The National Diabetes Inpatient Audit (NaDIA) 2015 1 Dr Gerry Rayman National Clinical Lead for Inpatient Diabetes.

The National Diabetes Inpatient Audit (NaDIA) 2015 1 Dr Gerry Rayman National Clinical Lead for Inpatient Diabetes

Contributors NaDIA Steering Group Gerry Rayman, Consultant Diabetologist & National Clinical Lead for Inpatient Diabetes (Chair) Bob Young, Consultant Diabetologist & National Clinical Lead for NDA Belinda Allan, Consultant Diabetologist, Michael White Centre for Diabetes and Endocrinology (Hull) Anne Claydon, Nurse Consultant for Diabetes, Barts Health NHS Trust Sophie Colling, NDA Project Support Officer, Diabetes UK Ketan Dhatariya, Consultant Diabetologist, Norfolk and Norwich University Hospitals NHS Foundation Trust Anna Duggan, Audit Coordinator, Health and Social Care Information Centre Laura Fargher, NDA Engagement Manager, Diabetes UK Sarah Fuller, Patient Representative Naomi Holman, Head of Health Intelligence (Diabetes), NCVIN, Public Health England Anne Kilvert, Consultant Diabetologist, Northampton General Hospital NHS Trust & Association of British Clinical Diabetologist Tom Latham, Audit Manager, Health and Social Care Information Centre Alistair Lumb, Consultant in Diabetes and Acute General Medicine at Oxford University Hospitals NHS Trust Maureen McGinn, Patient Representative Claire Meace, Higher Information Analyst, Health and Social Care Information Centre Omar Mustafa, Consultant Diabetologist, Kings College Hospital Raj Rajendran, Research Registrar, Ipswich Hospital NHS Trust Rustam Rea, Consultant Endocrinologist, Royal Derby Hospital David Roberts, Patient Representative Debbie Stanisstreet, Lead Nurse for Diabetes and Endocrinology (Lister Hospital) & Diabetes Inpatient Specialist Nurse Network Garry Tan, Consultant Diabetologist, Oxford Centre for Diabetes, Endocrinology and Metabolism Arthur Yelland, Senior Information Analyst, Health and Social Care Information Centre

National Diabetes Inpatient Audit Aim To provide a 'snapshot', 'real time' audit of inpatient activity, care and patient experience in all acute hospitals in England and Wales. Raise awareness of inpatient activity. Identify national and local deficiencies. Allow individual sites to benchmark themselves. Empower diabetes teams to lead change locally.

National Diabetes Inpatient Audit Long term aims Develop a process of annual re-audit to drive change. Encourage innovations in care. Firmly establish the speciality of inpatient diabetes. Provide evidence to commissioners for the need to invest in improving inpatient diabetes care.

Background- 6yr since first piloted 2009 pilot study (UK wide) –NHS Diabetes / DCC 2010 baseline audit (England only) –NHS Diabetes / DCC / Innove / YHPHO 2011 audit (England and Wales) –HSCIC / HQIP / Diabetes UK 2012 audit (England and Wales) –HSCIC / HQIP / Diabetes UK 2013 audit (England and Wales) –HSCIC / HQIP / Diabetes UK 2014 – no audit collection or report 2015 audit (England and Wales) –HSCIC / HQIP / Diabetes UK Unless otherwise stated, the significance testing in this presentation involved comparing the 2013 values against the 2015 values

Background National Diabetes Audit (NDA) Care Processes and Treatment Targets Complications and Mortality Uses data from Hospital Episode Statistics (HES) database and Patient Episode Database for Wales (PEDW) NaDIA Bedside Care Bedside Audit Hospital Characteristics Patient Experience

Participation (2015^) Number of submitting organisations Trusts (LHBs in Wales) England 200135 Wales 186 Total 218141 2013233 2012235 2011230 2010*169 *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Map of submitting organisations in the 2015 NaDIA

Has the previous audit resulted in change? Changes since the last audit

Time spent on inpatient and outpatient care* (2015) Inpatient teamHours per week per 100 beds InpatientOutpatientGeneral admin/ Meetings Strategic innovation/ management re inpatient care 2015 DISNs 8.31.1 0.6 DSNs 2.914.12.50.6 Consultant 3.28.42.70.9 Specialist diabetes dietitians 0.55.50.90.2 Non-specialist dietitians 1.30.40.10.0 Podiatrists 1.86.60.60.2 Diabetes specialist pharmacist 0.60.10.00.3 * Changes to the guidance in the Hospital Characteristics questionnaire mean that historic comparisons cannot be made.

Sites introducing initiatives since the audit began (2015) Number of sites % DKA and hypoglycaemia guidance (JBDS 2013)12669.7% Hypoglycaemia management in hospital (JBDS 2013)11162.2% Management of adults with diabetes undergoing surgery (JBDS 2011)8345.5% Self-management of diabetes in hospital (JBDS 2012)4724.1% Hyperosmolar Hyperglycaemia State (JBDS 2012)8143.6% Glycaemic management of enteral-fed stroke patients (JBDS 2012)5025.0% Admission Avoidance (front door/AMU protocols) (JBDS 2013)2210.5% Steroid use for inpatients with diabetes (JBDS 2014)3517.0% Discharge planning (JBDS 2014)2513.5% Variable rate insulin infusion (VRIII) for medical inpatients (JBDS 2014)7439.3% Regular ward nurse diabetes training14172.7% NHS Diabetes e-learning on safe insulin use11357.1% NHS Diabetes e-learning on other diabetes topics6835.2% NHS Institute for Innovation Think Glucose11054.7%

Sites introducing initiatives since the audit began (2015) (cont.) Number of sites % End of Life Care Clinical Care Recommendations6433.3% NICE inpatient foot guidance8143.5% ‘Putting Feet First’7037.0% Best Practice Tariff for DKA8644.1% Hypoglycaemia boxes16082.1% Insulin passport13381.0% Combined glucose monitoring/diabetes drug charts8845.0% Combined glucose monitoring/ insulin infusion chart12766.1%

Further changes implemented by some sites Best practice document which combines blood glucose monitoring and care plan Blood glucose monitoring 'Best Practice Document' Blood ketone hyperglycaemia guideline Blood ketone monitoring guideline Diabetes drug chart Electronic diabetes inpatient referral and triage system Electronic patient record Electronic prescribing Frailty and Diabetes Guidelines Glucose-potassium-insulin (GKI) Hypo Alert Sticker Hypoglycaemia and foot checks to be included on Ward Assurance Hypoglycaemia monitored using remote patient monitoring Inpatient diabetes care plan checklists Inpatient Ketone testing guidelines Ketone boxes Foundation of Insulin Group Insulin-only prescribing chart Alternative insulin list Link nurse pro forma and RN competency Local guidelines for diabetes inpatients having gastroscopy (OGD) and colonoscopy New glucose charts Safe Use of Insulin and You booklet Safe Use of Insulin training Self Medication Policy by Medicine Management team

The burden of inpatient diabetes Results

Participation 2010*2011201220132015^ No. of Bedside Audit forms completed 12,19112,80613,40914,19815,229 No. of Patient Experience forms completed 4,7456,6667,3017,7968,521 Patient Experience response rate 38.9%52.1%54.4%54.9%56.0% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available

Number of NaDIA questionnaires returned *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available

National prevalence of diabetes in inpatients *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available

Prevalence of diabetes amongst inpatients in acute hospitals Overall prevalence 2015: 16.8% 2013: 15.8% 2012: 15.3% 2011: 15.1% 2010: 14.6%

Prevalence of diabetes amongst inpatients in acute hospitals Overall prevalence 2015: 16.8% = 1 in 6 2010: 14.6% = 1 in 7

Prevalence of diabetes amongst inpatients in acute hospitals Low prevalence hospitals removed Overall prevalence 2015: 16.8% =1 in 6 2025: 25.0%? = 1 in 4?

Prevalence of diabetes amongst inpatients in acute hospitals 2025: 25.0%? = 1 in 4? ?

Proportion of inpatients with diabetes by age and sex (2015)

Age distribution of inpatients with diabetes (2015) Diabetes inpatients All inpatients (HES: 2012, PEDW: 2015) EnglandWalesEnglandWales Median age76 6873 65yrs and over 78.8%79.2% 57.8% 64.4% 75yrs and over 53.5%55.9% 39.7% 44.8% 85yrs and over 19.9%21.6% 16.7% 20.3%

Type of diabetes (2015)

Insulin treated*: 36.7% *Insulin treated patients comprised Type 1, Type 2 (insulin treated) and Other (insulin treated) patients

Type of diabetes (2015) Insulin treated*: 36.7% *Insulin treated patients comprised Type 1, Type 2 (insulin treated) and Other (insulin treated) patients Insulin* and/or SU treated: 53.7%

Type of diabetes *Sites from Wales did not participate in the 2010 NaDIA. ^There was no audit collection or report in 2014, so 2014 data is not available. †"Other" diabetes type group was added for the 2011 audit and therefore results are not available for the 2010 audit. Differences in percentages between audit years may be a result of the addition of the "Other" group. Diabetes type Percentage of inpatients 2010*2011201220132015^ Type 17.0%6.7%6.6% 7.0% Type 2 (insulin treated)30.9%34.1%34.8%34.4%28.6% Type 2 (non insulin treated)45.5%39.4%39.5%39.1%43.4% Type 2 (diet only)16.7%18.6%17.7%18.4%19.2% Other † N/A1.2%1.5% 1.8%

Ethnicity of inpatients with diabetes (2015) Ethnic groupEnglandWales White † 85.5%96.0% Asian † 7.0%1.9% Black 3.5%0.3% Mixed 0.4% 0.1% Other 0.6%0.1% Unknown † 3.0%1.7% † Statistically significant difference between the two bolded values (p <0.05) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Reason for admission (2015) Diabetes inpatientsAll inpatients (HES/PEDW data) EnglandWalesEnglandWales Emergency*86.2%82.8% 80.7%77.1% Elective*8.8%9.8% 19.3%22.9% Medical81.9%78.0% 62.1%62.5% Surgical18.1%22.0% 37.9%37.5% *For diabetes inpatients, percentages for Emergency and Elective do not add up to 100 per cent because “transfer from another hospital” responses were used in the analysis but have not been included in this table

Reason for admission (2015) Diabetes inpatientsAll inpatients (HES/PEDW data) EnglandWalesEnglandWales Emergency*86.2%82.8% 80.7%77.1% Elective*8.8%9.8% 19.3%22.9% Medical81.9%78.0% 62.1%62.5% Surgical18.1%22.0% 37.9%37.5% Diabetes specific related admissions 9.0%10.6% *For diabetes inpatients, percentages for Emergency and Elective do not add up to 100 per cent because “transfer from another hospital” responses were used in the analysis but have not been included in this table

Percentage of inpatients admitted for a diabetes specific reason *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 Grand total values: 8.1% vs 9.1% (p <0.05)

Main reason for diabetes specific related admission Reason for admission 2010*2011201220132015^ Foot disease 44.3%47.1%45.2%47.2% 49.5% Hypoglycaemia † 20.4%16.1%16.4%17.7% 14.7% Hyperglycaemia 17.3%18.0%18.3%15.8% HHS 5.3%5.5%6.3%4.7% 4.6% DKA 12.7%13.2%13.7%14.7%15.3% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Main reason for diabetes specific related admissions Reason for admission 2010*2011201220132015^ Foot disease 44.3%47.1%45.2%47.2% 49.5% Rise in admissions for diabetic foot disease – ageing population? *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Main reason for diabetes specific related admissions Reason for admission 2010*2011201220132015^ Foot disease 44.3%47.1%45.2%47.2% 49.5% Hypoglycaemia † 20.4%16.1%16.4%17.7% 14.7% Hyperglycaemia 17.3%18.0%18.3%15.8% Fall in admissions for hypo and hyperglycaemia – better primary care services, better admission avoidance schemes? *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Main reason for diabetes specific related admissions Reason for admission 2010*2011201220132015 Foot disease 44.3%47.1%45.2%47.2% 49.5% Hypoglycaemia † 20.4%16.1%16.4%17.7% 14.7% Hyperglycaemia 17.3%18.0%18.3%15.8% HHS 5.3%5.5%6.3%4.7% 4.6% Possible fall in admissions for HHS *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Main reason for diabetes specific related admissions Reason for admission 2010*2011201220132015 Foot disease 44.3%47.1%45.2%47.2% 49.5% Hypoglycaemia † 20.4%16.1%16.4%17.7% 14.7% Hyperglycaemia 17.3%18.0%18.3%15.8% HHS 5.3%5.5%6.3%4.7% 4.6% DKA 12.7%13.2%13.7%14.7% 15.3% Steady rise in admissions for DKA – Reasons uncertain- the lost Tribe? *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Percentage of patients admitted for a diabetes specific condition by diabetes type *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 Type 2 (insulin) values: 11.4% vs 13.6% and Type 2 (non insulin) values: 4.0% vs 5.1% (p <0.05)

Prevalence of diabetic foot disease by diabetes type *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 Type 2 (insulin) values: 18.5% vs 20.8% and Type 2 (non insulin) values: 7.9% vs 9.4% (p <0.05)

Prevalence of renal replacement therapy by diabetes type *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Median number of nights in hospital at time of audit by admission method *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016. 2015: 30.3% > 14 days 13.7% > 28 days Mean = 14.1

Delivery of diabetes care Results

Delivery of diabetes care: How are we doing? Specialist input Glycaemic control Use of IV infusions Medication errors Harm to patients Foot care Patient experience

Delivery of diabetes care No change in percentage of sites with staff deficiencies: Percentage of sites that had: 2010*2011201220132015^ no inpatient DISNs 31.5%31.9%33.3%31.7%31.1% no specialist inpatient dietetic provision for people with diabetes 67.3%70.8%77.3%71.2%71.4% no inpatient podiatry service for people with diabetes 26.8%33.6%32.4%34.1%26.2% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of diabetes care Improvements in percentage of patients visited: Percentage of patients:2010*2011201220132015^ under a diabetes consultant 9.0%9.2%8.7%8.9% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of diabetes care Improvements in percentage of patients visited: Percentage of patients:2010*2011201220132015^ under a diabetes consultant 9.0%9.2%8.7%8.9% seen by a member of the diabetes team 31.0%30.5%31.9%34.7%35.5% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of diabetes care Improvements in percentage of patients visited: Percentage of patients:2010*2011201220132015^ under a diabetes consultant 9.0%9.2%8.7%8.9% seen by a member of the diabetes team 31.0%30.5%31.9%34.7%35.5% Patients who should have been referred according to the “Think Glucose” criteria 46.7%43.2%44.7%43.3%43.7% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of diabetes care Improvements in percentage of patients visited: Since 2013 NaDIA, 83.7% of sites reported an increase in patient referrals/patient contacts Percentage of patients:2010*2011201220132015^ under a diabetes consultant 9.0%9.2%8.7%8.9% seen by a member of the diabetes team 31.0%30.5%31.9%34.7%35.5% Patients who should have been referred according to the “Think Glucose” criteria 46.7%43.2%44.7%43.3%43.7% Of those, patients who were actually seen † 55.1%57.8%58.5%62.5%67.6% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Percentage of inpatients seen by the diabetes inpatient team *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between 2013 and 2015 values (p <0.05)

Perioperative diabetes care Nature of surgery Percentage with a pre-op assessment record to review YesNo Elective76.0%24.0% Emergency58.3%41.7% Grand total63.2%36.8% Percentage noted to have diabetes at pre- assessment YesNo Elective92.9%7.1% Emergency90.3%9.7% Grand total91.6%8.4% Percentage with a diabetes management plan YesNo Elective57.8%42.2% Emergency60.5%39.5% Grand total59.0%41.0%

Frequency of glucose monitoring: ‘Good glucose days’ Both adjusted to be equivalent to a 7 day stay Delivery of care: Glycaemic control Guidelines: Metformin or diet alone(1 or more/day) Long stay patient on diet and metformin with stable control(once weekly or more) Insulin, Exenatide, SU or > 1 oral agent including DPP4 inhibitors and glitazones (2 or more) Unwell, unstable diabetes or basal bolus(4 or more)

Frequency of glucose monitoring Number of days on which the frequency was to the audit standard (adjusted to the last seven days) *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available

Glycaemic control: ‘Good diabetes days’ No more than one result >11mmol/L and none <4mmol/L *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available

Delivery of care Use of insulin infusions 2010*2011201220132015^ Been on an infusion in the last 7 days † 12.5%11.2%10.3%9.8% 9.0% Infusions considered inappropriate 7.4%7.0%6.4%6.5% 6.3% Infusions considered inappropriately long 12.0%8.3%7.6%7.5% 6.2% Infusions that were 7 days or longer 10.0%8.0%7.6%9.7% 8.3% Transfers to s.c. insulin not managed appropriately 25.7%18.9%15.8%16.3%14.2% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Use of IV insulin infusions *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between 2010 and 2015 values (p <0.05)

Transfer from IVIII to s.c insulin injection *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between 2010 and 2015 values (p <0.05)

Inappropriate duration of IV insulin infusion *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available Most under diabetes team

Delivery of care Glucose control on insulin infusions In the last 24 hours on infusion: 2010*2011201220132015^ more than half of readings hyperglycaemic (>11mmol/L) 20.7%20.4%23.1% 20.6% more than a quarter of readings hypoglycaemic (<4mmol/L) 4.7%2.3%2.8%2.7% 3.8% less than 4 glucose readings carried out 3.2%4.3%2.4%2.9%2.4% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Medication errors (management and prescription) 2015 38.3%of charts had one or more management and/or prescription error* 23.9%had one or more management error 22.2%had one or more prescription error 22.5%had one or more insulin error *Both management and prescription errors comprised insulin and OHA

Delivery of care Medication errors (management and/or prescription) *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 values: 37.0% vs 38.3% (p <0.05)

Delivery of care Management errors *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 values: 22.3% vs 23.9% (p <0.05)

Delivery of care Prescription errors *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values: 21.9% vs 22.2% (p <0.05)

Delivery of care Insulin errors *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 values: 20.6% vs 22.5% (p <0.05)

Delivery of care Insulin prescription errors2010*2011201220132015^ Insulin not written up † 2.7%2.1%1.7% 2.2% Name of insulin incorrect (e.g. Humalog) 5.0%2.9%2.5%2.1% 1.8% Number (dose) unclear 3.5%2.3%2.1%1.9% 1.7% Unit abbreviated to ‘u’ or written unclearly † 6.3%3.4%2.5%1.9% 1.5% Insulin or prescription chart not signed by prescriber 2.8%2.4%2.1%1.9% 2.1% Insulin not signed as given 6.0%5.1%5.0%4.8% 4.9% Insulin given/prescribed at the wrong time † 3.9%3.1%3.0%3.1%3.7% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Delivery of care Insulin management errors2010*2011201220132015^ Insulin not increased when persistent BG >11 mmol/L and better glycaemic control is appropriate for this patient † 10.0%9.5%10.3%9.8% 11.5% Insulin not reduced if unexplained BG <4mmol/L † 3.8%4.0%3.5%3.3% 4.0% Inappropriate omission of insulin/OHA after episode of hypoglycaemia 2.4%2.1%1.9%1.8% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Delivery of care OHA prescription errors2010*2011201220132015^ OHA not signed as given † 5.6%5.1%5.2%4.6% 5.2% OHA given/prescribed at the wrong time 6.0%5.3%5.5%4.8% 4.6% Wrong dose 1.5%1.1%1.2%1.0% OHA not written up2.6%2.3%2.4%2.0%1.8% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Delivery of care OHA management errors2010*2011201220132015^ No action taken when persistent BG >11mmol/L and better glycaemic control is appropriate for this patient 9.2%9.0%10.5%9.5% 8.8% OHA not reduced if unexplained BG <4mmol/L 3.2%2.9%2.8%2.6% 2.3% Inappropriate omission of OHA after episode of hypoglycaemia 1.1%1.0%0.9%0.8%0.6% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Hospital Characteristics YesNoPartial 20132015^20132015^20132015^ Electronic patient record 25.1%30.4%44.8%42.2%30.0%27.5% Electronic prescribing 16.1%22.4%71.7%64.4%12.2%13.2% Remote blood glucose monitoring 33.0%39.6%56.2%50.0%10.8%10.4% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values Less prescription errors in sites with electronic prescribing than those without electronic prescribing* (21.0% vs 24.2%) * Statistically significant difference between the 2015 values: 21.0% vs 24.2% (p <0.05)

Delivery of care Have the mandatory safe insulin e-learning module been introduced in your hospital? Statusn% Yes12254.9% Locally adapted219.2% No6129.6% Unsure31.5% Unknown104.9% Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Delivery of care Mandatory safe insulin e-learning module (2015) Patients that had one or more:e-learning module introduced e-learning module not introduced medication error (management or prescription) 38.4%39.2% management error 23.6%25.1% prescription error 22.9%21.7% insulin error 22.6%23.6% hypoglycaemic episode (≤3.9mmol/L) † 22.5%20.3% † Statistically significant difference between the two bolded values (p <0.05) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Delivery of care Medication errors by ward Patients that had one or more: MedicalSurgical 2010*2011201220132015^2010*2011201220132015^ medication error †‡ 43.8%38.9%39.1%35.8%37.1%47.4%43.5%40.9%40.7%41.6% management error 24.4%22.7%24.5%22.3%23.8%23.6%24.3%22.6%22.9%24.3% prescription error ‡ 29.3%24.0%22.3%20.3%20.9%35.6%28.7%27.9%26.5%25.8% insulin error 25.8%22.1%21.6%20.4%22.6%26.2%24.3%21.4%21.5%22.4% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Medication errors comprised management and prescription errors ‡ Statistically significant difference between the two bolded values (p <0.05)

Harm from poor diabetes control Delivery of care Percentage of patients who:2010*201120122013 had mild hypoglycaemia (3.0-3.9 mmol/L) 22.8%23.1%20.4%20.0% had severe hypoglycaemia (<3.0 mmol/L) 11.8%10.6%10.5%9.3% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values ‡ Statistically significant difference between the 2015 values: 15.5% vs 7.5% (p <0.05)

Harm from poor diabetes control Delivery of care Percentage of patients who:2010*2011201220132015^ had mild hypoglycaemia (3.0-3.9 mmol/L) 22.8%23.1%20.4%20.0% had severe hypoglycaemia (<3.0 mmol/L) 11.8%10.6%10.5%9.3%9.8% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values ‡ Statistically significant difference between the 2015 values: 15.5% vs 7.5% (p <0.05)

Harm from medication mismanagement Patients with medication errors had over twice the rate of severe hypoglycaemia ‡ (15.5% vs. 7.5%) Delivery of care Percentage of patients who:2010*2011201220132015^ had mild hypoglycaemia (3.0-3.9 mmol/L) 22.8%23.1%20.4%20.0% had severe hypoglycaemia (<3.0 mmol/L) 11.8%10.6%10.5%9.3%9.8% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values ‡ Statistically significant difference between the 2015 values: 15.5% vs 7.5% (p <0.05)

Significant harm from poor diabetes control Delivery of care Percentage (and number) of patients who: 2010*2011201220132015^ developed severe hypoglycaemia requiring injectable treatment 2.4% (257) 2.2% (250) 2.3% (232) 2.2% (218) 2.1% (213) developed diabetic ketoacidosis during their stay 0.4% (44) 0.5% (68) 0.5% (61) 0.4% (63) 0.4% (66) *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care One or more hypoglycaemic episode (≤3.9 mmol/L) by diabetes type Diabetes type2010*2011201220132015^ Type 1 45.4%48.5%45.5%47.9%48.5% Type 2 insulin † 37.2%34.8%32.0%31.2%34.5% Type 2 non-insulin 20.3%20.5%15.3%15.8%14.7% Type 2 diet only 13.0%10.2%9.1%8.0%8.3% Grand total 26.1%25.7%22.4%22.0%21.1% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Delivery of care Hypoglycaemic episodes by diabetes type Diabetes type Minor hypoglycaemic episode (3.0-3.9mmol/L) Severe hypoglycaemic episode (<3.0mmol/L) 20132015^20132015^ Type 1 41.8%42.5%30.0%31.1% Type 2 insulin 28.2%31.1%14.4%17.2% Type 2 non-insulin 14.6%13.9%4.6%4.2% Type 2 diet only 7.6%8.0%1.8%2.0% Grand total 20.0% 9.3%9.8% ^There was no audit collection or report in 2014, so 2014 data is not available There is a statistically significant difference between the 2013 and 2015 Type 2 insulin values: minor hypo 20.6% vs 22.5%; severe hypo 14.4% vs 17.2%; any hypo 31.2% vs 34.5% (p <0.05)

Delivery of care Percentage of all hypoglycaemic episodes (<4mmol/L) across the last seven days broken down by time of day (2015)

Delivery of care (2015) 20.3% of patients were treated with sulfonylurea Percentage of patients who had one or more: Treated with sulfonylurea* only Treated with insulin † only minor hypoglycaemic episode (3.0-3.9mmol/L) ‡ 23.3%34.0% severe hypoglycaemic episode (<3.0mmol/L) ‡ 8.0%20.7% any hypoglycaemic episode (≤3.9mmol/L) ‡ 24.7%37.9% *Patients treated with sulfonylurea (SU) comprised Type 2 (non insulin treated), Type 2 (diet only, where SU may have been initiated in hospital) and Other (non insulin treated) patients treated with SU † Patients treated with insulin comprised Type 1, Type 2 (insulin treated) and Other (insulin treated) patients not treated with sulfonylurea ‡ Statistically significant difference between the two bolded values (p <0.05)

Delivery of care (2015) 20.3% of patients were treated with sulfonylurea Percentage of patients who had one or more: Treated with sulfonylurea* Not treated with sulfonylurea † minor hypoglycaemic episode (3.0-3.9mmol/L) ‡ 24.0%18.9% severe hypoglycaemic episode (<3.0mmol/L) 9.2%10.0% any hypoglycaemic episode (≤3.9mmol/L) ‡ 25.6%20.8% * All patients treated with sulfonylurea. This includes both insulin and non insulin treated patients. † All patients not treated with sulfonylurea. This includes both insulin and non insulin treated patients. ‡ Statistically significant difference between the two bolded values (p <0.05)

Multidisciplinary diabetic foot team (MDFT) in all trusts Refer to the MDFT within 24 hours All admissions to have a foot examination

Foot care: Established foot disease Percentage of patients who: 2010*2011201220132015^ had a history of foot disease on admission 12.3%12.2%12.8%12.6% 12.8% had active foot disease on admission 9.4%9.1%9.3%9.2% 8.9% were admitted for active foot disease † 4.0%4.3%3.8% 4.5% Delivery of care: Burden of foot disease *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Delivery of care Multidisciplinary diabetic foot team (MDFT) 2010*201120122013 Percentage of sites without a MDFT † 38.7%41.7%31.9%28.2% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Multidisciplinary diabetic foot team (MDFT) 2010*2011201220132015^ Percentage of sites without a MDFT † 38.7%41.7%31.9%28.2% 31.0% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Multidisciplinary diabetic foot team (MDFT) 2010*2011201220132015^ Percentage of sites without a MDFT † 38.7%41.7%31.9%28.2% 31.0% Those with active foot disease- input from the MDFT within 24 hours 50.3%57.9%53.3%61.1% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Multidisciplinary diabetic foot team (MDFT) 2010*2011201220132015^ Percentage of sites without a MDFT † 38.7%41.7%31.9%28.2% 31.0% Those with active foot disease- input from the MDFT within 24 hours 50.3%57.9%53.3%61.1%59.5% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values

Delivery of care Foot assessment/screen on admission ‡ 2010*201120122013 Documentation of foot examination within 24hrs † 23.2%21.3%28.8%36.3% Documentation of foot examination after 24hrs † 5.0%4.4%5.3%6.1% Documentation of foot examination at any time † 28.2%25.8%34.1%42.4% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05) ‡ Note that there were definitional changes for the 2015 NaDIA. The 2013 bedside audit form asked whether the inpatient had undergone a “foot risk assessment” only. The 2015 version adds more detail, specifying that a “specific diabetic foot risk (for ulceration) examination” took place, with an additional caveat excluding “Waterlow score, Norton score and similar general pressure sore checks”.

Delivery of care Foot assessment/screen on admission ‡ 2010*2011201220132015^ Documentation of foot examination within 24hrs 23.2%21.3%28.8%36.3% 27.7% Documentation of foot examination after 24hrs 5.0%4.4%5.3%6.1% 5.3% Documentation of foot examination at any time 28.2%25.8%34.1%42.4%33.0% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available ‡ Note that there were definitional changes for the 2015 NaDIA. The 2013 bedside audit form asked whether the inpatient had undergone a “foot risk assessment” only. The 2015 version adds more detail, specifying that a “specific diabetic foot risk (for ulceration) examination” took place, with an additional caveat excluding “Waterlow score, Norton score and similar general pressure sore checks”. Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Delivery of care Putting feet first/foot screening programme (2015) Programme introduced Programme not introduced Foot risk assessment in first 24 hours of admission* 32.1%21.3% Foot risk assessment after 24 hours of admission* 25.8%17.4% Seen by member of MDFT within 24 hours* 63.2%51.1% Input from MDFT in last 7 days*66.2%55.1% * Statistically significant difference between the two bolded values (p <0.05) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Delivery of care: Prevention of foot disease 2010*2011201220132015^ Percentage (and number) of patients who developed a foot lesion during their admission † 2.2% (257) n/a1.6% (210) 1.4% (196) 1.1% (153) *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Delivery of care Putting feet first/foot screening programme Audit yearFoot lesion during admission Programme introduced Programme not introduced 20131.6%1.1%

Delivery of care Putting feet first/foot screening programme Audit yearFoot lesion during admission Programme introduced Programme not introduced 20131.6% † 1.1% 2015^1.1% † 1.0% ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the 2013 and 2015 values (p <0.05)

Patient experience and patient involvement Results

Inpatient self-management (testing and insulin management) Diabetes type Percentage of inpatients Self-testing glucose? Self- administering insulin? Self-adjusting insulin dosage? Type 1 27.4%50.3%30.7% Type 2 (insulin) 11.7%31.8%9.7% Type 2 (non insulin) 4.5% Type 2 (diet only) 1.6% Grand total 8.1%

Patient experience and patient involvement- BG testing Percentage of patients who:2010*2011201220132015^ reported being able to test their own glucose 18.9%17.2%17.1%15.7% 17.1% wished to do so but were unable to 17.1%13.3%14.3%15.5% 14.2% were able to test their own glucose that had one or more hypoglycaemic episode (≤3.9mmol/L) 29.7%28.1%26.7%28.5%27.6% ‡ were unable to test their own glucose that had one or more hypoglycaemic episode (≤3.9mmol/L) † 24.8%24.1%21.3%20.5%21.1% ‡ *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values ‡ Statistically significant difference between the 2015 values: 27.6% vs 21.1% (p <0.05) Many patients reported disempowerment in their care

Patient experience and patient involvement- insulin Many patients reported disempowerment in their care Percentage of patients who:2010*2011201220132015^ reported being allowed to self administer insulin while in hospital 62.4%59.2%58.5%57.2% 56.5% wished to do so but were unable to 9.7%8.9%9.2%10.7% 9.3% were able to self administer insulin that had one or more hypoglycaemic episode (≤3.9mmol/L) 35.5%37.3%33.1%35.5% 35.1% were unable to self administer insulin that had one or more hypoglycaemic episode (≤3.9mmol/L) 40.0%36.7%37.6%35.5%36.7% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available There is no statistically significant difference between the 2013 and 2015 values ‡ Statistically significant difference between the 2015 values (p <0.05) – none found

Patient experience and patient involvement Dissatisfaction with meal timing and choice Percentage of patients who:2010*201120122013 reported that the choice of meals was sometimes, rarely or never suitable † 26.7%25.4%23.4%24.3% reported that the timing of meals was sometimes, rarely or never suitable † 22.3%21.0%17.8%18.7% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Patient experience and patient involvement Dissatisfaction with meal timing and choice Percentage of patients who:2010*2011201220132015^ reported that the choice of meals was sometimes, rarely or never suitable † 26.7%25.4%23.4%24.3% 34.1% reported that the timing of meals was sometimes, rarely or never suitable † 22.3%21.0%17.8%18.7%27.4% *Sites from Wales did not participate in the 2010 NaDIA ^There was no audit collection or report in 2014, so 2014 data is not available † Statistically significant difference between the two bolded values (p <0.05)

Patient experience and patient involvement Patients that reported that: Insulin treated*Non insulin treated 2015^20132015^ the choice of meals was sometimes, rarely or never suitable † 26.6% 39.1% ‡ 22.4% 31.2% ‡ the timing of meals was sometimes, rarely or never suitable † 21.9% 32.2% ‡ 16.4% 24.6% ‡ *Insulin treated patients comprised Type 1, Type 2 (insulin treated) and Other (insulin treated) patients † Statistically significant difference between the two bolded 2013 and 2015 values (p <0.05) ‡ Statistically significant difference between the 2015 values: insulin treated: 39.1% vs 32.2%; non insulin treated 31.2% to 24.6% (p <0.05) Insulin treated vs non-insulin treated patients

Patient experience and patient involvement Care planning by ward (2015) MedicalSurgical Take control of their own diabetes care* 57.3%65.2% Self administer insulin* 53.9%65.6% Staff able to answer questions 80.5%84.1% * Statistically significant difference between the two bolded values (p <0.05)

Benchmarking

Reports available next week Covers main areas from three questionnaires Compares each provider with distribution across England, Wales and England and Wales

Summary

NaDIA is in its 6th year A record number of patients (15,229) Prevalence has increased from 14.6% in 2010 to 16.8% in 2015 Prevalence may reach 25% by 2025 Widespread engagement in implementation of guidelines and in innovations in care Significant increase in patients seen by diabetes teams No increase in investment into staffing

Summary – Foot care Between 2011 and 2015: Reduction in number of sites without a MDFT (from 41.7% to 31.0%) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Summary – Foot care However Between 2013 and 2015: Increase in number of sites without a MDFT (from 28.2% to 31.0%) Slide revised since presentation at the 2016 Diabetes UK Conference on 2 March 2016.

Summary – hospital acquired foot lesions Between 2010 and 2015: Reduction in hospital acquired foot lesions from 2.2% to 1.1% 100 foot lesions (heel ulcers) less in the week of the audit Approximately 2600 less in a year @ £5,000 = saving of £13,000,000

Summary – Patient Experience No change in any particular parameters for self-management, Perception of hospital food worsening between 2013 and 2015

Summary – Outcomes Length of stay unchanged Improvements in use of IVII although glucose control on IVII remains unsatisfactory From 2010 to 2015: –Significant reductions in prescription errors particularly for insulin –Significant reductions in mild and severe hypoglycaemic rates However not sustained in 2014 -2015 with minor reversal

Summary – Harm Although there are improvements in ‘control’ measured by ‘good diabetes days’ and hypoglycaemic glucose readings, hypoglycaemic episodes requiring rescue treatment are unchanged as are the rates of hospital related DKA 20.0% experienced a mild hypoglycaemic episode (3.0-3.9 mmol/L) –An estimated 141,000 events/year 9.8% experienced a severe hypoglycaemic episode (<3.0 mmol/L) –An estimated 60,000 events/year 2.1% required IV Glucose/Glucagon –An estimated 11,000 events/year 0.2% developed HHS in hospital –An estimated 2,000 events/year 0.4% developed DKA in hospital –An estimated 3,000 events/year

Conclusion There is enormous enthusiasm amongst diabetes teams to provide better inpatient care as evidenced by the high participation in NaDIA. Significant year upon year improvements in inpatient diabetes evidenced in NaDIA but after the years gap there has been a minor reversal in some areas

Conclusion We need to continue to champion inpatient diabetes care including engaging other health care professionals and hospital managers. Did we take of eye off the ball in 2014? Every acute hospital needs an inpatient diabetes team.

Changing Inpatient Diabetes- open discussion NaDIA- feedback- what should we change? Given that 1:3 inpatients may have diabetes in 2025 how do will we manage without a change in staffing levels How do we reduce DKA in hospital? Some trusts have halved their rates of hypoglycaemia- how do we influence others? Mandatory e-learning has had a small influence on hypos. Is this enough evidence to make this mandatory in all hospitals? Good progress with foot care- especially hospital acquire lesions. Is this because of DiabetesUK’s campaigning? Why have we not had a campaign on diabetes inpatient care?

The National Diabetes Inpatient Audit (NaDIA) 2015 1 Dr Gerry Rayman National Clinical Lead for Inpatient Diabetes.

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The National Diabetes Inpatient Audit (NaDIA) 2015 1 Dr Gerry Rayman National Clinical Lead for Inpatient Diabetes.

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Presentation on theme: "The National Diabetes Inpatient Audit (NaDIA) 2015 1 Dr Gerry Rayman National Clinical Lead for Inpatient Diabetes."— Presentation transcript:

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