Diabetes care - progress against national priorities: commitments - 2021 to 2026

Priority 6 - Inpatient Diabetes

To improve the quality of care for people living with diabetes admitted to hospital by improving their glucose management and reducing the risk of complications during admission

The Diabetes Improvement Plan 2014 reported that at any one time 15-20% of inpatients will have diabetes and that there is clear evidence that inpatient care is suboptimal. Issues highlighted included prescribing and medication errors, diabetic ketoacidosis, hypoglycaemia and hyperglycaemia. Hyperglycaemia is associated with increased infection rates and hypoglycaemia with an increased length of stay and subsequent mortality. Feedback from patient surveys undertaken by Diabetes Scotland highlighted areas where people living with diabetes would like to see improvement such as general understanding of diabetes, suitability and timing of food and insulin administration.

Action 6.1 Improve glycaemic control of people admitted to hospital

Diabetes, Think, Check, Act

In 2014, Healthcare Improvement Scotland supported inpatient diabetes improvement through the initiative 'Diabetes Think Check Act'. This involved development of a package of measures, interventions and education, using improvement methodology, for roll out across Scotland. The Diabetes Think, Check, Act tool provides a range of resources and online learning for in-patient improvement projects and the rational for improving in patient care. However the roll out of this initiative to all hospital wards in Scotland has been challenging.

The Scottish Health and Social Care Delivery Plan (2016) included a commitment to reduce unscheduled bed-days by up to 400,000 by 2018. In March 2017, Dr Jason Leitch, National Clinical Director Healthcare Quality & Improvement Directorate sent a letter to each NHS board on 'Reducing Unscheduled Bed Days through Improving Inpatient Care for Patients with Diabetes'. This summarised the opportunity to reduce unscheduled bed days across NHS boards through improving inpatient care of people with diabetes who are being cared for in non-diabetes settings. Each health board was asked to nominate a non-diabetes specialist lead to be responsible for the further roll out of Diabetes, Think, Check, Act within their board area including increasing the use of hypo-boxes.

Introduction of 'Hypo boxes'

Approximately 15 - 20% of patients in a hospital at any time have diabetes and have potential to experience problems with hypoglycaemia. Hypo-boxes are now available in hospital wards to promote access to prompt and effective treatment for all patients in the event of hypoglycaemia. In 2018, additional funding was provided to Boards to ensure that hypo-boxes were available in every ward in every hospital in Scotland. Use of hypo-boxes is being expanded to include other areas where people with diabetes may be for example care homes, health centres etc.

Inpatient Data Linkage in NHS Tayside

There is currently no national approach to recording inpatient diabetes outcomes despite ongoing discussions regarding secure data capture in each health board in collaboration with IT departments and the pharmaceutical providers of blood glucose systems.​​ This is something we continue to work towards in all health boards with some board areas being closer to this than others. Ongoing developments within SCI-Diabetes to develop an in-patent diabetes dashboard will support this.

In NHS Tayside, IT linkage of admission, discharge and transfer (ADT) messages from the hospital Patient Administration System (PAS), and SCI-Diabetes and blood glucose monitoring systems has been established since December 2016. This linkage captures blood glucose tests undertaken in each ward and department in people with diabetes, the incidence of hypoglycaemia and resolution of hypoglycaemia within one hour. These data are utilised in NHS Tayside by the specialist team to assess clinical activity and inform quality improvement. The data from Ninewells Hospital demonstrates that between December 2016 and May 2020 the incidence of hypoglycaemia has reduced and the proportion of hypoglycemia resolved within one hour has improved.

Scottish Patient Safety Programme

Scottish Patient Safety Programme is a national initiative that aims to improve the safety and reliability of health and social care and reduce harm, whenever care is delivered. With approximately 15 - 20% of patients in our hospitals having diabetes at any one time it is crucial to consider how best to meet the needs of this population. There is a requirement to audit what care is currently being provided to people with diabetes to support initiatives to make improvements and to develop greater links with the Scottish Patient Safety Programme.

Action 6.2 Improve foot care outcomes

Check, Protect, Refer for Feet (CPR)

As discussed in Action 2.1 the Check, Protect, Refer for Feet (CPR) initiative aims to make sure all patients with diabetes who are admitted to hospital have their feet checked on admission, if they are at risk of developing a foot ulcer their feet are protected and if they have a current foot ulcer they are referred appropriately. To support improvements in care a range of information materials and training tools have been developed to support the uptake of this initiative across Scotland.

The recent national inpatient diabetes foot audit demonstrated that more patients were getting their feet checked when in hospital and there was an increase in use of foot protection. However the number of ulcers as consequence of being an in-patient did not decrease, but this may reflect greater awareness and detection of the problem. A local audit identified that more than half of all inpatient DKA episodes were precipitated by unrecognised foot infections.

Work continues to actively encourage the implementation of the CPR for Feet campaign across all care settings and encourage the use of the quality, fit for purpose and cost effective pressure redistribution devices.

Action 6.3 Improve the experience of people with diabetes admitted to hospital

Identifying people with diabetes in hospital

An inpatient domain is now available within SCI-Diabetes, the shared electronic record for the care of people with diabetes in NHS Scotland. In some health boards SCI-Diabetes receives admission, discharge and transfer messages from the hospital Patient Administration Systems and from connected blood glucose meters. This can be used to highlight individuals with diabetes in hospital, support risk stratification and lead to an early assessment of their needs. This data can also be utilised by the specialist diabetes team to target activity to improve patient outcomes and identify areas within the hospital who could benefit from additional training on caring for people with diabetes.

Only a small number of boards are using this functionality to its full potential but all are encouraged to work towards this as this is an opportunity to reduce the length of inpatient stays through proactive rather than reactive reviews.

Reducing Insulin Errors

While it has not been possible to introduce standardised insulin prescription and monitoring charts due to local governance and existing improvement work, the Scottish Diabetes In-Patient subgroup shares examples of best practice around this. It is recognised that achieving a standardised prescription and monitoring chart at board level remains an aspiration of many boards to standardise practice and reduce the number of insulin errors. It is anticipated that the roll out of electronic prescribing across health boards will support a reduction in insulin errors.