Improving insulin administration in a community setting

NHS England | March 2019 | Improving insulin administration in a community setting

Specialist Diabetes nurses have led on the development and implementation of a new, modular training programme for both community nurses and non-registered practitioners in diabetes care. 

Diabetes specialist nurses found variation in diabetes care in both the community and in residential care homes, with increased demand for district nurses to administer insulin.

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They identified an opportunity to  implement insulin delegation- the process by which a registered nurse allocates the task of insulin administration to a named, competent, non-registered practitioner, such as a healthcare assistant. An insulin delegation programme involves:

  • Developing an insulin delegation policy, and updating other relevant policies and procedures;
  • Assessing the diabetes knowledge and skills of everyone involved in diabetes care, including registered nursing staff;
  • Theoretical and practical training for all staff who require it, and additional training for staff administering insulin;
  • Competency assessment, mentoring and support for those administering insulin.

Specialist diabetes nurses carried out a detailed audit to establish the level of diabetes knowledge amongst community nurses and identify areas where delegation could be considered.  An audit was undertaken by registered community nurses, this underlined opportunities for upskilling colleagues in relation to insulin therapy, illness management, nutritional management and footcare.

The training programme that was developed comprises three modules:

  • Diabetes awareness
  • Expansion of diabetes knowledge
  • Insulin administration for non-registered practitioners

Some of the community staff became diabetes mentors for the programme, the mentors also participated in the same training course as the non- registered practitioners.

This programme led to better use of resources:

The insulin delegation programme offers a way of supporting complex care by providing skill and competency development, supported by robust governance infrastructure. Non-registered practitioners can administer diabetes care, including insulin, while still under the supervision of a community nurse, ensuring patient safety and quality of care. Community nurses can be released to support other patient groups. There is now improved diabetes care planning with the use of non-registered practitioners to support their own clients in residential care home settings, reducing the need for, and frequency and number of, district nurse visits, especially in rural locations ( Source: NHS England).

Improving insulin administration in a community setting

Barnsley and Rotherham: diabetic eye screening programme

Public Health England | March 2019 | Barnsley and Rotherham: diabetic eye screening programme

Public Health England (PHE) has now published an Executive summary of quality assurance (QA) visit to Barnsley and Rotherham held on 18 October 2018. 

Quality assurance (QA) visits are carried out by the Public Health England screening quality assurance service (SQAS)

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The evidence for this report comes from:

  • routine monitoring of data collected by the NHS screening programmes
  • data and reports from external organisations
  • evidence submitted by the provider(s), commissioner and external organisations
  • information collected during pre-review visits
  • information shared with SQAS (North) as part of the visit process

Full details from Public Health England

Screening Quality Assurance visit report NHS Diabetic Eye Screening Programme
Barnsley and Rotherham

Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial

Lean, M. E. et al |2019| Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial| The Lancet Diabetes & Endocrinology.

scale-diet-fat-health-53404.jpegSummary

Background

The DiRECT trial assessed remission of type 2 diabetes during a primary care-led weight-management programme. At 1 year, 68 (46%) of 149 intervention participants were in remission and 36 (24%) had achieved at least 15 kg weight loss. The aim of this 2-year analysis is to assess the durability of the intervention effect.

Methods

DiRECT is an open-label, cluster-randomised, controlled trial done at primary care practices in the UK. Practices were randomly assigned (1:1) via a computer-generated list to provide an integrated structured weight-management programme (intervention) or best-practice care in accordance with guidelines (control), with stratification for study site (Tyneside or Scotland) and practice list size (more than 5700 or more than or equal to5700 people). Allocation was concealed from the study statisticians; participants, carers, and study research assistants were aware of allocation. We recruited individuals aged 20–65 years, with less than 6 years’ duration of type 2 diabetes, BMI 27–45 kg/m 2, and not receiving insulin between July 25, 2014, and Aug 5, 2016. The intervention consisted of withdrawal of antidiabetes and antihypertensive drugs, total diet replacement (825–853 kcal per day formula diet for 12–20 weeks), stepped food reintroduction (2–8 weeks), and then structured support for weight-loss maintenance. The coprimary outcomes, analysed hierarchically in the intention-to-treat population at 24 months, were weight loss of at least 15 kg, and remission of diabetes, defined as HbA 1c less than 6·5% (48 mmol/mol) after withdrawal of antidiabetes drugs at baseline (remission was determined independently at 12 and 24 months). The trial is registered with the ISRCTN registry, number 03267836, and follow-up is ongoing.

Findings

The intention-to-treat population consisted of 149 participants per group. At 24 months, 17 (11%) intervention participants and three (2%) control participants had weight loss of at least 15 kg and 53 (36%) intervention participants and five (3%) control participants had remission of diabetes. The adjusted mean difference between the control and intervention groups in change in bodyweight was −5·4 kg and in HbA 1c was −4·8 mmol/mol, despite only 51 (40%) of 129 patients in the intervention group using anti-diabetes medication compared with 120 (84%) of 143 in the control group. In a post-hoc analysis of the whole study population, of those participants who maintained at least 10 kg weight loss (45 of 272 with data), 29 (64%) achieved remission; 36 (24%) of 149 participants in the intervention group maintained at least 10 kg weight loss. Serious adverse events were similar to those reported at 12 months, but were fewer in the intervention group than in the control group in the second year of the study (nine vs 22).

Interpretation

The DiRECT programme sustained remissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss.

The Library & Knowledge Service can provide access to this article for Rotherham NHS Staff, request a copy here 

Related:

Diabetes Insipidus – the danger of misunderstanding diabetes

BMJ talk medicine | February 2019 | Diabetes Insipidus – the danger of misunderstanding diabetes

Diabetes is synonymous with sugar, but diabetes insipidus, “water diabetes”, can’t be forgotten. Between 2009 and 2016, 4 people died in hospital in England, when lifesaving treatment for the condition was not given.

drink

This podcast from BMJ talk medicine, includes  some practical tips for non-specialists to aid diagnosis, and how patients should be managed during hospital admission.

Listen via Soundcloud 

See also:

Full BMJ practice article

Diabetes outcomes versus expenditure (DOVE) in local populations

Public Health England | March 2019 | Diabetes outcomes versus expenditure (DOVE) in local populations

Public Health England  have updated the Diabetes outcomes versus expenditure (DOVE) in local populations.  

Healthcare professionals can use the DOVE tool to explore the relationship between spending on diabetes treatment and local clinical outcomes for patients. This can help with planning and commissioning local services.

DOVE tool for CCGs and GP practices

DOVE tool: summary of results 2013 to 2018

Full details available from Public Health England

Introducing group consultations for adults with Type 2 diabetes

NHS England | March 2019 | Introducing group consultations for adults with Type 2 diabetes

General practice nurses (GPN) in the Premiere Health Team, Leigh (Wigan CCG) and West Gorton (Manchester CCG) medical practices introduced group consultations for adults with Type 2 Diabetes. This new approach has led to better outcomes, experiences and use of resources locally.

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The GPNs recognised a significant proportion of time was in consultations with patients about managing their diabetes, this advice was not impacting on health outcomes. Group consultations were identified as providing a potential opportunity to improve outcomes and access, engaging patients through a more social and less medical model of planned care. Experience in other parts of England suggested that it could also improve staff experience by reducing repetition and creating more time to care and support patients.

The programme was set up to reflect the drive in primary care to support patients through new consultation approaches. The aim being to improve continuity and convenience for the patient, and connect them directly with the most appropriate professional through new ways of working.

The first session focused on HbA1c, blood pressure, cholesterol, Body Mass Index (BMI), eye and foot checks and medicines. The second session centred around issues that patients wanted to explore further, which they identified at the first session.

As part of the session weight and blood pressure measurements were taken and it became clear that weight control was the group’s biggest issue.  At the follow-up consultations, the team prepared healthy recipes to encourage more home cooking and ran a food quiz to identify hidden sugars in common shopping basket foods. Alongside this, clinical aspects of diabetes such as impact on the kidneys and blood pressure were discussed.

This led to better use of resources, West Gorton practice calculated significant efficiency gains in clinician time. The nurse consulting saw 8-9 patients in one hour, which under the previous model four patients would have been seen in a 1:1 clinic (Source: NHS England).

See the Atlas of Shared Learning