staff looking after them knew enough to care about diabetes to meet their needs". This is above the national average of 65.5 %. Other diabetes teams throughout England have adapted and replicated our Hypoglycaemia Simulation module and further enquiries have been received from other Trusts wishing to develop their own Hypoglycaemia Simulation Training, using our model. The team received national recognition as a DISN team for its work, receiving two prestigious awards – QiC 2014 Judges Special award 'Highly Commended' and The Rowan Hillson Insulin Safety Award 2015 – runner up for the 'Best UK Inpatient Hypoglycaemia Prevention Initiative'.
Evaluation
One year post-delivery of Hypoglycaemia Simulation Training, local audit of hypoglycaemia incidents & SUIs was undertaken. This demonstrated 100% reduction in hypoglycaemia incidents seen on the pilot ward, 63% reduction in hypoglycaemia incidences and 100% reduction of SUIs throughout the Trust. 2015 NaDIA outcomes showed reduction in mild hypoglycaemia by approximately 20% and a remarkable reduction in severe hypoglycaemia by just over 50%. Comparing hospital NaDIA 2015 hypoglycaemia data to the national average in 2015 demonstrates a below the national average incidence in both mild and severe hypoglycaemia. Continued analysis of feedback received post Simulation Training illustrates ongoing positive and favourable learning outcomes and experiences across seven evaluation questions.
