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Diabetes patients develop preventable complications in hospital and access to specialist staff is 'inadequate'

Clinical audit shows patient care improving, but there is 'a great deal more to do'

June 26, 2014: Over a fifth (22.0 per cent) of patients with diabetes in hospital will have experienced a largely avoidable hypoglycaemic episode6 in hospital within the past seven days, according to a national audit report released today.

One in ten (9.3 per cent) will have experienced a severe hypoglycaemic episode and one in 50 (2.2 per cent) required injectable treatment due to the severity of the hypoglycaemia.

This is despite the fact that only 8.1 per cent of respondents had been admitted for their diabetes or a diabetic complication.

The findings are published today in the National Diabetes Inpatient Audit (NaDIA), carried out by the Health and Social Care Information Centre, in collaboration with Diabetes UK. NaDIA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme3

The report found that over a third of inpatients (37.5 per cent) who should have been referred to a hospital diabetes team did not see a diabetes specialist8; almost one third (31.7 per cent) of sites in the audit had no diabetes inpatient specialist nurses (DISNs); and over one in 20 (5.3 per cent) had no consultant time for diabetic inpatient care. Almost three quarters (71.2 per cent) of sites had no specialist inpatient dietetic staff time for people with diabetes.

This is despite the report's findings that almost one in six people in a hospital bed has diabetes and that the percentage of hospital beds occupied by people with diabetes has risen each year (from 14.6 per cent in 2010 to 15.8 per cent in 2013).

The report also found that the more than a third of patients (37.0 per cent) with diabetes experienced a medication error9, down from 39.9 per cent in 2011. Patients who had experienced a medication error were more than twice as likely to suffer a severe hypoglycaemic episode (15.3 per cent) compared to those with no error in their medication (6.8 per cent).

The National Inpatient Diabetes Audit (NaDIA) examines data about inpatients with diabetes collected by hospital teams in England and Wales on a nominated day in a defined week in September. It covers issues such as staffing levels, medication errors, patient harm and patient experience. The 2013 audit involved 14,198 patients with diabetes in 142 trusts in England and six local health boards in Wales.

The data also shows:

Diabetic Ketoacidosis

  • 63 patients (0.4 per cent) were reported to have developed diabetic ketoacidosis (DKA) after their admission. This is a life threatening but preventable complication, resulting from a severe shortage of insulin.

Podiatry

  • All patients with diabetes should have a foot examination on admission, to detect and prevent foot complications. There happened in 42.4 per cent of cases in 2013, a significant increase from 25.8 per cent in 2011.
  • 9.2 per cent of patients were admitted with active diabetic foot disease10, all of whom should be seen by the multidisciplinary foot care team within 24 hours of admission. Of these, 61.1 per cent were seen by a member of the team within 24 hours, and 69.3 per cent had seen a member of the team within the past seven days.
  • The proportion of patients developing a foot lesion in hospital has reduced from 2.2 per cent in 2010 to 1.4 per cent in 2013.

Patient satisfaction with timing and content of meals

  • 14.7 per cent of patients reported that the hospital did not provide the right kind of food to manage their diabetes.
  • 15.1 per cent of patients said that they needed food to be brought into hospital to meet their dietary requirements and/or manage their diabetes.

Audit lead clinician Dr Gerry Rayman said: "The purpose of this annual clinical audit is to drive improvements in care for inpatients with diabetes. We are therefore delighted to see year on year improvements including reductions in patient harm. This is good news but there is still a great deal more to do.

"Whilst it is welcome to see that the percentage of patients experiencing hypoglycaemia in hospital fell from 25.7 per cent in 2011 to 22.0 per cent in 2013, the number of patients developing this largely preventable complication remains unacceptably high. Additionally, although a 36 per cent reduction in hospital acquired foot ulceration from 2.2 per cent to 1.4 per cent is very impressive, the frequency of this wholly preventable complication remains significantly greater than in those without diabetes.

"The role of specialist diabetes staff within hospitals is crucial; it is therefore disappointing that staffing levels remain inadequate and it is unacceptable that over 30 per cent of trusts continue to have no diabetes inpatient specialist nurses.

"Diabetes is dependent on the whole of the hospital team working together to deliver safe care: from specialists, to junior medical staff, non-specialist nursing staff, health care assistants, dieticians, podiatrists, pharmacists and even catering staff.

"Were every trust in England and Wales to invest in a fully staffed inpatient diabetes team, many expensive and avoidable complications could be prevented with considerable savings in bed days. More importantly, there would be a significant improvement in patient satisfaction, and a reduction in morbidity and mortality."

ENDS


Notes to editors

  1. The Health and Social Care Information Centre (HSCIC) was established on April 1 2013 as an Executive Non Departmental Public Body (ENDPB). The trusted source of authoritative data and information relating to health and care, HSCIC plays a fundamental role in driving better care, better services and better outcomes for patients. It supports the delivery of IT infrastructure, information systems and standards to ensure information flows efficiently and securely across the health and social care system to improve patient outcomes. Its work includes publishing more than 130 statistical publications annually; providing a range of specialist data services; managing informatics projects and programmes and developing and assuring national systems against appropriate contractual, clinical safety and information standards. www.hscic.gov.uk
  2. Diabetes UK is the leading UK charity that cares for, connects with and campaigns on behalf of all people affected by or at risk of diabetes. It helps people manage their diabetes effectively by providing information, advice and support. Diabetes UK campaigns with people with diabetes and with healthcare professionals to improve the quality of care across the UK's health services. It funds pioneering research into care, cure and prevention for all types of diabetes. It works to stem the rising tide of Type 2 diabetes - through risk assessment, early diagnosis, and by communicating how healthy lifestyle choices can help many people avoid or delay its onset. www.diabetes.org.uk
  3. About HQIP, the National Clinical Audit Programme and how it is funded. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands. www.hqip.org.uk
  4. The aim of the National Diabetes Inpatient Audit is to drive improvements in care for inpatients with diabetes. It is the world's only national audit of inpatient diabetes and indeed the largest audit of bedside care for any condition.
  5. Diabetes comprises a group of disorders with many different causes, all of which are characterised by a raised blood glucose level. This is the result of a lack of the hormone insulin and/or an inability to respond to insulin. Insulin in the blood, produced by the pancreas, is the hormone which ensures that glucose (sugar) obtained from food can be used by the body. There are two main types of diabetes: Type 1 diabetes and Type 2 diabetes.
  6. For the purpose of this audit, mild hypoglycaemia was defined as a capillary blood glucose of between 3.0 - 3.9mmol/L and severe hypoglycaemia was defined as a capillary blood glucose of less than 3.0mmol/L. 20.0 per cent of inpatients had one or more mild hypoglycaemic episodes and 9.3 per cent had one or more severe episodes.
  7. Hospital staff were asked to report on the number of hypoglycaemic blood sugar readings on the patient's chart within the seven days up to the day of the audit. If the patient had been in hospital for less than seven days then the number of readings for the total period of the hospital stay was reported.
  8. Assessment of whether a patient should be seen by a member of the specialist diabetes team was made using the NHS Institute for Innovation's 'Think Glucose Criteria' www.institute.nhs.uk/quality_and_value/think_glucose/welcome_to_the_website_for_thinkglucose.html
  9. The most common medication errors were insulin or an oral hypoglycaemic agent not being increased when blood glucose was persistently high. Other recorded errors included staff failing to note that they had given diabetic medications, medications being given or prescribed at the wrong time and medications not being reduced when appropriate.
  10. The term "Active Foot Disease" applies to any condition of the foot which is either of recent onset, or chronic but deteriorating and include ulcers, blisters, inflammation or swelling, gangrene and other symptoms. Diabetic foot complications are a particular risk for people with diabetes and are the most common cause of lower limb amputation in the UK. www.diabetes.org.uk/Documents/Reports/Putting_Feet_First_010709.pdf
  11. Dr Gerry Rayman is Consultant Physician and Head of Service at the Diabetes and Endocrine Centre at Ipswich Hospital NHS Trust.
  12. For media enquiries to the HSCIC please call 0300 303 3888 or email media@hscic.gov.uk
  13. For media enquiries to Diabetes UK, please call 0207 424 1165 or email pressteam@diabetes.org.uk
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