Over the last decade, technology and the use of data to improve healthcare outcomes has increased dramatically. In no clinical area has this been more evident than in diabetes, with the development of improved continuous glucose monitoring systems, insulin pumps and other devices to enhance the care of people living with diabetes.
Nationally, the role of technology and data has been seen through the publication of the NHS Get It Right First Time (GIRFT) Diabetes report and the National Diabetes Inpatient Audit (NaDIA) in 2020. Utilisation of data in this format can help inform and advise healthcare systems and processes to improve the care for people with diabetes.
The NHS GIRFT Diabetes Report was published in November 2020. The report was developed around the GIRFT approach adapted from orthopaedic surgery, with a focus on reducing avoidable harms. The GIRFT team visited 108 acute hospital trusts to analyse diabetes services, explore variations and compile nationwide learnings.
The report lists fifteen recommendations around three key themes:
- Care of people with diabetes whilst in hospital
- Care of people with type 1 diabetes
- Improving diabetic footcare services.
The 2019 National Diabetes Inpatient Audit was also published in November 2020 and consolidated several of the themes described by the GIRFT report. This audit data is collected by trusts individually as a one day snapshot of diabetes inpatient care and collated nationally to extract trends and themes.
Five key learning points for pharmacists
1. Pharmacists are key within the multidisciplinary team
The GIRFT report presented a landmark moment for the recognition of pharmacists in diabetes care. It recommended that all trusts should have dedicated multi-disciplinary diabetes inpatient teams (MDiTs) which include pharmacist support. Furthermore, MDiTs should be led by a senior experienced member of staff, which could be a pharmacist.
2. Pharmacists can reduce insulin errors
Both the NaDIA and GIRFT data demonstrated that insulin errors are an ongoing risk for people with diabetes when they are in hospital. Insulin is the third most common cause of death or severe patient harm from medication error in the UK. Two fifths of inpatient drug charts for insulin-treated inpatients reviewed as part of NaDIA 2019 had one or more insulin errors.
Whilst improvements have been demonstrated year on year, errors remain too high. The GIRFT and NaDIA reports advise training for every professional who dispenses, prescribes and/or administers insulin. Pharmacists are ideally placed to review and analyse insulin errors and support education and training. Furthermore, pharmacists should be at the forefront of any proposed developments or changes in prescribing processes and systems.
3. Pharmacists can make improvements to reduce medication errors
The NaDIA data revealed that almost one third of inpatient drug charts had at least one medication error. Similarly to insulin errors, this has demonstrated an improvement but remains too high. The NaDIA report breaks down medication errors into different types, including glucose management and prescription errors.
It is worth noting that whilst overall errors have reduced, the proportion of glucose management and insulin errors have remained static. By analysing their trust’s NaDIA data pharmacists can identify specifically what errors are occurring and then target where they can help support and make improvements to optimise patient care.
4. Pharmacists can lead on self-management policies
People with diabetes are the greatest experts in their own care and usually self-manage their diabetes daily. However, the GIRFT data found that in hospital people with diabetes often have their insulin and devices removed and locked away. The GIRFT report recommends that all trusts should have and promote a self-management policy. Currently one third of trusts has no such policy in place.
Pharmacy teams can help facilitate and lead on self-management and assessment policies, working with medication safety teams and ward level teams to enable people with diabetes to remain in control of the management of their condition as an inpatient wherever possible.
5. Pharmacists should be part of their trust’s Diabetes and Insulin Safety and Strategy Board
The GIRFT report introduced the concept of each trust having a quarterly trust-level diabetes safety board to review the overall quality of an inpatient service. Crucially, it is recommended that this board reviews incident reports and diabetes medication errors. Therefore, it is imperative that there is pharmacist involvement, representation and leadership at this board. Pharmacists working in diabetes should aim to be aware of and involved in the review of all diabetes related medication errors.
So what can pharmacists do next to make use of this information?
Firstly, read the reports. There is a lot of useful information in these documents, and it can take some time to digest everything mentioned, so it is worth taking the time to read these. The GIRFT report also provides examples of good practice which can help you consider whether any of these models may be translatable or adaptable to your team or trust.
The GIRFT report presented a landmark moment for the recognition of pharmacists in diabetes care
Review your GIRFT and NaDIA trust level analysis. Every trust which received a GIRFT deep-dive visit will have been provided with a report including specific recommendations. Trust level NaDIA data is freely available online. Look at where your trust can improve and where your skills as a pharmacist could be utilised. It is important to critically appraise your data, be honest about the service that you provide, and the areas you can improve on.
Whilst it is disappointing that insulin and medication errors remain an area of concern for people with diabetes when in hospital, this data and recommendations provide a fabulous opportunity for pharmacists to highlight their value in improving care for these patients.
This is a challenge and an opportunity for us as a profession to grasp. Wouldn’t it be wonderful if the next reports show reduced errors attributed to even more value added by pharmacists to diabetes care?
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.