Summary
The findings of the 2009 National Diabetes Inpatient Audit (NaDIA) showed 22 per cent of all in-patients in the Dudley Group of Hospitals Foundation Trust (DGH) had diabetes, and had a longer length of stay and poorer outcomes than similar patients without diabetes.
A further audit showed that 23.3 per cent of referrals to the diabetes specialist nurses (DSNs) were inappropriate. The diabetes team decided to tackle problems highlighted by the NaDIA findings by launching ThinkGlucose.
Results
The implementation of ThinkGlucose has delivered impressive results for the Trust. The 2010 NaDIA showed the number of inpatients with diabetes was 11.6 per cent, down from 22.4 per cent in 2009.
Average length of stay was reduced by 0.61 days, generating efficiencies for the trust of £422k in the first eight months of the project.
ThinkGlucose education was given to more than 70 per cent of staff caring for in-patients. HbA1c levels three months post inpatient stay reduced by 1.71 per cent and 0.47 per cent for new-onset and known diabetes patients respectively.
Challenge
The team had three main aims:
To increase awareness and uptake of the Diabetes Outreach Team (DOT) and improve management of inpatients with diabetes through education and updated protocols and documentation
To deliver early specialist involvement to inpatients with diabetes, including clear discharge and follow up arrangements, improving patients’ quality of care and length of stay
To reduce prescription errors and improve the management of diabetes-related acute complications.
Solution
The ThinkGlucose project was launched on two pilot wards in April 2010 and Trust-wide in August 2010. The project was led by the Diabetes Outreach Team (DOT) which included a lead consultant, diabetes specialist nurses (DSNs) and junior doctors.
Activities were linked to the three key objectives:
Raising awareness: The team arranged for leaflets to be attached to payslips and for posters and banners to appear around the trust
Induction programme: They presented at induction days for junior doctors and nurses, and briefed senior nursing staff about the programme
Education programme: They developed and delivered at dedicated sessions for doctors and at night time teaching sessions for nurses.
To support appropriate referral to, and early involvement of DOT, major service reconfigurations were made. The consultant and specialist registrar job plans were changed to incorporate four dedicated sessions each per week for ThinkGlucose, and the DSNs increased their service to provide six day-a-week cover for inpatients.
Admission documentation was amended and a new referral form and referral criteria was developed. Follow up arrangements were made for patients who were discharged after DOT review.
Finally, to reduce insulin errors and improve care for acute diabetes complications the team introduced a variety of new tools to trigger staff to take appropriate action.
The Trust now has a new blood monitoring chart and DKA monitoring chart, both with management guidance on the reverse. Twenty per cent dextrose and blood ketone meters are available on acute wards to enable the introduction of new DKA guidelines.
Insulin prescription charts show meal times rather than clock times, with preprinted “units” and instructions.
