Hospital acquired foot ulcers reduced by 50 per cent since diabetes inpatient audit launched

Published: 27 Jun 2016

Only 1.1 per cent of inpatients with diabetes1 developed a new foot lesion during their admission to hospital, a significant decrease from 2.2 per cent when inpatient auditing began in 2010.

However, more than two thirds (67.0 per cent) of inpatients included in the 2015 audit did not have a specific diabetic foot risk examination during their hospital stay and 31 per cent of hospital sites still do not have a multi- disciplinary diabetic foot care team, despite being highlighted as important in each audit round. Addressing these could further impact on this devastating and costly preventable complication.

The findings are published in the National Diabetes Inpatient Audit (NaDIA), carried out by the Health and Social Care Information Centre, in collaboration with Diabetes UK. NaDIA is commissioned by the Healthcare Quality Improvement Partnership6 (HQIP) as part of the National Clinical Audit Programme.

Since 2010, similar improvements in the other two main hospital inpatient harms – severe hypoglycaemic episodes7 and diabetic ketoacidosis (DKA) – have not occurred.

The proportion of inpatients having one or more hypoglycaemic episode, since 2010, has reduced from 26.1 per cent to 21.8 per cent. However, there has been no significant reduction in the proportion of inpatients having one or more severe life threatening hypoglycaemic episodes that required emergency rescue with injectable treatment (2.4 per cent in 2010 compared to 2.1 per cent 2015).

Since the audit began in 2010, there has been no reduction in the proportion of inpatients developing the severe life threatening and wholly preventable condition DKA after admission – 0.4 per cent in both 2010 and 2015.

The percentage of hospital beds occupied by people with diabetes has risen each year from 14.6 per cent in 2010, to 15.8 per cent in 2013 and increased again to 16.8 per cent in the 2015 audit. 35.5 per cent of inpatients with diabetes were seen by a member of the diabetes team and 83.7 per cent of sites reported an increase in referrals/patient contacts since the 2013 NaDIA.

 Although levels of referrals and patient contacts have increased amongst diabetes teams, there has been no corresponding significant increase in staffing levels. Almost one-third of sites (31.1 per cent) have no diabetes inpatient specialist nurse (DISN) available, with no increase since the audit inception in 2010. Consultant access was also limited as 9.2 per cent of sites did not have any consultant time for diabetes inpatient care.There is no specialist inpatient dietetic staff time for people with diabetes at almost three quarters (71.4 per cent) of sites.

The proportion of inpatients experiencing medication errors9 has increased from 37.0 per cent to 38.8 per cent since the previous audit in 2013, partially reversing the earlier decreasing trend. A review of inpatient drug charts also found that 23.9 per cent had at least one medication management error within the previous 7 days, a significant increase from 22.3 per cent in 2013.

The National Inpatient Diabetes Audit (NaDIA) 2015 was carried out by diabetes teams in acute hospitals in 135 Trusts in England and 6 Local Health Boards in Wales on a nominated day in September. It covers issues such as staffing levels, medication errors, patient harm and patient experience. The 2015 audit surveyed 15,299 patients with diabetes.

The data also shows:

Diabetic Ketoacidosis

In the week of the audit, 66 patients (0.4 per cent) were reported to have developed diabetic ketoacidosis (DKA) after their admission; equating to almost 3,500 annually. This is a life threatening but preventable complication, resulting from a severe shortage of insulin.

Hypoglycaemic episodes

More than one fifth (21.8 per cent) of inpatients had one or more hypoglycaemic episodes over the previous 7 days of their stay10.

In the week of the audit, there were 213 severe hypoglycaemic events requiring rescue with injectable treatment, equating to over 11,000 events annually. This life threatening complication is wholly preventable by careful management of medications and nutrition and reflects a deficiency in care.

Inpatients whose drug chart had at least one medication error were more than twice as likely to have one or more severe hypoglycaemic episodes (15.5 per cent) compared to inpatients whose drug chart had no medication errors (7.5 per cent).

 Foot Care

Of the 8.9 per cent of inpatients that were admitted with active diabetic foot disease, only 59.5 per cent were seen by a member of the multi-disciplinary foot care team within the target time of 24 hours following admission.

 Insulin infusions

There has been a very significant improvement in the use of intravenous insulin infusions which had been previously inappropriately over used; 9.0 per cent of inpatients with diabetes had been on an insulin infusion within the last 7 days compared with 12.5 per cent in 2010, of which 8.3 per cent had been on an infusion for 7 days or longer down from 10 per cent in 2010.

 Patient satisfaction with timing and content of meals

 84.1 per cent of inpatients were satisfied or very satisfied with the overall care of their diabetes while in hospital.

 34.1 per cent of patients reported that the hospital did not always provide the right choice of food to manage their diabetes, significantly higher than the proportion in 2013 which was 24.3 per cent.

Audit lead clinician, Dr Gerry Rayman,11 said: “We are proud of what the audit has achieved since 2010 and the difference it has made to hospital care for patients with diabetes. However the results do show that, while the number of inpatients continues to rise, this is not being matched by resources and staffing which could make an even more significant improvement.

The 50 per cent reduction in hospital acquired foot ulcers since the introduction of NaDIA, on its own, equates to an estimated annual saving of over £30 million which would more than provide sufficient savings to fund the inpatient diabetes specialist teams that could help reduce the other harms. The achievements gained should be celebrated but there is still much more work to be done to reduce entirely preventable very serious treatment related complications.

In particular, the rise in medication errors is a cause for concern as the audit shows that patients with a medication error on their drug chart are more than twice as likely to have a severe hypoglycaemic episode. These are largely preventable. Diabetic ketoacidosis is due to patients being given insufficient or even no insulin. This should never happen. Yet the frequency of this wholly preventable and life threatening complication remains unchanged.

The audit has demonstrated a year on year increase in the number of patients with diabetes in hospital. As the number of referrals and patient contacts continue to rise, hospitals will struggle to meet targets and improve patient care without an increase in specialist staff. There is no specialist inpatient diabetes nurse service in almost one third of hospitals, no specialist dietetic staff time for people with diabetes at almost three quarters of sites and a third of hospitals do not have a multi-disciplinary foot care team. That such deficiencies exist during the working week is shocking, of greater concern is the almost total lack of specialist diabetes care at weekends with under 7 per cent of sites having an inpatient diabetes specialist nurse service.

Since 2010, the NaDIA has been an excellent tool for highlighting specific issues in patient care and driving forward changes that can save lives, improve inpatient experiences and save money for hospital trusts. Despite significant results in some areas, others remain static and will continue to do so until the existing overstretched specialist teams, who do an amazing job, are better supported and Trusts who have no inpatient diabetes service are commissioned to provide this.

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