Leading change

Nurses at Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) have developed and implemented a specialist inpatient diabetes service to address unwarranted variation in practice. This new service has led to improved outcomes and experience for diabetes inpatients as well as improved use of resources at the Trust.

Where to look

The Lead Consultant for Diabetology and the Diabetes Quality Nurses identified unwarranted variation in ‘length of stay’ for diabetic inpatients at the Trust, as well as in patient outcomes regarding transition back into community based health services. With ‘National Diabetes Treatment and Care Transformation’ funding, the Consultant and Nursing Matron identified an opportunity to ensure high standards of care by addressing this variation through leading improvements in inpatient services for diabetes.

In hospital, patients with diabetes have higher infection rates, longer lengths of stay – one to three more days than patients without diabetes – and increased mortality rates (British Diabetic Association, 2017). Indeed, the Improving Inpatient Care Programme highlighted that by 2030, one in four hospital beds could be occupied by a patient with diabetes, rising from the current estimate of one in six. These individuals are also at a heightened risk of developing additional health problems in hospital.

The literature suggests that to make service improvements, several initiatives can make an impact, for instance, education, screening and pharmaceutical therapy. High quality care planning is particularly important for patients with long term conditions as it ensures routine consultations between clinicians and patients are truly collaborative.

What to change

Senior nurses reviewed current practice and engaged with the Diabetes Specialist Nurses to identify key areas to focus on in the improvement programme. These areas included:

• Standardising diabetes management across wards;
• Educating and supporting medical and nursing staff to make evidence based decisions when dealing with hyper/hypoglycaemic events;
• Reducing length of stay (LOS) where appropriate for patients with diabetes by improving pathways;
• Ensuring safe transition of care into the community.

To address these changes, the Diabetes Inpatient Team recruited Diabetes Inpatient Specialist Nurses to:

• Develop and implement individualised management plans for all diabetic inpatients;
• Liaise with the community health and social care teams to ensure continuity of care;
• Develop and manage diabetes guidance and support service provision across the Trust;
• Offer consistent specialist staff support via an advisory service with referral on to the Diabetes Consultant for assessment and advice in complex cases.

How to change

The nurse leaders began by raising awareness of education services available for staff and subsequently rolled out specific education packages regarding diabetes, patient administration procedures, Multi-Disciplinary Foot Team (MDFT), Diabetes Inpatient Team (DIT), and prescribing pathways. Thematic reviews of prescribing incidents supported the nurse leaders to target training for staff.

To support this work, guidelines and policies regarding diabetes care were required. In addition to the education packs above being revised and updated, so too was the signposting to national guidance. In line with the Trust induction, there is also a four-day event for Type 2 Diabetes prevention available for all staff. This focuses on staff capacity and capability; undertaking risk assessments, blood glucose, blood pressure monitoring and delivering advice and support. An example of additional support and training resulting from this change programme is that the DIT Assistant Practitioner now works closely with the High-Risk Podiatrist to educate all ward based staff on the importance of foot inspections within 24 hours of admission and how to perform the assessment. An updated referral form has been devised to streamline the process. It is anticipated that the clinic will reduce the number of patients being referred for surgery or amputation.

Adding value

Better outcomes – The team have successfully created an effective ‘door to diabetes review’ process. Data to June 2018 identified 244 diabetes patients were reviewed by the diabetes team, with 100% being seen within 72 hours of admission. The team has supported over 2484 patients to receive individualised management plans for their diabetes, including a medication review in a bid to reduce medication errors. The average LOS has significantly reduced over the last 12 months as well as mortality rates which are now lower than the North-West average. Prescribing errors for diabetes medication have also reduced across the Trust.

Better experience – Patient feedback suggests the service improvements have been well received:

Excellent care and attention received, thorough action plan discussed, very happy overall, could not have been dealt with more thoroughly.

I was admitted to A and E and I wanted to take the opportunity to express my thanks and gratitude to the staff who treated me with such a degree of care and compassion.

Better use of resources – The team have provided a service that has supported improvements at the Trust. Diabetic Consultant care time has been more effectively utilised through support, education and empowerment of medical and nursing staff. The collaborative approach to patient transition from acute to community services, has consistently decreased duplication, releasing time for other activities.

Challenges and lessons learnt for implementation

The introduction of a new team into the hospital setting has been a learning experience for staff. There has been significant support from senior management which has allowed each member of the team to flourish.

The sharing of ideas and the willingness to drive change has resulted in service improvements.

The team have embraced the opportunity to create the best service for patients during a hospital stay. The team will continue to undertake audit and monitoring to maintain improvements to the service.

Find out more

For more information contact:

• Kate Williams (Diabetes Quality Nurse), kate.williams1@mcht.nhs.uk
• Tracey Molyneux (Diabetes Quality Nurse), tracey.molyneux@mcht.nhs.uk