Royal United Hospital Bath

1. Royal United Hospital Bath iSAID- insulin safety in Diabetes

2. Team Members • Dr Marc Atkin, Consultant Diabetologist, Inpatient Diabetes Lead • Ainslie Lang, Inpatient Diabetes Specialist Nurse • Leon Massey, Inpatient Diabetes Specialist Nurse • Rachael Pearce, Specialty Manager Diabetes • Lloyd Mayers, Senior Pharmacist, RUH

3. What are we trying to accomplish? Our Aim • Redduce serious untoward incidents involving insulin to zero and reduce adverse events by 75% in inpatients with diabetes (IWD) by May 2017 What we are going to do. • Reduce number of potential harm events • Reduce no of hypoglycaemic events • Reduce no of medication errors • Education and support for ward staff (doctors and nurses) in delivering safe and effective diabetes care for IWD • On the job training • Explore new ways of delivering education • Ease of access to specialist advice – real time & written • Improve the patient experience • Greater use of safe self administration of insulin • Increased patient confidence in staff knowledge • Better co-ordination of primary and secondary care • Examine how we use the ADT to achieve the above • Direct inreach – move the knowledge, not the patient • ?everywhere • Labour intensive • Proactive rather than reactive • Staff support and education • Influence over policy/significant decisions that may not be under our direct influence

4. Why are we doing this? We know we could do better. • NDIA data • Local Serious Untoward Incidents (SUIs) & recent coroners case • National recognition – priority of NHS England • Diabetes inpatients more numerous and more complex – approx 20% of all inpatients. The problem is only going to get worse. Benefit to the organisation • More proactive care rather than reactive • Improved quality of care = more effective care • Improved flow/ reduced LoS • Less time dealing with SUIs • Better reputation for inpatient diabetes care • Lessons learned can be replicated in other fields • Better co-ordination of primary and secondary care Supporting data/analysis • NADIA • Datix data/Serious untoward incidents Impact on patients • Improves experience/avoids harm • Greater confidence of patients and staff • Shortens the stay in hospital • Greater autonomy Team sponsor • Chief operating officer. Recognition as an issue – Trust Quality account for 2015-16

5. National Diabetes Inpatient Audit 2015Errors

6. National Diabetes Inpatient Audit 2015Insulin errors

7. National Diabetes Inpatient Audit 2015Hypoglycaemia

8. National Diabetes Inpatient Audit 2015Patient satisfaction

9. National Diabetes Inpatient Audit 2015Patient satisfaction

10. Why are we doing this? We know we could do better. • NDIA data • Local Serious Untoward Incidents (SUIs) & recent coroners case • Previous projects have been very effective (local & national) • National recognition – priority of NHS England • Diabetes inpatients more numerous and more complex – approx 20% of all inpatients. The problem is only going to get worse. Benefit to the organisation • More proactive care rather than reactive • Improved quality of care = more effective care • Improved flow/ reduced LoS • Less time dealing with SUIs • Better reputation for inpatient diabetes care • Lessons learned can be replicated in other fields • Better co-ordination of primary and secondary care Supporting data/analysis • NADIA • Datix data/Serious untoward incidents Impact on patients • Improves experience/avoids harm • Greater confidence of patients and staff • Shortens the stay in hospital • Greater autonomy Team sponsor • Chief operating officer. Recognised as an issue by the Trust – Trust Quality Account for 2015-16

11. What are we trying to accomplish? Our Aim • Redduce serious untoward incidents involving insulin to zero and reduce adverse events by 75% in inpatients with diabetes (IWD) by May 2017 What we are going to do. • Reduce number of potential harm events • Reduce no of hypoglycaemic events • Reduce no of medication errors • Education and support for ward staff (doctors and nurses) in delivering safe and effective diabetes care for IWD • On the job training • Explore new ways of delivering education • Ease of access to specialist advice – real time & written • Improve the patient experience • Greater use of safe self administration of insulin • Increased patient confidence in staff knowledge • Better co-ordination of primary and secondary care • Examine how we use the ADT to achieve the above • Direct inreach – move the knowledge, not the patient • ?everywhere • Labour intensive • Proactive rather than reactive • Staff support and education • Influence over policy/significant decisions that may not be under our direct influence

12. Expected Outcomes • Increase in safe self administration of insulin (?baseline/to protocol) • 75% reduction in hypo rates and medication/prescription errors • Reduction in SUI’s involving insulin by 100% • Reduction by 50% in datix / RM1’s (datix in the community) incidents involving IWD • Improved access to ADT for IWD – increase penetration to 75% • Training matrix in place and evidence of its use/effectiveness • Improved patient experience for IWD • Improved staff knowledge/confidence • Improved measures of productivity/efficacy for the ADT • Deliver within 12 months

13. How do we know that change is an improvement? • See above What unintended consequences could occur? • Deskilling of ward staff • Lack of engagement from ward staff • Over-reliance on ADT • Worsening of diabetes care out of hours

14. What changes can you make? • Proactive intervention from ADT • On the job teaching support for ward staff • Easier access to support/advice for ward staff • Explore other means of education/create an education matrix • Easier access/encourage use of standard protocols • Use of e-learning modules • Use of diabetes care plans • Diabetes checklists for discharge/admission • Explore how self administration uptake can be improved • Greater use of link nurses • Increase profile of Insulin safety within the Trust Use of ADT • Within existing staffing costs • Explore better use of precision web • Entire Trust proactive coverage vs. high density wards • Scoring card to triage referrals

15. Standardisation of charts. • Guidelines more accessible Change idea Reduce number of adverse incidents involving Insulin. Stop SUI’s involving insulin. • Self administration policy widely used • Standardized prescribing practice • Education ‘development matrix’ for nurses and junior doctors • Mandatory e-learning • Link nurses (local champions) • Diabetes simulations Improve insulin safety at Bath RUH. Increase education and training for all staff • Medicine reconciliation • Discharge summaries • Discharge and admission checklists Co-ordination of care, through admission to discharge • Set referral criteria • Creation of diabetes care plan • ED & MAU use of Acute DM service Streamline IDSN service