Select Committee on Health Written Evidence


Memorandum by Diabetes UK (PS 35)

PATIENT SAFETY

1.  INTRODUCTION

  1.1  Diabetes UK welcomes this inquiry by the Health Select Committee. Diabetes UK's response is focussed on aspects of safety relating to inpatient care for people with diabetes.

  1.2  We have concentrated our remarks to the issues where we feel we can most effectively contribute to the debate. We would be delighted to supply additional information, or clarification on any of the points raised in our evidence.

  1.3  Diabetes UK is the largest charity in the UK working for people with diabetes, funding research, campaigning and helping people live with the condition. We have over 170,000 members and represent the interests of people with diabetes, their carers, family and friends, by lobbying the government for better standards of care and the best quality of life.

  1.4  2.3 million people in the UK have been diagnosed with diabetes and it is estimated that more than 500,000 people have the condition but are not aware of it. Evidence suggests that 4 million people will be living with diabetes in the UK by 2025.

2.  EXECUTIVE SUMMARY

  2.1  At any one time, around 10 per cent of all hospital beds are occupied by people with diabetes. 1.34 million bed days per annum are attributable to people with diabetes. Based on unit cost per bed day estimates this amounts to £465.25 million per annum.[173] It is estimated that excess bed occupancy as a result of prolonged length of stay for people with diabetes is approximately 80,000 bed days each year in England, for those with a main surgical or medical specialty discharge code.[174] These figures demonstrate the clinical and financial scale of patient safety concerns for people with diabetes as inpatients. Proven models of care, including the availability of a diabetes specialist team and diabetes inpatient specialist nurses to support general wards should be implemented to assist in addressing patient safety concerns in inpatient diabetes care.

  2.2  The evidence demonstrates safety concerns surrounding the care of people with diabetes as inpatients. These safety risks can result in the development of the acute complications of diabetes including hypoglycaemia and hyperglycaemia (which can result in coma and possibly death), development of foot complications including lower limb amputations and increased length of hospital stay.

  2.3  The principal causes of adverse incidents for people with diabetes in hospital are prescribing and administration errors with regards to insulin, poor co-ordination of medication and food timings, poor foot care, poor communication between general ward team staff and both the diabetes specialist team and people with diabetes. The lack of knowledge of diabetes management by hospital staff has been identified as a significant issue. This is compounded further as many people with diabetes do not have access to the diabetes specialist team or those expert in insulin handling, during their stay.

  2.4  The following interventions can assist in bringing about improvements in inpatient care:

    2.4.1  Mandatory diabetes training for general ward staff including glucose monitoring and the management of acute complications.

    2.4.2  The establishment and use of protocols and guidelines covering the management of acute complications, referral and communication between ward staff and the diabetes specialist team, surgical procedures, and the identification of people with diabetes on wards.

    2.4.3  The establishment and implementation of clinical governance procedures, and audit and benchmarking measures and processes.

    2.4.4  Investment to support the availability of diabetes specialist teams to provide inpatient support, including the role of the Diabetes Inpatient Specialist Nurse.

    2.4.5  The development of indicators for use by the Care Quality Commission.

    2.4.6  Undertaking surveys of patient experience to inform service improvement.

    2.4.7  The sharing and implementation of proven models of good practice.

3.  WHAT THE RISKS TO PATIENT SAFETY ARE AND TO WHAT EXTENT THEY ARE AVOIDABLE

3.1  Systems failures

  3.1.1  1.34 million bed days per annum are attributable to people with diabetes. Based on unit cost per bed day estimates this amounts to £465.25 million per annum.[175] It is estimated that excess bed occupancy as a result of prolonged length of stay for people with diabetes is approximately 80,000 bed days each year in England, for those with a main surgical or medical specialty discharge code.[176] These figures demonstrate the clinical and financial scale of patient safety concerns for people with diabetes as inpatients.

  3.1.2  People with diabetes have identified significant safety concerns with their experiences as inpatients. These concerns are associated with prescribing and administration errors with regards to insulin, poor co-ordination of medication and food timings, poor foot care, poor communication between general ward team staff and both the diabetes specialist team and people with diabetes. The lack of hospital staff knowledge surrounding diabetes management has been identified as a significant issue. This is compounded by the fact that many people with diabetes do not have access to the diabetes specialist team or those expert in insulin handling during their stay. These risks can result in poor diabetes related health outcomes and a longer length of hospital stay. Poor health outcomes include the development of the acute complications of diabetes, including hypoglycaemia and hyperglycaemia (which can result in coma and possibly death), development of foot complications including lower limb amputations, increased length of stay and in some cases, death.

  3.1.3  Vital to diabetes management is the co-ordination of food and medication timings according to an individual's regimen, as well as individually calculated and changing medication dosages, particularly when the individual requires insulin. In addition people with diabetes need access to food and snacks to help address the onset of hypoglycaemia (low blood glucose levels). However, the evidence demonstrates that these aspects of diabetes care in hospital are not provided effectively in many cases leaving people with diabetes at risk.

  3.1.4  The failure to identify foot complications or to provide appropriate inpatient foot care management for people with diabetes can result the worsening of foot ulcers, inappropriately treated foot complications such as charcot foot, and amputation. The costs of foot problems for people with diabetes are high. Mortality rates after amputation are as high as 50 per cent after two years and 75 per cent after six.[177] In 2003 the UK costs of foot complications including amputations were £252 million.[178] Evidence demonstrates that the effective implementation of protocols, and referral to the diabetes specialist team can decrease the number of limbs lost and reduce length of stay in incidences of infection, ulceration or critical ischaemia.[179]

  3.1.5  These system failures result in increased risks of people with diabetes unnecessarily developing complications such as Diabetic Ketoacidosis, hypoglycaemia, and lower limb amputations. These complications are potentially life threatening for the individual if not managed appropriately and will result in an increased burden on NHS services.

  3.1.6  A lack of guidelines and protocols for the proactive identification of diabetes in hospital results in delays in diagnosing, and therefore treating diabetes. This increases the likelihood an individual will begin to develop diabetes complications.

  3.1.7  The lack of standardised systems for audit and benchmarking of inpatient care standards for people with diabetes prevents the availability of data to drive service improvement.

  3.1.8  A significant number of people with diabetes are admitted to hospital for something other than their diabetes and do not have their diagnosis of diabetes recorded on their file. However, their diabetes must be effectively managed, during their inpatient stay, to help prevent poor short and long term outcomes. One study demonstrated diabetes was missed as a discharge diagnosis in 20-25 per cent of cases.[180] A number of individuals may be admitted to hospital with undiagnosed diabetes but may be found to have elevated glucose levels which are subsequently not acted upon. The MINAP report demonstrated an increased mortality rate of 50 per cent in people who did not receive insulin for raised blood glucose levels.[181]

  3.1.9  People with diabetes have commented on a lack of communication/miscommunication whilst in hospital and on discharge, relating to changes in their treatment or the timings of procedures/operations. These can lead to the individual feeling disempowered and also impact on patient safety.

  3.1.10  The following quotations from people with diabetes demonstrate some of the issues:

    —"I had taken all my medications with me, insulins, blood pressure tablets, statins, aspirin, etc so they would know. These were all taken off me on ward admission|.I was traumatized by the whole experience, the loss of my control, the feeling of not being listened to; you are so vulnerable|"

    —"If it is stated on his sheet he is to have 30 units of insulin then that's all he gets even if his blood sugar is high. If he requests extra insulin|he has to wait 3-4 hours before a doctor is found who can authorise this"

    —"|suffered avoidably large excursions of blood glucose level, ranging from 2.2mmols/l to over 27mmols/l, including avoidable hypoglycaemias and avoidable levels of hyperglycaemia liable to produce ketosis."

    —"The next day I had a hypo, the nurse was called and did not know what to do|The charge nurse came and said|had nothing to give me, it was left for another patient on my ward to give me a sugary drink and biscuits, the nurses left, came back half an hour later, took my blood sugars, said the result was much better and with that they went, no food was offered|except by the patients on the ward."

  3.1.11  A collation of the inpatient experiences of people with diabetes can be found at: http://www.diabetes.org.uk/Professionals/Information_resources/Reports/Collation-of-inpatient-Experiences-2007/

4.  HOW FAR CLINICAL PRACTICE CAN BE RISK-FREE; THE DEFINITION OF "AVOIDABLE" RISK; WHETHER THE "PRECAUTIONARY PRINCIPLE" CAN BE APPLIED TO HEALTHCARE

  4.1  "|Nurse tried to give my father `fast-acting metformin' on two occasions instead of `slow acting metformin'. My father had to point out that they were the incorrect version of the medicine".

  4.2  "I was put on an insulin drip and it was soon very obvious that the nursing staff knew nothing about how to monitor it".

  4.3  Clinical practice cannot be entirely risk free, particularly as some people with diabetes may have complex care needs and multiple co-morbidities that could lead to worse clinical outcomes. However some of the issues identified by people with diabetes are "avoidable risks".

  4.4  Vital to achieving this is the training and education of general ward staff in diabetes care, linked into induction and on an ongoing basis. This must be mandatory. Protocols and guidelines must be in place to support this. These must be developed in partnership with the diabetes specialist team. The overall training and continuing professional development of healthcare professionals must promote holistic care delivery, to ensure those working in fields other than diabetes consider diabetes management. The diabetes specialist team has a vital role to play in providing leadership, training, and expertise to support staff and people with diabetes on wards. People with diabetes should have access to the diabetes specialist team and be cared for by individuals competent in administering diabetes related medications.

  4.5  Enabling people with diabetes who are able to, to self manage during their hospital stay is one aspect of supporting the avoidance of risk. Appropriate protocols, and regular review of the individual's ability to self manage should assist in reducing the risks that acute trusts may perceive if an individual is self managing. Examples of practice exist which demonstrate that self management is possible for people with diabetes as inpatients.

  4.6   "I kept requesting blood tests with the readings getting higher; the nurses said they had requested a doctor but they were busy. I said if I could have access to my insulin I could resolve the issue but you can see they have no experience nor discretion. I understand the legalities. By the morning I was begging the nurses to do something since my levels were up to 20."

5.  WHAT THE NHS SHOULD DO REGARDING PATIENT SAFETY

5.1  Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness

  5.1.1  Evidence has shown that the presence of a Diabetes Specialist Inpatient Nurse supporting general wards has resulted in a reduction in excess length of stay of between 27-47 per cent.[182] Reductions in length of stay, apart from improving clinical outcomes for people with diabetes will also result in financial savings through the number of bed days saved.

  5.1.2  "my blood glucose was very high and erratic, so they insisted that I stayed `til they got it under control, whilst I wanted to get home to get it back under control myself|The DSN, who I knew very well|arrived within 20 minutes and after a few minutes conversation with me told the wards staff `He's right. You're wrong. Let him go'".

  5.1.3  Further examples of good practice and proven models of care have been outlined in both the work of the National Diabetes Support Team and NHS National Institute for Innovation and Improvement.

  5.1.4  These examples include routine foot care by specialist multidisciplinary teams to prevent/treat acute foot problems in hospital. They have resulted in lower amputation rates, reductions in length of stay by two weeks, or the number of bed days being more than halved. In one example the saving in bed days resulted in savings 4-5 times greater than staff costs.[183]

5.2  How to determine best practice and ensure it is spread throughout the whole NHS

  5.2.1  The NHS National Institute for Innovation and Improvement undertook a small number of hospital site visits to help identify the key characteristics of high performing organisations.[184] Following on from this work the Institute is developing a range of tools and resources to disseminate the learning and findings from its work. The National Diabetes Support Team Working Group report also identifies models of best practice, standards and tools for service improvement. The work undertaken by these organisations must be championed and driven forward to help improve inpatient care for people with diabetes.

  5.2.2  Work is currently underway by Diabetes UK, ABCD (Association of British Clinical Diabetologists), and the Diabetes Inpatient Specialist Nurse group to develop guidelines for the management of diabetic ketoacidosis, hypoglycaemia, complex foot and peri-operative surgery. These guidelines will provide a basis to ensure a high quality standard of care delivery throughout acute trusts. These guidelines could also be used to help identify standards to be used by the Care Quality Commission to measure the performance of acute trusts. As around 10 per cent of all hospital beds are occupied by people with diabetes, there is a strong case for this.

  5.2.3  The views of people with diabetes must be regularly and meaningfully surveyed to capture elements of best practice and to identify learning for trusts, enabling them to reflect upon and work towards service improvement.

  5.2.4  Senior managers in acute trusts must work closely with the diabetes community (stakeholders involved in diabetes care including people with diabetes and the diabetes team) to develop protocols and guidelines, informed by the work outlined above.

  5.2.5  Training of general ward staff in diabetes care must be mandatory, part of induction and updates should be delivered regularly. Clinical areas must also be audited.

  5.2.6  A process for audit must be put in place. The Working Group document[185] identifies some suggested audits and audit areas including; "the availability of hospital wide pathways agreed with the diabetes speciality team and regular audit of components".

  5.2.7  The implementation of audit of clinical incidents, actions implemented and re-audit is critical to ascertain if there has been a reduction in clinical incidents. Clinical governance measures must also be put in place to ensure poor performing institutions are held to account and steps taken to address the problem areas identified.

  5.2.8  Data about patient experiences and audit outcomes such as length of stay and hospital protocols surrounding diabetes management could be published to inform people with diabetes making choices about elective care. It can also be used to inform the work and interventions of healthcare regulators with poor performing institutions.

5.3  What incentives there should be to improve patient safety

  5.3.1  Reducing the length of stay of people requiring an emergency bed and improving patient experience are both linked to Public Service Agreement Targets. This should incentivise trusts to make improvements in care delivery that can support reduced length of stay for people with diabetes as well as improving experience by providing better care.

  5.3.2  The current Payment by Results system encourages the identification of diabetes amongst inpatients, as it will add to the tariff that can be secured for treating a particular patient. If indicators regarding the quality of diabetes care were available these could inform patient choice and therefore be accurately reflected in Payment by Results tariffs.

  5.3.3  As a significant number of all hospital beds in the UK are occupied by people with diabetes, reducing their length of stay should have a significant impact on NHS resources when improved care has led to better clinical outcomes and an earlier discharge as a result.

5.4  How patients and the public can be involved in ensuring that services are safe

  5.4.1  To ensure an individual's needs are met people with diabetes should have an assessment of their needs and a care plan drawn up that includes medicines management and food choice, timings and access to snacks.

  5.4.2  People with diabetes in hospital should be supported to be as involved with their own care as they are willing and able to be. This could include administration of diabetes treatments, self monitoring of blood glucose levels and managing hypoglycaemia not requiring third party assistance.

  5.4.3  People must be supported to report poor experiences. Systems must be available to support people wishing to remain anonymous. People with diabetes must also be involved in the planning and design of diabetes services.

  5.4.4   "After a few days I insisted that I took charge myself with injections, the nurses spoke to their pharmacy about this and were told that the patient clearly know more about the use of insulin than they did! I signed my notes to say that I took full responsibility for my diabetes while in their hospital. A very unpleasant experience."

  5.4.5  "Ward regimes should not exclude patient involvement in Medication."

  5.4.6  "As far as Diabetes goes—Whom do you think is the best expert ?—The Patient."

September 2008








173   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

174   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

175   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

176   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

177   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

178   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

179   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

180   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

181   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

182   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

183   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back

184   NHS Institute for Innovation and Improvement (2008) Focus On: Inpatient care for people with diabetes NHS Institute for Innovation and Improvement. Back

185   National Diabetes Support Team (2008) Improving emergency and inpatient care for people with diabetes National Diabetes Support Team. Back


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2008
Prepared 30 October 2008