A lack of specialist nurses and other expert staff is continuing to contribute to unnecessary patient harms in hospital, according to the latest major audit of diabetes care.
It found a significant fall in diabetic foot ulcers over the last five years, but few changes in other patient harms and a continuing lack of specialist nurses in many hospitals.
“There is no specialist inpatient diabetes nurse service in almost one third of hospitals”
Only 1.1% of inpatients with diabetes developed a new foot lesion during their admission to hospital, a significant decrease from 2.2% when inpatient auditing began in 2010.
But 67% of inpatients in the latest audit did not have a specific diabetic foot risk examination while in hospital and 31% of sites do not have a multi-disciplinary diabetic foot care team.
The findings form part of the 2015 National Diabetes Inpatient Audit, which is carried out by the Health and Social Care Information Centre in collaboration with the charity Diabetes UK.
The 2015 audit was carried out in acute hospitals in 135 trusts in England and six local health boards in Wales on one day in September. More than 15,000 diabetes patients were also surveyed.
The audit covers issues including staffing levels, medication errors, patient harm and patient experience.
In comparison to foot lesions, improvements have not occurred in the other two main hospital inpatient harms – severe hypoglycaemic episodes and diabetic ketoacidosis.
The proportion of inpatients having one or more hypoglycaemic episode, since 2010, has reduced from 26.1% to 21.8%.
“Lack of specialist staff and subsequent medication errors mean patients continue to be put at increased risk”
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% in 2010 compared to 2.1% 2015.
Since 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% in both 2010 and 2015.
The audit noted that the percentage of hospital beds occupied by diabetes patients had risen each year from 14.6% in 2010 to 15.8% in 2013, and increased again to 16.8% in the 2015.
Although levels of referrals and patient contacts have increased among diabetes teams, the audit found no corresponding significant increase in staffing levels.
Almost one-third of sites (31.1%) have no diabetes inpatient specialist nurse available, with no increase since 2010. Consultant access was also limited.
The proportion of inpatients experiencing medication errors has increased from 37% to 38.8% since the previous audit in 2013, partially reversing the earlier decreasing trend.
Specialist diabetes teams must be ‘embedded’ in all hospitals
A review of inpatient drug charts also found that 23.9% had at least one medication management error within the previous seven days, a significant increase from 22.3% in 2013.
Audit lead clinician Dr Gerry Rayman said: “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.
“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,” he said.
He added: “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% of sites having an inpatient diabetes specialist nurse service.”
Chris Askew, chief executive of Diabetes UK, said: “Having diabetes specialists in place is a vital step to addressing early on, or even avoiding, devastating and costly complications.
“Their impact also extends to other hospital staff as they play a valuable role in training and building up their understanding of diabetes and the healthcare needs of patients with this complex condition helping to ensure these are met every time,” he said.
“The current lack of specialist staff and subsequent medication errors mean patients continue to be put at increased risk of having a severe hypoglycaemic episode or diabetic ketoacidosis, both of which can be life-threatening but are largely preventable,” he added.
Summary of audit findings:
- In the week of the audit, 66 patients (0.4%) were reported to have developed diabetic ketoacidosis after their admission, equating to almost 3,500 annually.
- More than one fifth (21.8%) of inpatients had one or more hypoglycaemic episodes over the previous seven days of their stay.
- In the week of the audit, there were 213 severe hypoglycaemic events requiring rescue with injectable treatment, equating to over 11,000 events annually.
- 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%) compared to inpatients whose drug chart had no medication errors (7.5%).
- Of the 8.9% of inpatients that were admitted with active diabetic foot disease, only 59.5% were seen by a member of the multi-disciplinary foot care team within the target time of 24 hours following admission.
- There has been a very significant improvement in the use of intravenous insulin infusions which had been previously inappropriately over used – 9% of inpatients with diabetes had been on an insulin infusion within the last seven days compared with 12.5% in 2010, of which 8.3% had been on an infusion for seven days or longer down from 10% in 2010.
Patient satisfaction with timing and content of meals
- 84.1% of inpatients were satisfied or very satisfied with the overall care of their diabetes while in hospital.
- 34.1% 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%.