Background & Problem
Guiting ward at Cheltenham General Hospital looks after patients needing vascular procedures. Many of these are diabetic patients who use insulin at home. When in hospital, these patients often want to continue self-administering their insulin and managing their condition as independently as possible. This should be encouraged, as self-administration of insulin is proven to result in better patient outcomes. However, patients should only be injecting themselves unsupervised if they are competent to do so. They should also be storing their insulin somewhere securely, in line with medication safety laws.
Previously there was no formal process for assessing the competence of patients, and patients could not access their bedside lockers, meaning they either had to ask a nurse to retrieve their insulin or leave it out at the bedside. Patients were unhappy with this arrangement and it was unsafe to have insulin lying about.
Aim
To increase the number of patients appropriately self-administering insulin by 50% over 4 months.
“Appropriately” here means there is documented assessment of self-administration if needed and the insulin in use is stored securely.
Method
Change 1: Ward staff education and reminder cards stuck to bedside lockers.
Change 2: Introduction of Trust documentation to assess patients as well as a separate prescription chart, designed to be filled in by patient (2 x PDSA cycles).
Change 3: Provision of lockable boxes, accessible to patients and to be kept at bedside, to keep insulin and equipment in (2 x PDSA cycles).
The lockable bedside boxes were obtained from Bristol Maid, using a donation kindly gifted by Cheltenham and Gloucester Hospitals Charity.
Huddles were held with the nursing staff to teach them about the new documentation and boxes.
Data was collected daily during pharmacist ward visit and recorded on a proforma. Data was gathered through examination of the prescription chart and observation of patient bed space. The location of insulin in use was also recorded.
Results
There was a clear increase in the number of patients appropriately self-administering (12% at baseline to 73%). There is now the means to assess patients wishing to self-administer insulin on the ward, and patient-accessible safe storage is available. Location of insulin in use saw an improvement - from just 58% of it being stored securely to 82% by the end of the project. There was a positive response by both patients and staff.
The 50% target in the aim was achieved, though it was difficult to sustain. The project ran over the 4 months originally intended.
Implications
The project was an overall success, and it is hoped that the interventions made will become a permanent feature on the ward. The ward may require additional support and training, which will be determined over the next few months. Ward staff are likely to need continued encouragement in using the tools provided with confidence. If the project proves sustainable in the long term, it could act as a model for other areas of the hospital to introduce insulin self-administration.
Quality Improvement Presenter(s)
Harriet Dykes, Pharmacist, Cheltenham General Hospital
Quality Improvement Team
Elisabeth Willis, Pharmacist
Rebecca Mustow, Medicines Management Nurse
Nursing staff, Guiting ward