Summary
Following negotiations with the local CCG the Trust developed the ‘Diabetes Outreach Team’. This team delivers seven-day, proactive ward rounds specifically targeting high risk patients and delivering a comprehensive set of interventions, which includes patient education, direct clinical input, identification and referral to psychology, smoking cessation and structured education programmes. A focus on supporting the emergency department has meant that readmission is avoided as much as possible and diabetic emergencies are dealt with by specialists.
Results
The percentage of patients with inappropriate duration of intravenous insulin started from a baseline of 27%, falling to 5 per cent in quarter three, and then to 0% in the fourth quarter. The proportion of patients needing referral to either structured education, psychology or smoking cessation fell from 22% in the third quarter to 18% in quarter four.
In quarter three, 63% of patients were satisfied with their involvement in their own care. The figure rose to seventy 1% in the following quarter. The mean length of stay fell from 7.8 days in quarter three to 6.1 days in quarter four.
Challenge
The East and North Hertfordshire NHS Trust caters for a population of 500,000 with just 800 beds, 18% of them occupied by diabetes patients at any one time. The trust is also a dialysis centre and a vascular unit, so sees a high degree of diabetes-related complications.
Data from the annual NaDIA results and local audits showed these patients receiving suboptimal care: 27% had intravenous insulin in situ for an innappropriate length of time, and patients felt that only 74.6% of staff knew enough about diabetes to care for them. Just 33% were seen by the diabetes specialist team, and the diabetes inpatient service was only delivered over a five day period.
Objectives
Quarterly targets were negotiated with the CCG as part of a CQUIN programme, alongside in-house improvement projects. A business case was made for expanding the inpatient team to form a Diabetes Outreach Team’ (DOT), increasing diabetes-specific ward rounds from five to seven days per week.
CQUIN targets for the end of year one included increasing patient coverage, reducing the use of inappropriately lengthy IV insulin regimes, and cutting insulin administration errors. Other goals included monitoring length of stay and rolling out a foot assessment tool in the renal unit.
All patients were to be reviewed to ascertain their understanding of their condition and medication, and their need of psychological support. Appropriate referrals were then made.
Solution
Coverage was expanded to twice daily ward rounds on weekdays and one a day on weekends and bank holidays. Staffing was significantly increased.
Bed requesting software helps dentify patients. Fields completed on admission highlight type of diabetes, glucose lowering therapy being taken, and the reason for the admission. The list of patients is used to prioritise the ward round list.
Each DOT member uses a laptop in real time to enable quick access to hospital systems and to document clinical information on the diabetes database.
Every hospital discharge letter is scrutinised and a diabetes specific-letter sent to the GP or community diabetes team. Diabetes-specific drug charts include pages for subcutaneous and IV insulin prescriptions, pump settings and glucose monitoring results.
Learnings
The team learnt that using electronic handover systems is essential (a simple spreadsheet has proven sufficient).
A single point of contact is much easier for teams to use in referring patients. The development of a diabetes specific drug chart has led to improvements in prescribing and administration, but also allows for more rapid assessment of patients.
The biggest challenge faced was that of increasing to seven-day working. A thorough consultation process with frequent and detailed communication has meant that the whole team now wholeheartedly embraces the practice.
Evaluation
The quarterly ‘mini NaDIA’ shows the effect on insulin errors and foot care, and participation in the national NaDIA helps with benchmarking. CQUIN targets are measured on a rolling basis and ongoing patient questionnaires carried out.
A discharge summary is sent out, with supplementary summary letters or phone calls, to keep primary care and community teams informed. Increasing awareness of services has helped prevent inappropriate admissions of patients.
The fact that the service is now available seven days a week allows for the workload to be spread somewhat but also ensures equal availability of specialist services to all patients as much as is possible.
