People with diabetes coming to hospital as Inpatients
St Helens and Knowsley Trust
Audits conducted in 1999 revealed that the experience of people with diabetes coming into the hospital as inpatients could be improved. At this time, Care Pathways were gaining ground as a useful tool for co-ordinating a person's journey through their care, and the team decided to develop a Care Pathway for inpatients with diabetes, and to monitor the impact of the pathway. The results of the evaluation have led to significant modification of the original pathway as well as changes to the way the Diabetes Specialist Nurses (DSNs) manage their in-patient workload.
How this service improves
The aim was for the Care Pathway to act as a prompt to ensure certain tests are completed and to encourage staff to use local evidence-based clinical guidelines that had been developed. The DSNs would also be available to problem solve difficulties ward staff were having with regards to the care of patients with diabetes.
To ensure people with diabetes receive appropriate care as inpatients.
To support ward staff in managing in-patients with diabetes.
The Care Pathway consisted of two parts, the care pathway itself (CP) and standards underpinning the CP to explain how the CP worked, these were based on locally developed in-patient guidelines. A Randomised Controlled Trial (RCT) was conducted to test the CP and found that some elements of the CP were utilised more than others. Overall, the RCT demonstrated that the CP was associated with improvements in the management of in-patients with diabetes, also, re-admission rates were lower for patients on a CP compared to those not on a CP. However, despite these positive results it was also apparent that there were many practical difficulties associated with implementing and sustaining the use of a CP in an acute setting and it would be difficult to use the full CP outside of a research study. Consequently, it was decided not to implement the full CP following the study but to take the Blood Glucose Monitoring section (which had worked very effectively) and implement this alone.
Additionally, it was apparent from the study that when staff received support from a DSN management of in-patients with diabetes was more appropriate than when there was no input. Prior to the study, the DSNs were available to support ward staff and patients with diabetes, but, this was on a reactive (waiting for referrals to come in) rather than a proactive basis. This has changed following the study and currently the two DSNs aim to attend each ward of the hospital each day to identify patients with diabetes and offer support before problems arise. They then refer people into one of the specialist diabetes clinics as needed.
The work overall is accountable to the Diabetes Team at St Helens and Knowsley Hospitals NHS Trust.
Formal evaluation of the current system has not yet been undertaken. However the following have been noted:
The Specialist Nurses are able to meet with people with diabetes whilst they are on the wards and review more patients under the new system.
Visiting wards each day has raised the profile of the Specialist Diabetes Team and of diabetes care for inpatients, and has helped develop relationships between staff which may lead to a more seamless service.
Problems can be dealt with earlier.
More people needing a referral to the Diabetes Clinic are receiving one.
The results of the RCT can be found in:
O’Brien SV, Michaels SB, Marsh J, Hardy KJ. The impact of an inpatient diabetes care pathway. Journal of Diabetes Nursing 2004; 8:253-256.
Dedicated time to develop the CP and guidelines
Dedicated time and resource of DSN out on the wards
Printing costs of the ICP
There are many issues relating to the successful implementation of a CP in the acute environment, if it is to work it needs to be simple and easy to use and there need to be dedicated resources for its development and ongoing use.
It is helpful to have a champion to drive the implementation of such tools and processes as it requires the support of many different teams and staff to ensure it is successfully used.
Re-evaluating as a result of feedback from staff is very important.
Maintenance and the development of tools such as the CP can be time consuming and need to be planned for.
The acute setting, with the environmental pressures, the high turnover of staff and patients, and the fact that patients may have more than one condition that requires consideration can hinder the use of CPs.