Specialist inpatient teams recommended for every trust to help prevent errors and protect patients

Every hospital should have a specialist team dedicated to caring for inpatients with diabetes to help ensure their safety, according to a new national report.

Up to 20% of all hospital beds are occupied by patients with diabetes, although the vast majority (92%) are admitted for other conditions and illnesses. The latest report from the Getting It Right First Time (GIRFT) programme – published on the eve of World Diabetes Day (14 November) –   outlines how uncoordinated inpatient diabetes care and insufficient specialist staffing can result in complications for some patients, which lead to them staying longer in hospital or put them at higher risk of mortality.

The COVID-19 pandemic has further highlighted the need for better inpatient services to ensure patient are safe. With the infection more adversely affecting people with diabetes, more people are currently being admitted to hospital and there has been an increase in mortality. Coordinated inpatient diabetes care is essential to manage their treatment in hospital during the pandemic and it is important for all trusts to now consider the safety of these patients in their future planning.

In line with the aims of NHS Long Term Plan, the authors of the GIRFT report – Professors Gerry Rayman (consultant physician at East Suffolk and North Essex NHS Foundation Trust) and Partha Kar (consultant in diabetes and endocrinology at Portsmouth Hospitals NHS Trust) – outline a series of recommendations to help improve outcomes for patients with diabetes receiving hospital care. These include:

• Establishing specialist multi-disciplinary diabetes inpatient teams (MDiTs) in every trust, to ensure patients with diabetes are monitored and managed throughout their stay in hospital – 30% currently don’t have one. The aim is to provide a seven-day service for patients.
• Training for every healthcare professional who dispenses, prescribes or administers insulin, to help reduce insulin errors in hospital.
• An electronic system in every hospital to identify people with diabetes on admission. This will ensure all staff in all hospital departments – from emergency department to operating theatre – are aware of a patient’s diabetes and can treat them accordingly.

Professor Rayman, who is also co-author of Diabetes UK’s report Making Hospitals Safe for People with Diabetes, said: “People who come to hospital for reasons other than their diabetes can suffer because their diabetes is not identified, or not effectively monitored or managed through the stages of their care. This can lead to miscommunication, insulin errors and hypoglycaemic events.

“This could be avoided if we work in a more effective way to reduce unwarranted variations and close current gaps in provision.”

The report also emphasises the need for lifelong support for patients with diabetes and calls for virtual clinics and online reviews to be adopted more widely and permanently. The changes in working practices brought about by the COVID-19 pandemic have reinforced the possibilities and benefits of using technology to help people better manage their diabetes – adopting them in the long term will help the NHS recover services and keep patients safer.

More than 4.7m people have diabetes in the UK (3.2m in England) and the number of diagnoses has doubled in the past 20 years. If not managed well, diabetes can lead to complications such as amputation, sight loss, kidney failure, stroke, heart disease and death. The NHS spends £2.5bn every year on caring for diabetes inpatients.

Professors Rayman and Kar visited more than 100 trusts as part of their national review, examining data, sharing good practice and noting unwarranted variation. Professor Kar, who is also the National Specialty Adviser for Diabetes with NHS England, said: “We were encouraged by the openness of colleagues to engage with the process and listen to what the data tells us about variations and areas for improvement.”

As well as addressing inpatient safety, the 15 recommendations in the report also include measures to improve services and psychological support for people living with type 1 diabetes (8% of diabetes patients), including better transition services for young adults to help manage the spike in 19-25-year-olds being admitted to hospital as a result of diabetic ketoacidosis (DKA), and creating equitable access to technology such as insulin pumps, flash glucose monitors and continuous glucose monitors which help keep blood glucose levels stable. There is also a need for both staff and patients to be educated and trained in the use of such technology.

Professor Kar added: “While teams across the country are working exceptionally hard, we found that some services for people living with type 1 diabetes are falling short of what we should expect. Often, type 1 patients do not have the right support to manage their condition throughout their lives, especially during the transition from childhood to adulthood. This means some patients become disengaged with their diabetes which in turn leads to many avoidable harms.

“Thankfully, there are some great examples of good care going on across the country – many of them highlighted in the report – and our focus now is on helping trusts to emulate such good practice.”

Another theme in the report looks at footcare services. Diabetes-related ulcers and consequent amputation costs the NHS around £1bn a year and there are 140 foot and toe amputations every week. The GIRFT report recommends every provider should have a multi-disciplinary footcare service (MDFS) in hospitals, integrated with a community-based footcare protection service (FPS) to help prevent ulcers.

Alongside improving patient care, the report outlines opportunities to save up to £117m for the NHS by reducing length of stay, admissions and readmissions.

The GIRFT diabetes report is welcomed by the charity Diabetes UK. Chief executive Chris Askew said: “As we continue to navigate the challenges of the pandemic, and while vital services remain under immense pressure, we must not forget that serious conditions – like diabetes – cannot be put on hold. This report, and the recommendations it makes for vital improvements in key areas of diabetes care, speak directly to the concerns of many people living with diabetes. 

“The COVID-19 pandemic has disproportionately affected people with diabetes, and has shone a light on the potential impact on care when they are unable to access fully staffed multidisciplinary diabetes inpatient teams, foot protection services, and diabetes specialist nurses. Without action, people with diabetes will – unnecessarily – continue to be at increased risk of serious and life-altering complications. It is vitally important that these recommendations are acted upon as soon possible to ensure that people with diabetes get the best care possible.”

The Association of British Clinical Diabetologists (ABCD) also supports the report. Chairman Dr Dinesh Nagi said: “The unique aspect of GIRFT is a visit by specialists to specialists enabling valuable challenge, support and dialogue backed up by a common dataset.

“We appear to be on the cusp of a more advanced era for diabetes care – the publication of the GIRFT diabetes report is therefore welcomed and timely.”