1. Improving Inpatient Safety by Standardizing Care Ruth Miller Lead Nurse Diabetes Service Royal Free Hospital Foundation Trust February 2014

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

3. 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

4. Working Party Set up PART (patient at risk team) Risk & Safety team Pharmacy Anaesthetics Diabetes Inpatient Team

5. 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

6. 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

7. 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

8. Standardising treatment of Hypoglycaemia

10. Subsequent National Inpatient Audit Results 58% reduction in the use of insulin sliding scale 70% reduction in hypoglycaemia

11. 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