Hypoglycaemia and Pre-Pregnancy Care Projects Dr Peter Winocour - Consultant Physician and Clinical Director for Diabetes and Endocrine Services Sarah Woodley - Clinical Nurse Educator Karen Moore-Haines - Project Manager East and North Herts Institute of Diabetes and Endocrinolgy (ENHIDE)

EAHSN Strategic goals:  Innovative population based transformational models of delivery  Using data to address unwarranted variations  Using proven science methods and professional networks to deliver improvement in outcomes for major chronic diseases  Engaging industry to deliver innovative interventions and systems  Developing workforce capacity and capability

Diabetes CSG – nodes Cambridge Norwich Stevenage Colchester Marcus Bailey- EoE Ambulance Trust Dr Charles Bodmer Dr John Clarke Dr Martin Hadley Brown Dr Clare Hambling Dr Vithian Karunakaran Dr Helen Murphy Dr Gerry Rayman Dr Rosemary Temple Dr Mike Streather Dr David Simmons Prof Mike Sampson Dr Peter Winocour Commissioners

Improving outcomes and reducing variance in diabetes pregnancy in the EAHSN (‘EASIPOD2’) Murphy (CUHFT) / Temple (NNUHFT) Serious adverse outcome rates (major malformation and perinatal mortality) are about 55/1000 diabetes births, a three to fourfold higher rate than in the background maternity population. EASIPOD programme ( ) reduced East of England adverse outcomes from 7.8 to 1.3% (p = 0.009), based on improved preconception care and is a simple primary and secondary care based preconception education programme for patients and HCP Wide variance in outcomes driven by ethnicity, obesity, deprivation Intervention To restart improved EASIPOD programme for all practices and all Acute Trusts Primary end point Foetal loss and major malformation (at 6 weeks post partum) Impact women with diabetes deliver over 5 years in EAHSN area, and potentially 40 + prevented major foetal malformations /perinatal deaths and reduced variance in pre pregnancy care and pathways

Reducing admissions for severe acute hypoglycaemia (SAHE) in EAHSN area Sampson NNUHFT/All Over 9,000 blue light 999 severe acute hypoglycaemia calls annually in EAHSN area. Annual tariff-indirect cost £2.1M Hypoglycaemia one of 5 National Clinical Performance Indicators for Ambulance Trust High proportion of frequent fliers. Evidence base for prevention through education and action. 2 – 4 fold variance in EAHSN area for hospital conveyance, admissions and readmissions with hypoglycaemia Intervention To develop new single point of contact service and OOH service with enhanced case management pathways linked to new BPT, with Ambulance Trust collaboration. Primary end point VisiCad Ambulance Trust data for Hypo Impact A reduction of SAHE events by 20% through reducing recurrent episodes would be over 1000 SAHE admissions and contacts avoided per annum

Hypo Leaflet

Ambulance attend call out Pt managed at the scene Pt given Hypo leaflet Pt info given to SPOC 3 days cooling off period for patients to opt out of being referred for follow up. SPOC sends to Pt taken to hospital and given hypo leaflet Discharged Home & Check Hypo Leaflet given Pt admitted Pt admitted to ward Yes No Yes No Severe Acute Hypoglycaemic Episode Pathway 14 days cooling off period for patients to opt out of being referred for follow up, if admitted to hospital

After 3/14 days patient info passed to hypodiabetesherts.enh- Identify where patients care is managed? GPCommunityAcute Trust Attempt to contact Patient via the telephone to offer education Contact GP advising unable to contact patient Able to contact patient Education given and letter to GP advising what was discussed. No Yes SPOC Pathway

EAHSN Data  Project launched mid December 2014 in Norfolk and Norwich -first referral 20/12/14  The Single Point of Contact (SPOC) within the East of England Ambulance Service (EEAS) started in East and North Herts February 2015  As of 31 st August 2015 the project has received 1071 referrals, of which 116 are within East and North Herts

Total Referrals (n=1071) East and North

Gender And Age (n=1071) On average 55% of all referrals were ‘Male’ in the East of England. In East and North Herts 65% of referrals received were ‘Male’

Conveyance (n=128 ) East and North

Medication (n=1071) East and North

Previous Severe Hypo (n=1071) 34% 30% 32% 42% 29% 41% 40% 34% East and North

Blood Glucose Levels (n=116) 36% 3% 17% 6%

Loss of Consciousness (n=1071)

Hypo Treatment for East and North Herts (n=116)

 67yr old, Male, Type 1 since 1967 – under acute  Lives at home with family  Taking Humalog mix 25 am Insulatard pm  Recent HbA1c 68 mmol/L  5 SAHE call outs over a 5 week period (March-April)  First BG ranges on arrival at the scene 1.9 mmol/L – 2.5 mmol/L  LOC x3 - All but one hypo occurred mid-morning  All severe events treated with IV/IM treatments  No entry for driving on CIPTS  Had not disclosed to diabetes team Hypo case study

 Failed attempts to contact patient by DSN  DSN contacted GP asked to reduce insulin  Patient found to be a non-driver  Insulin regime changed to Humulin M3  ECG showed ST -T wave abnormality in inferior lead  Found to have strong family history IHD  On-going foot complications  Most recent HbA1c 46 mmol/L (7.5%) Outcomes

 Improve awareness/access to PPC for T2D women (currently 30% attend)  Improve quality of PPC for women with T1D who do not attend (currently <50% T1D who attend achieve Hba1c <7%)  Target hard to reach high risk women with T1D or T2D (previously poor outcomes)  2 Specialist Midwives to provide women with support and education. Pre-Pregnancy Care Project

Steps taken so far…  Contacted Practices in East and North Herts to ask to send a PPC leaflet out to women aged between 16-45yrs (short exclusion list)  In total 2118 PPC Leaflets have to sent out by GP practices in the East of England  Visited all Tesco, Sainsbury and Asda Pharmacies Superstores in area to hand out PPC leaflet with medication  Visited a number of Health Centres/Childrens Centres to display leaflets as various clinics Pre-Pregnancy Care Project

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