‘DICE- Diabetes Inpatient Care
and Education’
The DICE Team
What is the DICE project
• A whole systems approach to improving
inpatient diabetes care
• 6 months observation, audit and development
of tools and pathways to improve care
• 6 months implementation and continual audit
• 6 months of comparison audit
• Analysis of patient harm, LOS, readmission,
patient satisfaction, health economic analysis
etc
The National Diabetes
Inpatient Audit (NaDIA)
2012
Gerry Rayman
Ipswich Hospital, Suffolk
National Clinical Lead
for Inpatient Diabetes
The Burden of Inpatient Diabetes- Bed Usage
30
Prevalence of diabetes amongst inpatients in
acute hospitals
Overall prevalence:
15.3%
Number of hospitals
25
20
15
10
5
0
<5 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25>25
Per cent
Prevalence
National Inpatient Diabetes Audit
•
•
•
•
•
•
>14, 000 patients in 219 hospitals audited
1 in 4 patients with hypoglycaemia
1 in 10 patients with severe hypoglycaemia
1 in 50 hypoglycaemic coma
40% on insulin had prescription errors
3% developed foot complications in hospital
National Inpatient Diabetes Audit
• 60 patient developed DKA/wk = 3,000/yr
• 260 had a hypoglycaemic coma= 13,000/yr
• 400 had developed a foot complications
=20,000/yr
Junior Doctors Induction
Insulin: Armed and Extremely
Dangerous
Insulin errors
• Insulin errors are the 3rd
most common cause of
serious harm or death
• Can lead to health care
professional being
prosecuted for
manslaughter
FATAL insulin errors-UK
Cox, AR, and Ferner RE. Br. J Diabetes Vasc Dis 2009; 9:84-88
• Junior doctor ignorant of insulin syringe use administered 50
units instead of five of 5 units: attributed to lack of training
• Junior doctor: Poor handwriting in prescribing led to 40 units
being given instead of 4 units with fatal consequences
• Junior doctor used wrong syringe, believing 1 unit of insulin in
1 ml; 100 times overdose, attributed to lack of training
Doctor gives fatal insulin Patient given 'insulin
overdose'
dose
Doctors in NI are to receive fresh
A 92-year-old man died of a heart attack
guidance on how to administer
after a junior doctor gave him a drugs
insulin. It follows an inquest into
overdose, an inquest has heard.
the death of an elderly woman
who was given ten times the dose
of insulin she needed.
Mrs Pitt's 62-year-old husband, David, said: "The entire family is distraught by her
death and it's hard not to remain angry that she was let down so badly by the
nurses that were employed to care for her and make her better."
A coroner ruled in June 2012 that Jackie Charman committed a gross failure in not
taking a blood sugar reading for Mrs Pitt.
A second nurse, Sarah Morgan, who was described as a diabetes specialist, had
misunderstood what to do when she found Mrs Pitt had low blood sugar levels
and failed to give a proper handover.
She was admitted to the hospital, which had treated her for more than 12 years, on
27 September with a chest infection.
She fell into the coma as a result of hypoglycaemia [low blood sugar] on the night of
29-30 September and suffered brain damage as a result.
She never regained consciousness and died from bronchial pneumonia on 13
October, the hearing was told.
Dr Carlyon heard staff had changed the interval in which her blood sugar was
monitored from every two hours to every six.
A witness told the coroner's court her case should have been reviewed by a specialist
diabetes team.
In a narrative ruling, Dr Carlyon said Ms Harry died because the hypoglycaemia "was
not recognised or treated in time to avoid death".
The trust added that 11 changes had been made at the hospital as a result of the
death.
They include the provision of treatment boxes in every ward and department, extra
staff on Carnkie Ward and a programme of education for all nursing staff
Peter Galsworthy from the Health and Safety Executive said the hospital would be
prosecuted under the Health and Safety at Work Act.
He said: "The immediate cause of death was the failure to administer insulin to a known,
diabetic patient”.
"Our case alleges that the trust failed to devise, implement or properly manage structured
and effective systems of communication for sharing patient information, including in
relation to shift handovers and record-keeping."
Catherine Beeson Gillian Astbury's daughter “How could they miss she needed insulin? It's
just basic care”
DICE Care Pathway
• Admission chart
• DPAR score
• Patient self administration and self test
assessment
• Foot protection tool
• Glucose monitoring and diabetes prescription
chart
• Insulin infusion charts/regimens
• Safe discharge check list
• Advice for JDs and nursing staff
Patients at risk need heel protection!
FoB uptake
uptakeon
onwards
wards- -Completed
Completed
FoB
Assessments(%)
(%)
Assessments
90
80
100
90
70
80
60
70
50
60
40
50
30
40
20
30
20
10
010
0
NaDIA
0.5
3
4
5
10
CQUIN
NaDIA Months
0.5 Months
3 Months
4 Months
5 Months
2009
Months
Months
months 10
Jan 2012
2009
Months
months
Reduction in Foot Lesions
2008-9 2009-10 2010-11
2011-12
Grade 2
30
22
9
8
Grade 3
5
5
2
2
Grade 4
2
2
1
0
Total %
reduction
73%
Patients at risk need heel protection!
FoB uptake
uptakeon
onwards
wards- -Completed
Completed
FoB
Assessments(%)
(%)
Assessments
90
80
100
90
70
80
60
70
50
60
40
50
30
40
20
30
20
10
010
0
NaDIA
0.5
3
4
5
10
CQUIN
NaDIA Months
0.5 Months
3 Months
4 Months
5 Months
2009
Months
Months
months 10
Jan 2012
2009
Months
months
Reduction in Foot Lesions
2008-9 2009-10 2010-11
2011-12
Grade 2
30
22
9
8
Grade 3
5
5
2
2
Grade 4
2
2
1
0
Total %
reduction
73%
Diabetes Specialist Support
• 1 full time and 2 part time inpatient nurses
• Part time weekend cover
• Referral via the DPAR system and
electronically through evolve
• Support from the ICU outreach team out of
hours
• Diabetes Consultant support for all DPAR
scores of 8 or greater
Further work
• Peri-operative pathway
• Pathway in ED
• Central point for JDs to access diabetes
guidelines
• Linking discharge to the community DSN when
in place
• Development of a dashboard of KPI