‘DICE- Diabetes Inpatient Care and Education’

The DICE Team

What is the DICE project

• A whole systems approach to improving inpatient diabetes care

• 6 months observation, audit and development of tools and pathways to improve care

• 6 months implementation and continual audit• 6 months of comparison audit • Analysis of patient harm, LOS, readmission,

patient satisfaction, health economic analysis etc

Gerry RaymanIpswich Hospital, Suffolk

National Clinical Lead for Inpatient Diabetes

The National Diabetes Inpatient Audit (NaDIA)

2012

The Burden of Inpatient Diabetes- Bed Usage

<5 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 >25

0

5

10

15

20

25

30

Prevalence

Num

ber o

f hos

pita

lsPrevalence of diabetes amongst inpatients in

acute hospitals

Per cent

Overall prevalence:15.3%

National Inpatient Diabetes Audit

• >14, 000 patients in 219 hospitals audited• 1 in 4 patients with hypoglycaemia• 1 in 10 patients with severe hypoglycaemia• 1 in 50 hypoglycaemic coma• 40% on insulin had prescription errors• 3% developed foot complications in hospital

National Inpatient Diabetes Audit

• 60 patient developed DKA/wk = 3,000/yr• 260 had a hypoglycaemic coma= 13,000/yr• 400 had developed a foot complications

=20,000/yr

Junior Doctors Induction

Insulin: Armed and Extremely Dangerous

Insulin errors

• Insulin errors are the 3rd most common cause of serious harm or death

• Can lead to health care professional being prosecuted for manslaughter

FATAL insulin errors-UK

• Junior doctor ignorant of insulin syringe use administered 50 units instead of five of 5 units: attributed to lack of training

• Junior doctor: Poor handwriting in prescribing led to 40 units being given instead of 4 units with fatal consequences

• Junior doctor used wrong syringe, believing 1 unit of insulin in 1 ml; 100 times overdose, attributed to lack of training

Cox, AR, and Ferner RE. Br. J Diabetes Vasc Dis 2009; 9:84-88

Doctor gives fatal insulin doseA 92-year-old man died of a heart attack after a junior doctor gave him a drugs overdose, an inquest has heard.

Patient given 'insulin overdose'Doctors in NI are to receive fresh guidance on how to administer insulin. It follows an inquest into the death of an elderly woman who was given ten times the dose of insulin she needed.

Mrs Pitt's 62-year-old husband, David, said: "The entire family is distraught by her death and it's hard not to remain angry that she was let down so badly by the nurses that were employed to care for her and make her better."

A coroner ruled in June 2012 that Jackie Charman committed a gross failure in not taking a blood sugar reading for Mrs Pitt.

A second nurse, Sarah Morgan, who was described as a diabetes specialist, had misunderstood what to do when she found Mrs Pitt had low blood sugar levels and failed to give a proper handover.

She was admitted to the hospital, which had treated her for more than 12 years, on 27 September with a chest infection.

She fell into the coma as a result of hypoglycaemia [low blood sugar] on the night of 29-30 September and suffered brain damage as a result.She never regained consciousness and died from bronchial pneumonia on 13 October, the hearing was told.Dr Carlyon heard staff had changed the interval in which her blood sugar was monitored from every two hours to every six.

A witness told the coroner's court her case should have been reviewed by a specialist diabetes team.

In a narrative ruling, Dr Carlyon said Ms Harry died because the hypoglycaemia "was not recognised or treated in time to avoid death".

The trust added that 11 changes had been made at the hospital as a result of the death.

They include the provision of treatment boxes in every ward and department, extra staff on Carnkie Ward and a programme of education for all nursing staff

Peter Galsworthy from the Health and Safety Executive said the hospital would be prosecuted under the Health and Safety at Work Act.

He said: "The immediate cause of death was the failure to administer insulin to a known, diabetic patient”.

"Our case alleges that the trust failed to devise, implement or properly manage structured and effective systems of communication for sharing patient information, including in relation to shift handovers and record-keeping."

Catherine Beeson Gillian Astbury's daughter “How could they miss she needed insulin? It's just basic care”

DICE Care Pathway

• Admission chart• DPAR score• Patient self administration and self test assessment• Foot protection tool• Glucose monitoring and diabetes prescription chart• Insulin infusion charts/regimens• Safe discharge check list• Advice for JDs and nursing staff

Patients at risk need heel protection!

0102030405060708090

100

NaDIA 2009

0.5 Months

3 Months 4 Months 5 Months 10 months

FoB uptake on wards - Completed Assessments (%)

0102030405060708090

NaDIA 2009

0.5 Months

3 Months

4 Months

5 Months

10 months

CQUIN Jan 2012

FoB uptake on wards - Completed Assessments (%)

Reduction in Foot Lesions

2008-9 2009-10 2010-11 2011-12 Total % reduction

Grade 2 30 22 9 8

73%Grade 3 5 5 2 2Grade 4 2 2 1 0

Patients at risk need heel protection!

0102030405060708090

100

NaDIA 2009

0.5 Months

3 Months 4 Months 5 Months 10 months

FoB uptake on wards - Completed Assessments (%)

0102030405060708090

NaDIA 2009

0.5 Months

3 Months

4 Months

5 Months

10 months

CQUIN Jan 2012

FoB uptake on wards - Completed Assessments (%)

Reduction in Foot Lesions

2008-9 2009-10 2010-11 2011-12 Total % reduction

Grade 2 30 22 9 8

73%Grade 3 5 5 2 2Grade 4 2 2 1 0

Diabetes Specialist Support

• 1 full time and 2 part time inpatient nurses• Part time weekend cover• Referral via the DPAR system and

electronically through evolve• Support from the ICU outreach team out of

hours• Diabetes Consultant support for all DPAR

scores of 8 or greater

Further work

• Peri-operative pathway• Pathway in ED• Central point for JDs to access diabetes

guidelines• Linking discharge to the community DSN when

in place• Development of a dashboard of KPI