Improving Inpatient Safety by

Standardizing Care

Ruth MillerLead Nurse Diabetes Service

Royal Free Hospital Foundation TrustFebruary 2014

Background

Following iv insulin related SUI in 2008, hospital-wide iv insulin prescribing was audited over a one month period

Audit Findings• Audit confirmed wide variation in prescribing

practices and high % of prescriptions did not follow existing guidelines

• Absence of protocols/guidelines

• Poor diabetes knowledge & staff training

• Widespread inappropriate use of iv insulin

• Many patients managed on tablets should never be given iv insulin

• No standardised treatment for hypoglycaemia

• Poor understanding of hypoglycaemia causes and treatment

Working Party Set up

• PART (patient at risk team)

• Risk & Safety team

• Pharmacy

• Anaesthetics

• Diabetes Inpatient Team

Diabetes Pilot 2008-2011

Using the PDSA change cycle

• Democratic ‘bottom up’ change cycle

• Raising profile and awareness of diabetes

• Development of diabetes management chart

• Standardised hypoglycaemia treatment algorithm

• Standardised iv insulin prescription

• Development of the iv insulin procedure pack

Development of Standardised

Insulin Prescription &

Procedure Pack• Variable rate intravenous insulin infusion (VRIVII)

• Non returnable Y connector

• Everything in the pack (other than insulin)

• Reduce risk of error

• Intravenous insulin must never be given without simultaneous intravenous 10% dextrose

• Insulin Sliding Scale is a temporary solution

Training all Clinical Staff key to Pilot

Success• Short term intervention /review need daily

• Consider risk versus benefit

• Type 1 diabetes / type 2 on tablets/insulin

• Consider whether appropriate for type 2 diabetes on tablets only

• Acutely ill, nil by mouth or perioperative

• Do not use for patients who are eating and drinking

• Tube fed patients should be referred for review

Standardising treatment of

Hypoglycaemia

Subsequent National Inpatient Audit

Results• 58% reduction in the use of insulin

sliding scale

• 70% reduction in hypoglycaemia

Ongoing work: preventing Inpatient

Hypoglycaemia…• Connected blood glucose meters

• DSN central access to all blood glucose results

• Proactive daily identification of hypoglycaemia in inpatients not known to team

• Targeted intervention and prevention of reoccurrence

• Powerful opportunity to teach clinical staff