I was watching a Jeremy Hunt interview recently..where you couldn't fault him for the logic he put forward as regards improving patient care. Sure, depending on your political leaning, you could question the motive or applaud him for grasping the nettle, but the principle was spot on. He mentioned that sadly the NHS still has incidences of the wrong limb being amputated and that needs to be resolved. Had to be tackled and data was indeed aimed at the bigger principle...improving patient care and safety. I personally wholeheartedly support this but beg to differ as to whether triangulating everything to the Consultant is the way ahead. Do we risk elevating the Consultant once again to the God-like pedestal...with Him lies everything...or do we use this to force the Consultants to take up the baton of accountability, be the leader of the whole team and service? Maybe...but we shall see..but anyhow I digress.
So we don't want to see wrong limb amputations- quite correctly too...and recently I asked a group of senior and junior doctors what they think should happen if a doctor concerned does indeed do this? Struck off? GMC censure? Lots of debate- but in general the consensus was it was unacceptable whichever way one looked at it. It was a "Never Event"...an event each acute trust strives to ensure never happens. In fact there is a list of them from the Department of Health...events which have been deemed to be the white line teams shouldn't cross. I will even quote the definition for you..."Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures are put in place"
And there's 25 of them...look through them...all make perfect sense.."maternal death due to post partum haemorrhage after elective CS"; "misidentification of patients";"wrong route administration of chemotherapy"...and ensconced among them in point number 9 is.."maladministration of insulin". Number 9 no less, not even bottom of the list...so someone must have thought it to be important enough. The folks to whom I was doing the talk to expressed surprise laced with incredulity..."same level as wrong limb amputation?!!"...and in a nutshell, summarised perhaps the general attitude towards patients with diabetes in hospitals.
Don't believe me..think I am just being a diabetologist waving the flag of specialism?...OK...read this from a national audit .."in a 5 day period, within hospitals, more than 60 patients developed DKA which results from a severe shortage of insulin".In short, these patients, due to one reason or the other were not given their insulin. Ah, so you don't believe data either? What about patient experiences? Have a read of this from Nick Guerin..makes for a sobering read doesn't it?
So what is it that stops us from improving things? Do the rest of the fraternity not care much about diabetes? Is it the belief that it's "nothing that serious"? Is it the belief its not that "important"? Is it because we instantly associate diabetes with being overweight, pretend not to understand the difference between type 1 and Type 2 diabetes? Did someone just say "education"? I can promise you, no absolutely guarantee you the problem with that is the sheer sustainability as well as trying to keep on top of the fast turn over of nurses and doctors on wards. We have a crack inpatient diabetes team..well staffed, education laid out in all formats possible..and yet, we can't eliminate all..perhaps we never will...but somewhere the attitude also needs to change. Type 1 diabetes patients deserve better than an untrained orthopaedic junior refusing a patient their normal medications..also known as insulin..also known as the drug which keeps them..simply put..keeps them alive.
So where to next...keep plugging the education...but perhaps turn up the heat a bit? At any given time, about 15-20% of hospital beds are occupied with patients who also have diabetes- admitted for a variety of reasons. We owe it to them to do better, or perhaps even show a bit better understanding of the disease rather than a cursory shrug of the shoulder.As per the audit, not every hospital has diabetes inpatient teams...thats fine..as long as the other teams show the responsibility to look after those patients. So..either learn about the disease process, know how to look after them..or step aside and create room for people who know more than you. We locally are very lucky to have a high quality 5 day cover and our mortality data, error rates etc compared to neighbouring Trusts supports this...the next step is to see whether we can do so for 7 days...but now I think the time has come to add an extra edge to it.
Next time there is an error or mismanagement causing harm, it maybe now down to individual or team accountability. Educational supervisor, Deanery, GMC...as far as it goes. After all, you would do the same if Mrs Bloggs had her left leg amputated rather than the designated right one..so why should it be different if Mr Bloggs goes into DKA because someone forgot to give him or prescribe his insulin? It does, after all, carry the same weight as per the DH Never Event list.
There is a time and a place for working together, having group hugs...there's also a time and place where the need of the patient supersedes the need for professional bonhomie. To all those who read this and are involved in patient care, next time you see a patient with diabetes and not sure what to do..ask someone who does.For those Trusts who don't have inpatient teams, either educate the present staff or think of having one,seriously. No time for a cowboy or a cowgirl...just remember if you get it wrong, in spite of all the protocols, educational materials and courses which you have chosen not to attend... the local diabetes team may come hunting.
As the local diabetes lead, I am also the person who is supposed to be the advocate for people who have diabetes. So..attend those educational programmes, get yourselves familiar with the on-line protocols, ask the nurse specialist who covers the ward, ask me...anything you want...but try and avoid making a fatal mistake. As otherwise, I will, indeed, come looking. Promise.