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Hospital acquired foot ulcers reduced by 50 per cent since diabetes inpatient audit launched

27 June 2016 ยท Clinical audit shows a significant fall in foot ulcers but few changes in other patient harms and a continuing lack of specialist staff in many hospitals

Regional information is available from this audit

Only 1.1 per cent of inpatients with diabetes1 developed a new foot lesion2 during their admission to hospital, a significant decrease from 2.2 per cent when inpatient auditing3 began in 2010.

However, more than two thirds (67.0 per cent) of inpatients included in the 2015 audit did not have a specific diabetic foot risk examination during their hospital stay and 31 per cent of hospital sites still do not have a multi-disciplinary diabetic foot care team, despite being highlighted as important in each audit round. Addressing these could further impact on this devastating and costly preventable complication.

The findings are published in the National Diabetes Inpatient Audit (NaDIA), carried out by the Health and Social Care Information Centre4, in collaboration with Diabetes UK5. NaDIA is commissioned by the Healthcare Quality Improvement Partnership6 (HQIP)as part of the National Clinical Audit Programme.

Since 2010, similar improvements in the other two main hospital inpatient harms - severe hypoglycaemic episodes7 and diabetic ketoacidosis (DKA) - have not occurred.

The proportion of inpatients having one or more hypoglycaemic episode, since 2010, has reduced from 26.1 per cent to 21.8 per cent. However, there has been no significant reduction in the proportion of inpatients having one or more severe life threatening hypoglycaemic episodes that required emergency rescue with injectable treatment (2.4 per cent in 2010 compared to 2.1 per cent 2015).

Since the audit began in 2010, there has been no reduction in the proportion of inpatients developing the severe life threatening and wholly preventable condition DKA after admission - 0.4 per cent in both 2010 and 2015.

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 and increased again to 16.8 per cent in the 2015 audit. 35.5 per cent of inpatients with diabetes were seen by a member of the diabetes team8 and 83.7 per cent of sites reported an increase in referrals/patient contacts since the 2013 NaDIA.

Although levels of referrals and patient contacts have increased amongst diabetes teams, there has been no corresponding significant increase in staffing levels. Almost one-third of sites (31.1 per cent) have no diabetes inpatient specialist nurse (DISN) available, with no increase since the audit inception in 2010. Consultant access was also limited as 9.2 per cent of sites did not have any consultant time for diabetes inpatient care. There is no specialist inpatient dietetic staff time for people with diabetes at almost three quarters (71.4 per cent) of sites.

The proportion of inpatients experiencing medication errors9 has increased from 37.0 per cent to 38.8 per cent since the previous audit in 2013, partially reversing the earlier decreasing trend. A review of inpatient drug charts also found that 23.9 per cent had at least one medication management error within the previous 7 days, a significant increase from 22.3 per cent in 2013.

The National Inpatient Diabetes Audit (NaDIA) 2015 was carried out by diabetes teams in acute hospitals in 135 Trusts in England and 6 Local Health Boards in Wales on a nominated day in September. It covers issues such as staffing levels, medication errors, patient harm and patient experience. The 2015 audit surveyed 15,299 patients with diabetes.

The data also shows:

Diabetic Ketoacidosis

  • In the week of the audit, 66 patients (0.4 per cent) were reported to have developed diabetic ketoacidosis (DKA) after their admission; equating to almost 3,500 annually. This is a life threatening but preventable complication, resulting from a severe shortage of insulin.

Hypoglycaemic episodes

  • More than one fifth (21.8 per cent) of inpatients had one or more hypoglycaemic episodes over the previous 7 days of their stay10.
  • In the week of the audit, there were 213 severe hypoglycaemic events requiring rescue with injectable treatment, equating to over 11,000 events annually. This life threatening complication is wholly preventable by careful management of medications and nutrition and reflects a deficiency in care. 
  • Inpatients whose drug chart had at least one medication error were more than twice as likely to have one or more severe hypoglycaemic episodes (15.5 per cent) compared to inpatients whose drug chart had no medication errors (7.5 per cent).

Foot Care

  • Of the 8.9 per cent of inpatients that were admitted with active diabetic foot disease, only 59.5 per cent were seen by a member of the multi-disciplinary foot care team within the target time of 24 hours following admission.

Insulin infusions

  • There has been a very significant improvement in the use of intravenous insulin infusions which had been previously inappropriately over used; 9.0 per cent of inpatients with diabetes had been on an insulin infusion within the last 7 days compared with 12.5 per cent in 2010, of which 8.3 per cent had been on an infusion for 7 days or longer down from 10 per cent in 2010.

Patient satisfaction with timing and content of meals

  • 84.1 per cent of inpatients were satisfied or very satisfied with the overall care of their diabetes while in hospital.
  • 34.1 per cent of patients reported that the hospital did not always provide the right choice of food to manage their diabetes, significantly higher than the proportion in 2013 which was 24.3 per cent.

Audit lead clinician, Dr Gerry Rayman,11 said: "We are proud of what the audit has achieved since 2010 and the difference it has made to hospital care for patients with diabetes. However the results do show that, while the number of inpatients continues to rise, this is not being matched by resources and staffing which could make an even more significant improvement.

"The 50 per cent reduction in hospital acquired foot ulcers since the introduction of NaDIA, on its own, equates to an estimated annual saving of over £30 million which would more than provide sufficient savings to fund the inpatient diabetes specialist teams that could help reduce the other harms. The achievements gained should be celebrated but there is still much more work to be done to reduce entirely preventable very serious treatment related complications.

"In particular, the rise in medication errors is a cause for concern as the audit shows that patients with a medication error on their drug chart are more than twice as likely to have a severe hypoglycaemic episode. These are largely preventable. Diabetic ketoacidosis is due to patients being given insufficient or even no insulin. This should never happen. Yet the frequency of this wholly preventable and life threatening complication remains unchanged.

"The audit has demonstrated a year on year increase in the number of patients with diabetes in hospital. As the number of referrals and patient contacts continue to rise, hospitals will struggle to meet targets and improve patient care without an increase in specialist staff. There is no specialist inpatient diabetes nurse service in almost one third of hospitals, no specialist dietetic staff time for people with diabetes at almost three quarters of sites and a third of hospitals do not have a multi-disciplinary foot care team. That such deficiencies exist during the working week is shocking, of greater concern is the almost total lack of specialist diabetes care at weekends with under 7 per cent of sites having an inpatient diabetes specialist nurse service.

"Since 2010, the NaDIA has been an excellent tool for highlighting specific issues in patient care and driving forward changes that can save lives, improve inpatient experiences and save money for hospital trusts. Despite significant results in some areas, others remain static and will continue to do so until the existing overstretched specialist teams, who do an amazing job, are better supported and Trusts who have no inpatient diabetes service are commissioned to provide this."


Notes to editors

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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. 21.8 per cent of inpatients had one or more hypoglycaemic episode (mild and/or severe).

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'

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. 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.

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 0845 257 6990 or email

13. For media enquiries to Diabetes UK, please call 0207 424 1165 or email

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