The diabetes specialist nurse at Bolton NHS Foundation Trust led a programme of work to reduce rates of hypoglycaemia within inpatients at the Trust. This has led to improved outcomes for patients as well as improved experiences and use of resources.
Where to look
Bolton NHS Foundation Trust is provider of hospital and community health services in the north west of Greater Manchester, delivering services from the Royal Bolton Hospital and also providing a wide range of community services from locations across Bolton. Working as part of a multi-disciplinary diabetes service at the hospital and within the Bolton Diabetes Centre, the specialist nurse works alongside complex diabetes cases to ensure patients are supported effectively. The document making hospital safe (Diabetes UK 2018) highlighted to the team the unwarranted variation in practice seen in inpatients with diabetes. It was apparent from the annual data collected via the National Diabetes Inpatient audit that Bolton had higher rates of hypoglycaemia than other areas.
As hypoglycaemia is associated with an increased mortality rate in older people with diabetes, and in people over 70 years it is associated with a two-fold increased mortality rate during hospitalisation and at 3-month follow up (Kagansky et al, 2003). Aside from its acute physiological effects, hypoglycaemia has been associated with an elevated risk of cardiovascular events, fall-related fractures, and death, particularly among hospitalized patients, all of which add to the length of stay and total cost of treatment.
What to change
Initial audits highlighted that the highest number of hypoglycaemic episodes occur overnight/early morning which is supported by the evidence base (Rajendran et al, 2014).
The specialist nurse went on to collect both subjective data via observed practice and objective data through an internal audit of fifty patient records who experienced nocturnal hypoglycaemia so that a full root cause analysis could be undertaken. The result highlighted that staff required additional support to identify those at risk of hypoglycaemia and to understand the implications of these events upon patient outcomes. Documentation reviews highlighted that blood glucose monitoring charts did not allow for increased testing when the nurses wished to do so, which hindered practice and they didn’t allow space to record blood ketone testing.
How to change
Using evidence from the literature and a PDSA cycle methodology, the specialist nurse led the diabetes team in an improvement programme for hypoglycaemia. The team increased their visible presence on the wards and departments to encourage relationships, support staff and to motivate others to support the changes to follow.
A new blood sugar monitoring chart was developed and this now provides staff to risk assess patients using a red/amber/green status, as well as guiding them to the expected parameters, what to do when levels are outside of these and best practice in terms of capillary blood glucose monitoring. This was rolled out across all wards to replace existing charts in use with hypoglycaemia stickers and a care package developed and implemented alongside them to support staff to provide evidence-based practice. To support this, the specialist nurses offered education and support for staff to understand the need for change and new resources highlighting where to seek additional advice and support were provided.
The inpatient diabetes ward agreed to change its standard practice and test capillary blood glucose levels earlier in the morning in those deemed to be at risk of nocturnal hypoglycaemia in an attempt to reduce their occurrence.
A patient experience story and video were developed with one of the Trust’s lived experience patients who had recent inpatient experience and severe hypoglycaemia episodes. This has been built into education and learning tools for staff and played on the intranet during hypoglycaemia awareness week.
Better outcomes – Post implementation audits have identified a reduction in hypoglycaemia occurrence overnight of forty eight percent on the diabetes ward, which is extremely positive. As hypoglycaemia can also trigger behavioural changes in those with cognitive impairments the impact on reducing events will translate to a safer environment and a more settled experience.
Better experience – Staff are extremely positive about the changes and report they have imbedded this into clinical practice as they have confidence that it has made a difference. The patient story video has been shown routinely at divisional level to consultants and senior managers alike, who have welcomed the feedback and taken recommendations on board. The next steps are to join the Trust’s patient experience group and provide feedback to our lived experience patient representative who helped develop the staff video / learning tool.
Better use of resources – Working in partnership with the patient and ward staff to drive patient safety to maximise their health whilst in hospital has meant the Trust can embed the values of care – vision, openness, integrity, compassion and excellence. As a result of the changes there has been a reduced length of stay for a number of patients by reducing instances of hypoglycaemia. In terms of cost savings one study suggests that the estimated total average per patient cost for patients with hypoglycaemic episodes was £2,235 compared with £1,591 for those patients who hadn’t had hypoglycaemic episodes (McEwan, et al 2015).
Challenges and lessons learnt for implementation
It’s important to have better understanding of the impact of care and keep people at the centre of everything done.
Some of the challenges so far have been obtaining data from patient notes to audit and interpretation of documentation.
It is imperative to engage with all levels of staff from matrons, ward managers, nurses, doctors, health care support workers and catering staff in order to drive change forward.
It is important to keep changes simple and effective.
Future challenges will be how to disseminate the importance of hypoglycaemia prevention and considering changes in practice of traditionally routine based services.
Find out more
For more information contact:
- Amy Savage – Diabetic Specialist Nurse, Amy.Savage@boltonft.nhs.uk