Summary
The aim was to improve the review of those vulnerable, housebound patients who have insulin administered by community nursing teams. Embedding technology (flash glucose monitoring) into community nursing teams allowed safe and appropriate review of those patients on insulin. Also, community nursing teams were trained in recognising the risks of hypoglycaemia and hyperglycaemia, and the appropriate treatment pathway for these often challenging situations.
Innovation
Community nursing teams often have a substantial caseload of elderly, frail or vulnerable people with diabetes who require support and assistance with insulin administration. During COVID-19 in 2020, the specialist diabetes team supported the community nursing teams with insulin administration. At one point, there were 103 visits per day for insulin administration. In the long term, having other specialist teams to support community nurses and ‘fill the gaps’ was not viable. Holistic assessment was needed as these people did not always have an annual review and medication review opportunities were limited. There had been Datix adverse event incidents surrounding insulin timing, particularly with mealtime/mixed insulin and community nurses did not have a broad knowledge of insulin regimens, timings or management of hypoglyaemia/hyperglycaemia. The diabetes specialist team believed that available technology should become the ‘norm’ and embedded into community nursing caseloads. The plan was not only to enable more enhanced reviews, but also to upskill them. The diabetes specialist team worked with community nurse leads and senior representatives within their organisation to embed the technology in community nursing caseloads, agreeing ongoing and substantive support for these teams and the patients. The work relied on current resources, so a review of caseloads and prioritising teams were the initial foci. Committing experienced staff to support the community nursing teams improved integrated working and allowed a comprehensive caseload review.
Equality, Diversity and Variation
Equality and diversity is under-reported in this community population of people with diabetes, and technology deprivation played a big part in implementing this work. Vulnerable, housebound adults, or those in a care environment, are often overlooked by the evidence. Reliance on others to administer insulin means access to technology is limited, because community nurses do not necessarily know the benefits and there are challenges in setting it up and offering ongoing support. The patients do not have the variety of, or access to, technology, or the IT support needed. A majority do not have WiFi, or an email address, and supported living/ care homes have shared internet services. Many patients are unable to self scan. This lack of ‘basic’ technology is a barrier to the use of flash glucose monitoring and supporting those patients is time-consuming and challenging. Despite the barriers, these groups are a priority to consider for the technology, because they do not have the robust reviews of insulin regimens or the ability to self manage.
Results
The results demonstrated the need for using technology in this particular group of people. The main outcomes measured were: number of visits by community nursing teams pre- and post-intervention; HbA1c measurement, plus prescribing costs. The priorities were to improve outcomes for people with diabetes and to increase safety around insulin prescribing and administration. Prescribing costs were also important. At the start, there were over 70 people having their insulin administered by community nursing teams, totalling 105 visits per day. The technology was new to community nursing teams, so the work involved educating them while identifying patients most at risk. Data was collected from April 2021 to October 2022. A total of 72 patients had Freestyle Libre (FSL) to measure their glucose levels. A Band 5 educator from the diabetes specialist team supported the patients and set up a caseload. Clinical decisions were made by the clinical lead and senior DSNs in the team. The senior nursing team supported with review of the data and changes to any regimens, but a Band 4 post helped with application of the sensors plus the education and support of the community nursing teams. At the end of the period, 48 patients had been discharged from the caseload (either self managing or needing no specialist support); 12 of these had been taken off insulin and 23 had their insulin regimen changed. Community nursing visits reduced by about a quarter. The average HbA1c improved from 85mmol to 66mmol, but, importantly, the percentage of those patients with a HbA1c below 55mmol decreased from 19% to 12%. Pre-intervention prescribing costs of £902.02 reduced to £674.85 post intervention.
User Feedback
Feedback was not formally invited, but the results and improved working were shared at board level and used as an example of successful integrated and innovative working across the organisation. The support from the diabetes specialist was well received. Access to the diabetes specialist team was easier, with a DSN at the end of the phone to give advice. This gave the community nurses more confidence when administering insulin, and the organisation is now investigating ‘delegation of insulin’ for staff who are not registered nurses, or in care homes. There is increased understanding of the different insulin regimens, with community nurses more confident. READ (Recognise deterioration, Escalate, Act and Document) training gave staff formal education around diabetes care and a practical session with the FSL, where they wore a sensor and learned to upload data and interpret it in a basic way. The feedback from these days was positive.
Dissemination and Sustainability
This joint-working approach has now become standard. The majority of community nursing teams can now initiate FSL for their vulnerable patients on insulin. Dissemination has been in place since its inception and its success and the reduction in insulin errors and hospital admissions demonstrate its value. There are now two Band 4 members of staff working across the two services. The work has been published in diabetes journals and shared with external HCPs, plus primary care colleagues. This wider training and dissemination of the work is supported by Abbott primary care team.
