Friday, March 17, 2017

The number game

Numbers. Audits. do you interpret them? With views of evangelism? Rose tinted spectacles? Shades of Doom? How much does our confirmation bias affect us? These sort of things do swirl in my mind whenever I am sent an audit to review.
I suppose it depends...if you genuinely believe that all fault is due to politicians, then it's natural to look for the gaps and blame it on them...that's the confirmation bias in full swing. On the flip side, if you want to be positive and believe in the fact that the NHS is unparalleled and will not tolerate a bad word about it, then the good news shine through.

So it is with similar swirls of thoughts that I looked at the National Diabetes Inpatient audit. What does it say? I suspect your interpretation will sit on how you want to see it. But let's take a step back and just take a time out for a second.
To begin with, this is categorically the most stand out data set as regards inpatient diabetes care across any country. 205 hospital sites contributed to it...this is no subset...this is an audit and a half. Much kudos to the energy and drive of many but especially Gerry Rayman from Ipswich who has helped us get to know what actually does go in hospitals- beyond the anecdotes, personal opinions etc

Let's look at some facts to cheer you up - and especially if you have diabetes and have to be admitted to a hospital for any reason whatsoever. More folks with diabetes are being seen by a specialist team- and hypoglycaemic rates in hospitals are down by about 20%. Foot ulcers picked up whilst in hospitals are also down- so to all the diabetes inpatient teams, especially the nurses who form the backbone of these, please, take a bow. A Herculean effort in present times and the diabetes community owes you all a collective thank you for that.

Now for the flip side...about a quarter of hospitals still don't have a diabetes inpatient team, 2 out of 5 diabetes drug-charts have errors in them while 1 in 25 patients with type 1 diabetes go into DKA as an inpatient- a mostly iatrogenic error where someone has forgot to give a type 1 diabetes patient their insulin. Take a pause and think of that. No insulin given in a hospital to a type 1 diabetes patient. In 2017. In a 1st world country. 
If you are a health care professional, that makes you wince a bit, no? And oh, yes, places which have e-prescribing have lesser errors. And lest we forget, patients aren't happy with content or timing of their meals in hospitals- though generally satisfied with care received.

So what next? We have done audits for about 5 years- we have seen some improvements, some haven't shifted...time to get cracking on those I reckon. Money is available specifically to help fund specialist nurses in the hope that this will drive those errors lower but it isn't just that. Simple initiatives such as policies of self management ( unbelievably those who live with diabetes seem to know more about their insulin needs and times than a fair few professionals...would you believe that....), learning from centres which do well, e-prescribing can make a difference too. Benchmarking is on its way too- and for sure, inpatient hospital safety for diabetes patients will figure very high on the list. At Diabetes UK conference, I heard some amazing examples from Southampton, Leicester and Derby while the work in areas such as Kings are well known too

It's time to get the negative bits right and we, as a diabetes community, have the levers in place, I reckon, to make it happen. Money, benchmarking and learning from areas of excellence are indeed nice but what gives me a ton of hope is the zeal of clinical leaders - whether it be from the nursing community via TREND or folks like Mayank Patel, Omar Mustafa, Kath Higgins etc. 
Lets look at this again- 2 out of 5 drug-charts have errors in them and 1 in 25 type 1 patients go into DKA while in hospital. 
So...Heres a challenge. Lets keep it 3 years, let's make that 1 out of 5 errors and get that DKA number to 1 in 100 and in 5, we aim for zero. 

Impossible, you say? Perhaps. But as the saying goes, if you aim high enough..even falling just short? Not too shabby. In my book, it's certainly within our gift to give it a try.

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