1. Welcome Improving physical health assessment in a PICU
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Improving physical health assessment in a PICU
Laura Smith and Louise Sawford
Welcome

2. Situation
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Learning from Serious Incident occurring where patient developed diabetic ketoacidosis on our PICU
Mental health presentation was the main focus of care
Learning from the incident has helped drive changes in practice

3. Background
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44 year old female with a past medical history of treatment resistant schizophrenia, on clozapine since 2000; history of drug and alcohol abuse; type 11 diabetic, on insulin; epilepsy; peripheral neuropathy; arthritis; asthma.
Admitted to Psychiatric Intensive Care Unit via Emergency Department
Handover documents uploaded to clinical record:
urine analysis: ++++ glucose; +ketones; +protein
Blood glucose 19
Type 1 diabetic recorded
Medical clerking- known diabetic type 11 in our clinical records.
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4. Background
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Medication reconciliation completed- advised to contact diabetic nurse for insulin dosage. Insulin not prescribed as diabetic nurse on annual leave.
Confusion regarding type of diabetes and whether insulin should be prescribed.
Medical clerking plan:
Plan
Patient not currently eating- can omit regular insulin as type 2 DM
However if does start eating, and BLOOD GLUCOSE is consistently > 20- could use novorapid 4 units as prescribed as advice given, but I would avoid this given she is a type 2 Diabetes Mellitus. I believe if she becomes unwell eg with HONK (Hyperglycaemic Hyperosmolar Nonketotic Coma) it will be apparent, and much less likely to develop Diabetic Ketoacidosis (DKA) as a type 2 Diabetic.
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5. Blood Glucose Monitoring
What happened
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Blood sugars taken:
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Blood Glucose Monitoring
Date AM PM
Nocte
24/03/2017
Not recorded
25/03/2017
14.4
18.3
16.1
26/03/2017
20.2
14.6
27/03/2017
13.8
15.1
28/03/2017
29/03/2017
18.4
15.9
30/03/2017
18.1
14.1
31/03/2017
Record illegible
01/04/2017
09:00- 23; 10:20 26
Inconsistent recording- within progress notes, drug chart or specific sections on RiO

6. Welcome What happened Patient not eating and drinking
Began vomiting- this continued for 4 days
Became incontinent of urine
Increasingly drowsy, struggling to communicate
Day 4 became increasingly thirsty- drank 2900mls in a few hours.
Respiration rate increased
At the same time
Increasingly paranoid
Verbally aggressive
Hallucinating
Administered clopixol accuphase on two occasions, plus medication to calm and sedate
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7. Welcome Learning from the incident Root causes identified:
Transfer nursing documentation and CAS card plan from acute hospital was not followed or acted upon
Main focus of care was mental health presentation and physical health overlooked
Failure to prescribe and administer insulin in line with Trust Policy
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8. Welcome PDSA Testing Ramps for physical health clinic
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DATA FEEDBACK TO FRONTLINE STAFF
Cycle 1G: Review of updated recording location.
Cycle1F: Changes to recording location made
Cycle 1E: Recording form developed
Cycle 1D: Tweaks to clinic format made
Cycle 1C: Physical health clinic idea devised and format trailed
Cycle 1B: RGN appointed
Cycle 1A: Advert on NHS jobs for RGN to work in PICU

9. Update
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Blood glucose recording. Initially staff had increased awareness of the need to record, and this was documented on the drug chart
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10. Welcome Update Physical health clinic development
Documentation and assessment forms developed and trialled
Advanced Nurse Practitioner from physical health supporting the ward in development of the RGN role
Observation folders created for each patient
Greater participation in physical health clinics from patients
Teaching sessions for ward staff
Links to primary care and acute Trust made (RGN will attend twice a month clinically)
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11. Welcome Recommendations
Bridging gap between mental and physical health.
Value of RGN working in acute mental health
Sharing of learning across boundaries, sites and teams
Medical participation and engagement
Use of QI methodology to measure and develop physical health clinics.
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12. Key improvement message learnt
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The value of a holistic approach to patient care no matter what setting.