Admissions avoidance and diabetes: guidance for …

1 Admissions avoidance and diabetes : guidance for clinical commissioninggroups and clinical teams Produced by the Joint British diabetes Societies for Inpatient Care (JBDS IP)December 2013 This document is coded JBDS 07 in the series of JBDS documents:Other JBDS documents:The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes August 2012 JBDS 06 Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes June 2012 JBDS 05 Self-Management of diabetes in Hospital March 2012 JBDS 04 The Management of Adults with diabetes undergoing Surgery and Elective Procedures: improvingStandards April 2011 JBDS 03 The Hospital Management of DKA in Adults Revised September 2013 JBDS 02 The Hospital Management of Hypoglycaemia in Adults with diabetes Mellitus Revised September 2013 JBDS 01 These documents are available to download from the ABCD website and the diabetes UK website NHS faces a relentless and unsustainable rise in emergency hospital Admissions , and reversing thistrend is an absolute priority for the ,2 However, only a minority of primary care trusts (PCTs) inEngland managed to reduce overall emergency Admissions , despite the intense focus on this area bycommissioners and health care problem has had a substantial impact on elective capacityand waiting times, is an issue in across all UK nations, and is of increasing importance in the context ofA&E pressures and out of hours (OOH)

2 Now know from the National diabetes Inpatient Audit (NaDIA)5that about 1 in 6 hospital beds inEngland are occupied by someone with diabetes and health economic analysis suggests diabetesadmissions in England alone accounted for 607,581 excess bed days (compared to the equivalentpopulation without diabetes ), at a total estimated excess tariff expenditure of 573 million in one is due to increased admission (and readmission) rates, a prolonged length of stay once admitted,disease specific Admissions , and a bias against day case surgery in the diabetes also know there is substantial variability between clinical commissioning groups (CCGs) and AcuteTrusts in diabetes admission rates. There is strong evidence for models that reduce variability and overalladmission rates, but which are often not commissioned, or are not available. This makes diabetes a priorityfor commissioning attention, with the potential for real and rapid improvement in admission rates fromthe UK diabetes population of more than 3 million.

3 This document has been produced by the Joint British diabetes Societies for Inpatient Care (JBDS IP) onbehalf of diabetes UK, the Association of British clinical Diabetologists (ABCD), and the diabetes InpatientSpecialist Nurse (DISN) UK Group, in collaboration with NHS diabetes , and the Primary Care DiabetesSociety (PCDS). This document is not a clinical guideline, but a summary document for health care planners andcommissioners in the UK which complements the recent Best Practice for commissioning DiabetesServices6Dr Belinda AllanConsultant Diabetologist, Hull and East Yorkshire Hospitals NHS TrustDr Chris WaltonConsultant Diabetologist, Chair Association of British ClinicalDiabetologists, Hull and East Yorkshire Hospitals NHS Trust Tracy KellyHead of Care, diabetes UK Esther WaldenDiabetes Inpatient Specialist Nurse, Chair diabetes Specialist Nurse(DISN) UK Group, Norfolk and Norwich University Hospitals NHSF oundation TrustProfessor Mike SampsonConsultant Diabetologist, Chair JBDS IP, Norfolk and Norwich University Hospitals NHS Foundation TrustForeword and policy context 1 Sarah Purdy.

4 Avoiding hospital Admissions : what does the research evidence say? The King's Fund. 2010. The King's Fund, 11-13 Cavendish Square, London W1G OAN. 2 Goodwin Nick et al. Integrated care for patients and populations: Improving outcomes by working together. Report to the Department ofHealth and NHS Future Forum from the King's Fund and Nuffield Trust. S. Rising hospital Admissions : can the tide be stemmed? (Editorial). British Medical Journal 2010; 340: p 636. ; Casualty Units must be reformed to meet demand Jeremy Hunt (2010) 6( ). 5 Foreword and policy context3 Index 5 Authorship and acknowledgements6 Who this document is intended for 7 Summary of key points and recommendations8-101. Overall diabetes Admissions , bed occupancy, and cost11-152. diabetes specific admissions16-183.

5 Readmission rates and diabetes194. Variability in diabetes admission rates 20-225. A whole systems approach to reducing diabetes Admissions 23-26 Primary Care26-28 Vulnerable Groups28-30 Specialist Care30-326. Improving day case surgery listing for people with diabetes33-347. Reducing diabetes specific Admissions and readmissions35 Diabetic ketoacidosis (DKA)35-39 Hypoglycaemia and Ambulance Trusts40-41 Diabetic foot disease42-448. commissioning care to reduce hospital bed occupancy45-469. National out of hours support line for people with diabetes4710. At a glance guide 48 Contents6 Authorship and AcknowledgementsLead authorshipDr Belinda Allan, Hull and East Yorkshire Hospital NHS TrustProfessor Mike Sampson, Norfolk and Norwich University Hospitals NHS Foundation TrustSupporting organisationsDr Paul Downie Primary Care diabetes Society (PCDS)Tracy KellyDiabetes UKFiona KirklandPrimary Care diabetes Society (PCDS)Esther Walden Chair, diabetes Inpatient Specialist Nurse (DISN) UK Group Dr Chris WaltonChair, Association of British clinical Diabetologists (ABCD)

6 Writing and review groupDr Belinda Allan, Hull and East Yorkshire Hospital NHS Trust *Dr Hamish Courtney, Belfast Health and Social Care Trust, Northern Ireland *Dr Ketan Dhatariya, Norfolk and Norwich University Hospitals NHS Trust *Dr Daniel Flanagan, Plymouth Hospitals NHS Trust Professor Kevin Hardy, St Helens and Knowsley Teaching Hospitals NHS TrustDr Roselle Herring, Royal Surrey County Hospital NHS Foundation TrustJune James, University Hospitals of Leicester NHS Trust *Kathryn Leivesley, Liverpool Heart and Chest NHS Foundation Trust Dr Peter Leslie, NHS BordersDr Rif Malik, King s College Hospital NHS Foundation Trust *Dr Colin Perry, NHS Greater Glasgow and Clyde *Dr Gerry Rayman, The Ipswich Hospitals NHS Trust *Dr Stuart Ritchie, NHS Lothian *Dr Aled Roberts, Cardiff and Vale University NHS Trust *Professor Mike Sampson (Norwich), Joint British diabetes Societies (JBDS) Inpatient Care Group Chair *Professor Alan Sinclair, Institute of diabetes for Older People (IDOP), UKDr Maggie Sinclair-Hammersley, Oxford University Hospitals NHS Trust *Debbie Stanisstreet, East and North Hertfordshire NHS Trust *Professor Jonathan Valabhji, National clinical Director for Obesity and diabetes *Esther Walden, Norfolk and Norwich University Hospitals NHS Foundation Trust *Dr Chris Walton, Hull and East Yorkshire Hospital NHS Trust *Dr Peter Winocour, East and North Hertfordshire NHS Trust *We are particularly grateful to Naomi Holman (Yorkshire and Humber Public Health Observatory) andMarion Kerr (Health Economist, Insight Health Economics)

7 For their advice and for allowing us to quotetheir extremely useful work in this area. With special thanks to Christine Jones (DISN UK Groupadministrator) for her administrative work and help with these guidelines and with JBDS IP*Member of JBDS IP core groupThis document was reviewed on behalf of the Scottish diabetes Group, and while there are differencesbetween the healthcare systems North and South of the border, the Scottish diabetes Group supports theclinical content and broad aims of the document is not a clinical guidelineor adefinitive guide to Admissions avoidance andinpatient diabetes care. It is a short documentdirected at clinical commissioning groups (CCGs) inEngland, health care planners in Scotland, Walesand Northern Ireland, and senior management inUK Acute Hospitals. The document draws togetherwork, projects and data from many differentsources into a single hope it will also be useful for clinical teams inprimary and secondary care in their discussionswith commissioners about diabetes services in thenew NHS.

8 The document emphasises the scale of the clinicaland financial problem of diabetes Admissions toUK hospitals and commissioners, and describesmodels shown to reduce variability. The document may be valuable for healthsystems looking to reduce A&E attendances, andimprove out of hours cover. The document concentrates on areas for whichthere is a reasonable evidence base, and forpractical changes which might be achievable inthe real world, and avoids options that requiremassive societal change or immediate huge investment. The document emphasises the special case offrail and vulnerable older people with diabeteseither living housebound in the community, oras residents of care homes. Here, proactiveintervention to reduce unnecessary hospitaladmission should be a key objective of mostcommunity-based solutions. Most of the recommendations could bedelivered with modest pathway and servicemodel review and concentration of resources inkey areas, and with a reasonable expectation ofimprovement in the short term.

9 The document can be used as a resource forcommissioners, clinical teams and Acute Trustswhen making the economic argument forchange and improvement in clinical services. We are very grateful to Naomi Holman andcolleagues at the National diabetes InformationService (NDIS) and to Marion Kerr (Insight HealthEconomics) and colleagues at NHS diabetes fortheir support in developing this document, andfor allowing us to quote their exceptionallyvaluable work. Please note that NHSI mproving Quality (NHS IQ) took overresponsibility for the content of the NHSD iabetes website from July 2013. There are other available publications that stressthe gaps in clinical care in inpatient diabetesservices which complement this document, inparticular the data from the national diabetesinpatient audit and other JBDS IP documents. Who this document is intended for8 There is substantial and well documented postcode variability in diabetes specific admission andreadmission rates.

10 There are evidence based servicemodels that have been shown to reduce admissionand readmission rates for people with can be put in place relatively quickly withthe likelihood of early benefit, and accuratebenchmarking between areas for outcomesis possible. Recommendations To reduce diabetes Admissions , clinicalcommissioning groups and health boardsshould commission diabetes service modelsshown to be effective. Commissioners should:1 Obtainreadily available benchmarking datafrom the National diabetes Information service(NDIS)7and from the National diabetes Inpatientaudit (2012)8, for their area and their localproviders on overall diabetes admission rates, diabetes specific admission rates (diabeticketoacidosis, severe acute hypoglycaemia, hospitaladmission rates of care home residents withdiabetes, and diabetic foot disease) and from theirregional Ambulance Trusts (for severe acutehypoglycaemia).