Hypoglycaemia is now recognised to be a significant contributor to emergency admissions as well as having a major impact on clinical wellbeing, overall diabetes control and regimen concordance. Hypoglycaemia is the most common diabetes-related cause of paramedics being called out, and it is associated with increased morbidity and mortality (Brackenridge et al, 2006). Within the UK, the ambulance service manages around 90 000 call-outs per year for hypoglycaemia (Sampson et al, 2006). In 2009–10, ambulance call-outs cost the NHS £13 million based on a unit cost applied to the estimated number of cases of severe hypoglycaemia requiring emergency attendance (National Audit Office, 2012).
In November 2011, the “Super Six” model of care was introduced, integrating acute and community diabetes care across South East Hampshire (Kar, 2013). As part of this project, the diabetes team at the Diabetes and Endocrine Centre, Portsmouth Hospitals NHS Trust, had the opportunity to concentrate its specialist resources on specific areas, including inpatient diabetes. Analysis of admission data showed significant admissions to be of a recurrent nature, whether secondary to diabetic ketoacidosis or as a result of severe hypoglycaemia. There was also the need for the trust to meet Commissioning for Quality and Innovation (CQUIN) targets as regards overall acute admissions (NHS Institute for Innovation and Improvement, 2013), thus making this area one to target, to help reduce admissions.
Admissions as a result of diabetic ketoacidosis occur predominantly in young people with type 1 diabetes. The Portsmouth Hospitals NHS Trust aimed to tackle this by re-shaping and developing the adolescent diabetes team; admissions as a result of severe hypoglycaemia were tackled in a multi-pronged approach, as detailed below.
Identifying the areas to target
The analysis of admissions (unpublished data) revealed that a significant number were driven by inappropriate application of Quality of Framework (QOF) targets to, for instance, elderly and frail individuals. There also seemed to be a trend in which some individuals had recurrent admissions without receiving appropriate medication adjustment or advice, something which might have prevented it.
There also appeared to be two distinct categories of paramedic call-outs to people with diabetes experiencing hypoglycaemia: those for individuals who needed admitting to hospital; and those where the individual was treated by the paramedics and was able to remain at home. A striking finding was the lack of data transfer from the local ambulance crew to primary care clinicians or hospital specialists in cases where individuals were treated for severe hypoglycaemia based on a 999 call but were not admitted, thus not giving either primary or secondary care the opportunity to review the person with diabetes accordingly. Consequently, any pathway development needed to ensure patient information was passed on and acted upon where necessary.
The main objectives of the projects were:
- To target people who were admitted with hypoglycaemic episodes, ensuring that they were being discharged with appropriate advice and also trying to ensure that they did not have a repeat admission.
- To enable education levels in primary care to be raised, in order to enable hypoglycaemic episodes to be avoided where possible.
- To make sure that paramedics could safely flag all people with diabetes experiencing hypoglycaemia to the specialist team, who could then work with the individual, the community team and the GP surgery to prevent a recurrence if possible, with education being the cornerstone.
- To continue to improve on the existing relationships shared between all teams involved in diabetes care in the locality.
For implementing a solution, the decision was taken to build on the Super Six diabetes model, which already ensured that a consultant and diabetes specialist nurse (DSN) were visiting each GP surgery locally twice a year. This local community care model thus gave the potential for consultants and DSNs to approach each GP practice and specifically target the area of hypoglycaemia.
A key aspect of the solution was establishing a new pathway, built around the idea of a “Hypoglycaemia Hotline, which was introduced in January 2013. This involves the paramedics letting the secondary care diabetes team know via telephone of any 999 calls made in which hypoglycaemia is reported. For individuals not admitted to hospital, the DSN team then contacts the person highlighted by the paramedic service within 24 hours of the emergency phone call to check on his or her well-being. If any adjustments to the individual’s medication regimen are required, this is then communicated to his or her GP, as well as to the community team if necessary (a flowchart for the pathway is provided in Figure 1 and supplementary details are presented in Box 1).
The pathway was developed in joint working with the local ambulance trust (South Central Ambulance Services), local GP commissioners (in South East Hampshire and Portsmouth Clinical Commissioning Group) and the acute trust (Portsmouth Hospitals NHS Trust).
Besides the new pathway, educational sessions were also set up, directed at residential and nursing homes to highlight the importance of diabetes control and relevance of hypoglycaemic events for emergency admission.
Education has also been directed at each individual GP surgery, using the Super Six model. The education highlights medications, such as sulphonylureas, that can be reviewed, and has enabled discussions to take place on, among other things: the impact of renal failure on blood glucose levels; the appropriate use of insulin (e.g. exploring analogue insulin and nocturnal hypoglycaemic episodes); and the relevance of QOF targets (especially for elderly and frail people).
Finally, the inpatient diabetes team now gives supplementary advice to any patients admitted with hypoglycaemia before discharge from hospital.
The three-pronged approach is summarised in Box 2.
Data and feedback
Data on this new initiative were collected between January and September 2013 (the project continues). These are presented in Box 3. The admission rates due to severe hypoglycaemia have been measured since November 2010 in preliminary analyses, and a marked drop in admissions secondary to hypoglycaemic events has been noted since the Super Six model of care was launched, in conjunction with the other initiatives such as the one described in this article.
Feedback on the Hypoglycaemia Hotline from people with diabetes has been positive. In particular, the education and reassurance provided to them through this service has led to high satisfaction. People with diabetes now feel more confident in managing their hypoglycaemia, having spoken to a specialist. Feedback from paramedic staff has been similarly positive, and South Central Ambulance Service has noticed a reduction in paramedic calls for hypoglycaemia.
The project was not undertaken in isolation, but was one which developed following the overlap from the different projects already being undertaken by the Portsmouth diabetes team. Work in the inpatient setting illustrated the issues within the acute trust while community-based working helped to highlight the issues within primary care. A combined view revealed the poor nature of information flow between paramedics and primary care.
It should be acknowledged that there are examples from other parts of the country where a part of the overall project that we have embarked on has already been employed, such as having a pathway for paramedic contact to the specialist team (in Hull and Leicester). However, we have used a three-pronged approach to tackle a broad range of areas with the intention not only to make sure that people with diabetes who do experience hypoglycaemic episodes receive the best care possible, but also to ensure that there is an overarching primary aim of preventing such episodes, as far as possible.
We are not aware of any models of this nature for which significant improvements in outcomes have been shown, but our preliminary data, encouragingly, are suggesting that a wide-ranging approach might well be able to deliver these. Due acknowledgement is paid to the centres that have helped us to embark on this project.
We feel that our general success is attributable, in large part, to a simple initiative that has put the well-being of the person with diabetes into sharp focus, applying clinical reasoning rather than blind pursuance of guidelines and targets above all. The pre-existing strong working relationship between local clinicians and commissioners, which have been instrumental in the development of the Super Six model, have undoubtedly helped in designing, developing and implementing this new pathway. A strong overall will to help in the process of patient care has also been noticeable and has emphasised the importance of having relationships between primary and specialist care that are unimpeded by artificial boundaries that could result in a hindrance of the well-being of people with diabetes.
This pathway has also resulted in four trusts (namely, Portsmouth Hospitals NHS Trust, Southern Health NHS Foundation Trust, Solent NHS Trust and South Central Ambulance Service NHS Foundation Trust), along with 79 GP surgeries, working together to a single goal.
As a diabetes centre, we are fortunate to have such an eclectic mixture of professionals and managers within the same system who have come together for the betterment of patient pathways. We feel such pathway improvements can be replicated in other areas but that this hinges, most significantly, on relations between commissioners and providers, along with the willingness to work across multiple providers.
The authors would like to thank all of their diabetes specialist nurse and consultant colleagues, as well as giving special mentions to: Dr Chris Walton and Dr Belinda Allen from Hull, for sharing their idea; Neil Cook from South Central Ambulance Services; and Jim Hogan and Melissa Way, their local commissioners, for helping to put the initiative in place.