Summary
The complexity of diabetes management, with advances in therapies and best practice, can be difficult for general ward staff to manage, leading to clinical risks, such as maladministration of insulin, clinical inertia and episodes of hypoglycaemia, often resulting in suboptimal care. With limited time and resources, inpatient diabetes specialist nurses (DSNs) are often unable to address all the issues. Locally a large number of medication errors and ‘near misses’ were identified on the wards. The diabetes inpatient team discussed ideas and looked for inspiration nationally but felt that a new approach was required. The project focused on upskilling inpatient clinical pharmacists through completing the advanced diabetes management course, followed by a new, collaborative-working initiative involving regular clinical supervision and support from the North East Essex Diabetes Service (NEEDS) inpatient DSNs. Previously, pharmacists had just performed medicine reconciliation advice on medication interactions and side effects while assisting with discharge planning. The project demonstrated that clinical pharmacists were expertly placed to improve medication safety through performing a medication review, highlighting and identifying any clinical risks, and optimising patient therapy. They gained the skills and confidence to support diabetes management at ward level, leading to improved patient safety, reduced DSN workload, plus greater diabetes awareness and knowledge within the hospital.
Innovation
NEEDS is finding new ways to shape how diabetes care is provided to keep up with increasing demands and numbers of people living with diabetes. Experience shows that working collaboratively with other departments in the hospital and organisations in the community can often solve problems more quickly and efficiently. It has worked with the pharmacy department for many years, offering guidance and medication advice, so a closer working relationship to resolve issues like medication errors and lack of staff knowledge seemed a natural step. While there are many examples of collaborative working within the community, there are fewer in the diabetes inpatient setting. This is believed to be the first example of upskilling inpatient pharmacists to become ‘diabetes champions’, giving them in-depth understanding of the holistic approach required to care for diabetes inpatients, while empowering them to make safe decisions without seeking advice from the diabetes nurse, who is not always available. This collaborative relationship has led to daily contact between the DSNs and pharmacists. A seamless discharge process, where errors can be picked up at the point of documentation, catches the ‘near misses’ and ensures optimum patient safety. Pharmacists have also shared their learning with other members of the multidisciplinary team. This collaborative model could be used in other hospitals, leading to further improvements in patient safety nationally.
Results
There has been a reduction in the numbers of medication errors reported in the Hospital Patient Safety Incident Report (Datix), from around 12 per month to a maximum of six per month. Reported hypoglycaemia episodes have been reduced from eight to three a month and there has been a reduction in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS). Though there is no direct data proving better glycaemic control, anecdotally there has been an improvement. DSNs’ time has been saved as, with fewer Datix reports coming through, more time is available to provide in-house training for key/high patient volume areas, such as the Emergency Assessment Unit and clinical skills nurses. Additional benefits include: an improved discharge process, reducing time on wards and frequency of discharge errors, which had caused problems for GPs and district nurses in the community; a huge increase in diabetes awareness and eagerness to learn within the hospital; staff from other clinical areas wanting to become diabetes champions and to complete the university course, and two further pharmacists undergoing the training. Three-day training courses, certificated by Essex University, are planned.
Dissemination and Sustainability
The pharmacists attended a one-off diabetes module funded from the health professional training budget. Historically the money has always been spent on primary care, but this cost has been outweighed by the money saved. Other areas could replicate this using any regulated diabetes course, possibly free of charge, depending on the local set-up. To maintain competencies NEEDS will continue to invite pharmacy champions to its existing development updates and offer diabetes training sessions to the whole local health service, as part of its existing offer. Three pharmacy champions are not enough to provide cover to the inpatient population (580 beds). They are allocated specific areas and have contact details for the whole NEEDS specialist team. Two more pharmacists are undertaking the diabetes course. The project is sustainable and saves costs, which justifies any future training for the pharmacists required. It could be replicated in other hospitals.
Method
The inpatient DSN team took the idea to the pharmacy leads to agree a plan. The lead pharmacists for urgent care, care of the elderly and surgery were chosen as their experience would help to address where the clinical risks were. Two of them were already independent prescribers, which would help speed up the clinical decision-making. It was agreed that they would attend the ‘advanced management of diabetes’ course, a university-run programme aimed at enhancing each health professional’s specialist knowledge of the holistic care required in diabetes. Funding was agreed via the ‘Health Professional Training Budget’, which had only been allocated to inpatient or practice nurses and GPs historically. Once the course was completed, the pharmacists were assigned a specialist nurse as a mentor and feedback sessions were organised. Post-course the pharmacists were able to review blood tests, optimise therapy and reduce clinical risk through stopping, changing, or initiating diabetes medications treatment. Medication errors were audited using the National Diabetes Inpatient Audit (NaDIA) template every week and reported through the harms audit.
