Diabetes…Improving Inpatient Care

Dr Mayank Patel BM DM FRCP

Diabetes & Acute Medicine Consultant

University Hospital Southampton

May 2018

My disclosures

I have received honoraria for speaking at meetings from:

Eli Lilly & company

Sanofi

Novo Nordisk

MSD

AZ

Mylan

Boehringer Ingelheim

Who am I?

Delivering Inpatient Diabetes Care:Aims of talk

• To present some guiding principles based on my local experience and learnings from elsewhere

Inpatient Diabetes:setting the scene

• Majority of patients with diabetes are not admitted for diabetes reasons

• Majority of patients are under the care of a non –diabetes clinical team

• Diabetes: Destabilised by acute illness and hospital interventions

• Diabetes medication errors, especially with insulin, have harmed patients

• There are some knowledge gaps around ‘basic’ diabetes among HCPs , which can increase clinical risk

• 10% of national inpatient spend in hospitals is on diabetes

• 1 in 3 - 1 in 5 adult inpatients in UK hospitals have diabetes

• 1 in 4 UK trusts have no inpatient diabetes team

How is the inpatient diabetes experience in my hospital?

• Patient experience?

• Risk?

• What’s the temperature? Is there appetite for development?

• Tools that can help:– NaDIA report

– CQC

– Complaints

– Diabetes reported adverse events

– Patient stories

Inpatient diabetes: where to start?

A roadmap...

• Admission

• During Admission

• Discharge

• ‘marginal gains?’

• There is no single toolkit to solve it all….

Diabetes: The flight analogy…

Welcome to NHS airlines…

• Have a safe flight?!

Planning the trip…

• Primary care:

– Elective admissions (how is the diabetes control?)

– UHS: ‘PEGASUS’ (work with pre-assessment teams)

• Patients:

– Article (Diabetes Research & Wellness Foundation)

https://www.drwf.org.uk/news-and-events/news/diabetes-care-hospital

Or search: 'Diabetes care in hospital'

Check in...Is your trust diabetes aware?

• Patient identification & Diabetes type? (IT/ documentation processes)

• Safe Prescribing (insulin) & Footchecks

• UHS: newly diagnosed Type 1 diabetes OOH pathway

• Staff training in diabetes

In flight

• Cleared for take off…

Examples of interventions at UHS

• To raise profile of ‘inpatient diabetes’:

– Worked with other departments (e.g. oncology, vascular, cardiac, pancreatic surgery) to raise diabetes awareness, Link nurses etc

– Full MDT ward rounds: ‘a visible presence’

– Inpatient Diabetes elearning resource

– eReferral system

– Networked point of care BG meters

• Set up alerts for early notification of dysglycaemia

– Set up alerts for early notification when ‘at risk’ patients admitted

During the flight…

• Ensure patient is aware of impact of admission on diabetes (‘in flight reading?’)

• Ensure BGM occurring

• Involve diabetes team if needed (only 40hrs/wk?)

It was all going so well…

• Turbulence?

‘Glucose encounters of the absurd kind...’

Glucose encounters of the absurd kind:The challenges...

• BGLs not on Early Warning Scores…

• Need to educate (specialist v non-specialist diabetes responsibilities)

• More than 40hrs in a week

• Need to encourage ownership of the issue (‘all grades’)

• How to inform and support ‘at scale’?

2016: MicroGuide DiAppBetes

• Advises on things the diabetes team take for granted!

• Free to download

• Option for other Acute trusts to bespoke the content for their own needs

App Screenshots (1)

What might support a better inpatient diabetes future?

• An appropriately resourced diabetes team

• Leadership, enthusiasm and persistence from diabetes teams

• Teamwork & patient stories

• Make the case, generate data, cost it

• Drivers for change: LoS data, error rates, complaints, executive and stakeholder support, financial savings

• Create a ‘diabetes friendly’ workplace culture

• Taking ideas from all corners – staff, patients, execs etc

• Mandatory training in diabetes for all?

• (Diabetes UK: Shared practice library)

In conclusion:Inpatient Diabetes

• The brand of inpatient diabetes is well established

• A National issue with no single solution, but Local initiatives and Local leadership and enthusiasm is ESSENTIAL

• People with diabetes have died in UK hospitals through errors in care – learn from errors

• IT is a key enabler

Thanks for listening