# National Diabetes Inpatient Audit England, 2019 England 13 November 2020 Full Report

## Foreword

NaDIA 2019 shows that, since the audit began in 2010, the very impressive improvements in many aspects of inpatient diabetes care have continued, including reductions in medication errors, severe **hypoglycaemia** and hospital-acquired diabetic **foot lesions**.

However, the occurrence of some important and life-threatening harms remain unchanged:

•
Severe hypoglycaemic episodes in inpatients with type 1 diabetes
•
Hospital-acquired diabetic ketoacidosis (DKA)
•
Hospital-acquired hyperosmolar hyperglycaemic state (HHS)
DKA and HHS are preventable and should not occur during a hospital admission. In this respect it is of interest that all medication errors have reduced with the exception of one, the failure to increase insulin when the capillary blood glucose1 (CBG) is persistently above 11 
mmol/L, suggesting that focusing on staff training in hyperglycaemic management and insulin dose adjustment may reduce these life threatening harms. 

It is important to recognise the hard work of diabetes teams and the almost one hundred per cent participation in this annual audit, without which we may not have realised these improvements nor identified where we need to redouble our efforts. No other healthcare service in the world has such comprehensive national data to evidence and direct change in inpatient care; a unique achievement for which we should be proud.

Gerry Rayman, Clinical Lead for the National Diabetes Inpatient Audit, Diabetes UK lead for Inpatient Diabetes, GIRFT Co-lead2
Partha Kar, National Specialty Lead, Diabetes, NHS England, GIRFT co-lead2

## Contents

| Main report                  |   Slide |
|------------------------------|---------|
| Executive Summary            |         |
| 4                            |         |
| Introduction                 |         |
| 7                            |         |
| 1                            |         |
| Participation and prevalence |         |
| 11                           |      39 |
| 2                            |         |
| Inpatient harms              |         |
| 12                           |      49 |
| 3                            |         |
| Medication errors            |         |
| 17                           |      48 |
| 4                            |         |
| Care improvement initiatives |         |
| 20                           |      46 |
| 5                            |         |
| Staffing levels              |         |
| 26                           |      43 |
| 6                            |         |
| Access to the diabetes team  |         |
| 29                           |      44 |
| 7                            |         |
| Surgical care                |         |
| 33                           |         |
| 8                            |         |
| Patient experience           |         |
| 36                           |      51 |
| Glossary                     |         |
| 39                           |         |
| Additional information       |         |
| 53                           |         |

Deep-dive reports are available for each of the numbered chapters, plus the following topics: foot disease management, blood glucose monitoring, use of insulin infusions and a separate report on **hypoglycaemic episodes**.

The deep-dive reports contain additional background, analysis and clinical commentary. See slide 9 for further information.

Supporting 
data is 
outlined 
on slide 9

## Executive Summary: Improvements In Diabetes Inpatient Care

188 out of 193 hospital sites known to be eligible for NaDIA took part in the 2019 
audit (97 per cent)1. The **commitment** and **hard work** by hospital teams to collect data and their dedication to using the analysed results to alter their practice has delivered some very encouraging **improvements**. This has been achieved with the help of an appreciable increase in staffing levels since NaDIA 2017, treating a consistently high proportion of people in hospital who have diabetes - 18 per cent in NaDIA 2019.

## Nadia Team In The Face Of This Heavy Workload Teams Have:

**Delivered more personal care** to inpatients with diabetes - 75 per cent of those surveyed in 
2019 were **seen by the diabetes team** where appropriate2 compared to only 54 per cent in 
2010.
Reduced the proportion of inpatient drug charts found to contain **medication errors** by 15 
percentage points since 2010 (from 45 to 30 per cent).
Reduced **severe hypoglycaemic** episodes from 12 per cent of inpatients during the last 7 
days of their hospital stay in 2010 to 7 per cent in 2019.
Reduced the need for **injectable rescue treatment** for severe hypoglycaemia - from 2.4 per 
cent of inpatients during the last 7 days of their hospital stay in 2010 to 1.4 per cent in 2019.
Reduced patients developing **foot ulcers** at any point during their hospital stay –
from 2.2 per cent of inpatients audited in 2010 to 1.1 per cent in 2019.

## Executive Summary: Areas Where Further Improvement Needed

Despite the significant and important improvements documented in slide 4, NaDIA 
also demonstrates that there is still **considerable scope for further improvements**.

## On The Day Of The Audit In 2019, Nadia Found High Levels Of:

•
Medication errors - almost 1 in 3 of the inpatient drug charts surveyed had at least one 
medication error.
•
Insulin errors - two fifths of inpatient drug charts for insulin-treated inpatients had one or 
more insulin error. 
•
Hospital-acquired **diabetic ketoacidosis** (DKA): on the day of the audit, 3.6 per cent of 
inpatients with type 1 diabetes had developed in-hospital DKA at any point during their hospital stay.
•
Capillary blood glucose1 (CBG) levels not being recorded at all recommended stages of the 
perioperative pathway2.
All of these findings clearly demonstrate the benefit of NaDIA in identifying areas on which to focus service improvements, and in driving and tracking change.

## Nadia Team

Notes: 1. The concentration of glucose in the blood. 2. At sign-in and sign-out stages of the surgical safety checklist, during surgery, in theatre recovery, on arrival on the ward.

## Executive Summary: Areas Where Action Is Recommended

Recommendation 2: Training should be provided for every healthcare professional who dispenses, prescribes and/or administers insulin, appropriate to their level of responsibility, including an assessment of competency. Electronic records and prescribing should be implemented in support.

Recommendation 1: The MDiT1 should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board. All hospital-acquired lifethreatening episodes of hypoglycaemia, DKA and HHS should be recorded as serious incidents, submitted to NaDIA-Harms and root cause analysis undertaken.

Recommendation 6: 
All trusts should have and promote a self-management policy, which supports patients who want to self-manage their diabetes to safely do so while in hospital, as clinically appropriate and in line with wider NHS England and NHS Improvement policies on inpatient self-management emergencies and elective and non-elective surgery, and a triage system to identify those at risk and rapidly refer them to the diabetes team. This should be an electronic system, integrated with web-linked blood glucose meters which provide an alert system for staff when any out-of-range reading is recorded.

Recommendation 5: 
All hospital trusts should have clear, audited perioperative pathways from pre-assessment through to discharge. 

These should be broadly in line with NCEPOD recommendations.

Recommendation 3: All trusts should have a dedicated multi-disciplinary team of specialist diabetes inpatient practitioners as indicated in the NHS Long Term Plan. Trusts should work towards providing base level specialist diabetes cover at weekends where this does not exist.

Recommendation 4: 
All trusts should have a robust system to identify all people with diabetes on admission to hospital, including 

## Introduction: Overview

•
The National Diabetes Inpatient Audit (NaDIA) measures on one day the quality of diabetes care provided to all people with diabetes while they are admitted to hospital whatever the cause, and aims to support quality improvement.
•
Data is collected and submitted by hospital staff in England. Wales did not participate in NaDIA 2019. Following a change in 
legal basis1 in England to a Direction from NHS England for 
NHS Digital to process data, the Welsh Assembly government 
have been pursuing a request as a legal basis, but this was not completed in time for Welsh hospitals to participate.
•
The NaDIA audit is part of the National Diabetes Audit (NDA) programme within the National Clinical Audit and Patient Outcomes Programme (NCAPOP), commissioned by the Healthcare Quality Improvement Partnership (HQIP).
Supported by:
This is the full report. **Deep-dive** reports are available for individual chapters, including four additional chapters. Local reports and supporting data are also published.

Buttons - available on some slides 
= Home 
= Further info
(section/
(glossary)
contents) 
i

## Notes: 1. Eu General Data Protection Regulation. Article 6: Lawfulness Of Processing: Introduction: Audit Questions

The audit sets out to measure the quality of diabetes care provided to people with diabetes while they are admitted to hospital, by answering the following questions: •
Did diabetes management minimise the risk of avoidable complications? 

•
Did harm result from the inpatient stay? 
•
Was patient experience of the inpatient stay favourable? 
•
Has the quality of care and patient feedback changed since NaDIA 
2010, 2011, 2012, 2013, 2015, 2016 and 20171? 
The report will be of interest to the public, especially to people with diabetes. Health planners and policy makers, as well as acute NHS trusts, Clinical Commissioning Groups (CCGs), Local Health Boards (LHBs), Sustainability and Transformation Partnerships (STPs), Clinical Networks (CNs; formerly Strategic Clinical Networks or SCNs) and other providers and commissioners of specialist diabetes services will also make use of the information in this report.

Notes: 
1. Wales did not participate in NaDIA 2019 (see slide 7), so data from earlier years has been re-analysed to include English hospital sites only. 

To help ensure that tables and charts remain uncluttered as the audit duration increases, NaDIA 2011, 2012 and 2016 have been excluded from most tables and charts. There was no audit collection or report in 2014, so 2014 data is not available. Wales did not participate in NaDIA 2010.

## Introduction: Supporting Data Nadia Publishes A Wealth Of Supporting Data In Addition To This Report:

| Deep-dive reports                 | Local reports              |
|-----------------------------------|----------------------------|
| 0                                 |                            |
| Key messages                      |                            |
| Hospital Level                    |                            |
| Analysis 2010-19                  |                            |
| 1                                 |                            |
| Participation and prevalence      |                            |
| 2                                 |                            |
| Inpatient harms                   |                            |
| Hospital                          |                            |
| Characteristics                   |                            |
| Report 2019                       |                            |
| 3                                 |                            |
| Medication errors                 |                            |
| 4                                 |                            |
| Care improvement initiatives      |                            |
| 5                                 |                            |
| Staffing levels                   |                            |
| Hospital                          |                            |
| Characteristics                   |                            |
| Responses 2010-19                 |                            |
| 6                                 |                            |
| Access to the diabetes team       |                            |
| 7                                 |                            |
| Surgical care                     |                            |
| Main Areas For                    |                            |
| Improvement Report                |                            |
| 2015-19                           |                            |
| 8                                 |                            |
| Patient experience                |                            |
| 9                                 |                            |
| Foot disease management           |                            |
| Supporting documents              |                            |
| 10                                |                            |
| Blood glucose monitoring          |                            |
| One-page summary                  | Summary of the main report |
| 11                                |                            |
| Use of insulin infusions          |                            |
| Open data                         | Backing data in CSV format |
| 12                                |                            |
| Hypoglycaemic episodes            |                            |
| Data quality statement            |                            |
| Details about the data collection |                            |
| Methodology                       |                            |
| Details about the methodology     |                            |

Bold = Not covered in the main report (this document). 

A wide range of NaDIA outputs at hospital site-level from 2010 to 2019 All 2019 Hospital Characteristics results at hospital site-level, compared to national data
Time series of all comparable Hospital Characteristics results at hospital sitelevel from 2010 to 2019 Main areas for improvement at hospital site-level identified by inpatients with diabetes 2015 to 2019

## Introduction: Terminology Main Abbreviations

DISN
diabetes inpatient specialist nurse
DKA
diabetic ketoacidosis
DSN/DISN
diabetes (inpatient) specialist nurse
HHS
hyperosmolar hyperglycaemic state
MDiT/MDFT multi-disciplinary (inpatient/foot care) team
NICE
National Institute for Health and Care Excellence
OA-DA
oral anti-diabetic agent

The above acronyms will not always be footnoted in the report. 

For an extended list of abbreviations, see Glossary: Acronyms. 

## Cohorts Used In The Report

| Audit year          | Notes       |
|---------------------|-------------|
| Wales unless stated |             |
| 2010                | Full NaDIA, |
| England             |             |
| only                |             |

Wales did not participate in NaDIA 2019, so NaDIA data from earlier years has been reanalysed to include **English hospitals only**.

| 2011              |
|-------------------|
| first             |
| England and Wales |

Outputs are often split by **audit year** (see right) and/or **diabetes type**.

2012 & 2013
Full NaDIA
2014
No NaDIA
2015 to 2017
Full NaDIA

Inpatients with **type 1** diabetes are reported as a single group. Inpatients with type 2 
diabetes are grouped into three subcategories based on their treatment type:

| 2018                         | Hospital                |
|------------------------------|-------------------------|
| characteristics only         |                         |
| -                            |                         |
| Type 2 (insulin)             |                         |
| -                            |                         |
| Type 2 (non insulin)         |                         |
| 2019                         | Full NaDIA,             |
| England                      |                         |
| only                         |                         |
| -                            |                         |
| Type 2 (diet only)           |                         |
| For further information, see |                         |
| Glossary: Patient harms      | and                     |
| Medication errors:           |                         |
| Definitions                  | .                       |
| For further information, see | Glossary: Diabetes type |

## Patient Harms And Medication Errors

The audit looks at the proportion of inpatients that experience the following **patient harms** during their hospital stay: 

| -                                   | Severe hypoglycaemic episodes in the last 7 days   |
|-------------------------------------|----------------------------------------------------|
| -                                   | Hypoglycaemic episodes requiring injectable        |
| rescue treatment in the last 7 days |                                                    |
| -                                   | Hospital-acquired DKA and HHS                      |
| -                                   | Hospital-acquired diabetic foot lesions            |
| Medication errors                   |                                                    |
| are broken down into two main       |                                                    |
| sub-types:                          |                                                    |
| -                                   | Prescription errors                                |
| -                                   | Glucose management errors                          |
| A further sub-category of           |                                                    |
| insulin                             |                                                    |
| errors                              |                                                    |
| covers prescription and             |                                                    |
| glucose management errors           |                                                    |
| relating to insulin.                |                                                    |
| A single inpatient drug chart may   |                                                    |
| contain multiple medication         |                                                    |
| errors and a single inpatient may   |                                                    |
| experience multiple patient         |                                                    |
| harms.                              |                                                    |

## 1. Key Messages: Participation And Prevalence

Findings
•
188 out of 193 hospital sites known to be eligible for NaDIA took part in the 
2019 audit (**97 per cent**)1. 
•
Bedside data on 15,479 inpatients in England was submitted, almost 600 
more inpatients than NaDIA 20172.
•
Over half of inpatients returned a Patient Experience questionnaire (56 per cent). 
•
Around **1 in 6** hospital beds are 
occupied by a person with diabetes (18 per cent, an increase from 14 per cent in 2010). 1 in 15 of the total population have diabetes (7 per cent).
•
In 11 hospital sites, over one quarter
of inpatients have diabetes (25 to 31 per cent).
Notes: 1. Eligibility inferred from past NaDIA participation. 

## 2. Key Messages: Inpatient Harms Findings

•
The proportion of audited inpatients that developed a diabetic foot ulcer or needed a hypoglycaemic 
rescue has **reduced** since 2010, though there has 
been **no reduction** since 2017.
•
Although the proportion of inpatients experiencing 
severe hypoglycaemia has **dropped** overall, there 
has been **no reduction** amongst inpatients with 
type 1 diabetes since 2010.
•
And there has been **no significant change** in 
inpatients acquiring diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS) since data collection began.
Recommendation 1: The MDiT should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board. All hospital-acquired life-threatening episodes of hypoglycaemia, DKA and HHS should be recorded as serious incidents, submitted to NaDIA-Harms and root cause analysis undertaken.

## Inpatient Harms: Severe Hypoglycaemia

Diabetes type
Significant difference (p <0.05)

| 2010 to 2019     | 2017 to 2019   |
|------------------|----------------|
| Type 1           | Static         |
| -                |                |
| Static           |                |
| -                |                |
| Type 2 (insulin) |                |
| Down             |                |
| ▼                |                |
| Static           |                |
| -                |                |

•
Severe hypoglycaemic episodes have **decreased** for 
all type 2 groups since 2010, though proportions have remained static since 2017.

Type 2 (non insulin)
Down
▼
Static
–
Type 2 (diet only)
Down
▼
Static
–
Total
Down
▼
Static
–

•
On the audit day in 2019, more than **1 in 4** inpatients 
with type 1 diabetes had experienced at least one severe hypoglycaemic episode in the last 7 days of 
their hospital stay. There has been no significant 
reduction in severe hypoglycaemia 
episodes in patients with type 1 diabetes.
Notes: * = statistically significant at the 0.05 level (vs. current audit year). 

n = not statistically significant (vs. current audit year).

## Inpatient Harms: Hypoglycaemic Rescue

n

Findings
•
On the audit day in 2019, **1 in 70** inpatients had 
required hypoglycaemic rescue during the last 7 
days of their hospital stay. 
* There was no audit collection or report in 2014, so 2014 data is not available.

Notes: 
* = statistically significant at the 0.05 level (vs. current audit year). 

n = not statistically significant (vs. current audit year).

1. See Glossary: Patient harms.

•
Hypoglycaemic rescue has decreased
since 2010, though not since 2017.

## Inpatient Harms: Dka And Hhs

34
* There was no audit collection or report in 2014, so 2014 data is not available.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year). 

There has been no significant change in either DKA or HHS since data collection began.

## Inpatient Harms: Foot Ulcers

Comparison
Significant difference 
(p <0.05)
2010 to 2019
Down
▼
Findings
•
On the audit day in 2019, around **1 in 90** inpatients with 
diabetes had developed a foot ulcer at any point during their hospital stay.
2017 to 2019
No change
–
•
The proportion of inpatients that had developed diabetic 
foot ulcers during their admission has **reduced** since 
2010 (from 2.2 per cent to 1.1 per cent), but has 
not changed since 2017.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year).

1. See Glossary: Patient harms.

## 3. Key Messages: Medication Errors Findings

- Almost **one third** of inpatient drug charts audited 
in 2019 had at least one medication error (30 per 
cent). This has **reduced** from 45 per cent in 
2010.

- **18 per cent** of inpatient drug charts had one or 
more insulin error during their hospital stay, which 
is an **improvement** from 26 per cent in 2010. 
- The proportion of inpatient drug charts with at least 
one prescription error has **decreased** since 2017 (from 19 to 17 per 
cent), although the proportion of glucose management and insulin 
errors has remained **static** over this period.

## Clinical Comment: Despite Improvements In Recent Years, The Proportion Of Inpatient Drug Charts With Medication Errors Is Still Too High, Even In Hospital Sites That Have Adopted Health Technologies (See Slides 22 And 23). Medication Errors: Error Type

Error type1
Significant difference (p <0.05)
2010 to 2019
2017 to 2019
Medication error
Down
▼
No change
–
Prescription error
Down
▼
Down
▼
Glucose management error
Down
▼
No change
–
Insulin error
Down
▼
No change
–

Notes: * = statistically significant at the 0.05 level (vs. current audit year). 

n = not statistically significant (vs. current audit year).

1. See Medication errors: Definitions for explanation of error types.

•
In the 2019 audit, **3 out of 10** inpatient drug 
charts had at least one medication error (30 per cent).
•
The proportion of inpatient drug charts having 
medication errors has **decreased** by 14 
percentage points since 2010.

## Medication Errors: By Diabetes Type

| Diabetes type        | Significant difference    |
|----------------------|---------------------------|
| (                    |                           |
| p                    |                           |
| <0.05)               |                           |
| 2010 to 2019         | 2017 to 2019              |
| Type 1               |                           |
| Down                 |                           |
| ▼                    |                           |
| No change            |                           |
| -                    |                           |
| Type 2 (insulin)     |                           |
| Down                 |                           |
| ▼                    |                           |
| No change            |                           |
| -                    |                           |
| Type 2 (non insulin) |                           |
| Down                 |                           |
| ▼                    |                           |
| No change            |                           |
| -                    |                           |
| Type 2 (diet only)   |                           |
| Down                 |                           |
| ▼                    |                           |
| No change            |                           |
| -                    |                           |
| Total                |                           |
| Down                 |                           |
| ▼                    |                           |
| No change            |                           |
| -                    |                           |

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year).

•
In the 2019 audit, **4 out of 10** drug charts for 
insulin-treated inpatients had at least one medication error (40 per cent). •
The proportion of inpatient drug charts with 
medication errors has **reduced** for all diabetes types since 2010, but has **not changed** since 2017.

## 4. Key Messages: Care Improvement Initiatives Findings

•
An **increasing** proportion of hospital 
sites are now fully-utilising electronic prescribing (EP) and electronic patient record (EPR) systems, and remote blood glucose monitoring (BGM). 
•
Inpatient drug charts are **less likely** to 
contain medication errors if EPR or EP 
are used.

## Recommendation 2: Training Should Be Provided For Every Healthcare Professional Who Dispenses, Prescribes And/Or Administers Insulin, Appropriate To Their Level Of Responsibility, Including An Assessment Of Competency. Electronic Records And Prescribing Should Be Implemented In Support.

Clinical comment: NaDIA has found that 
1 in 10 hospitals manage to print carbohydrate content on their hospital menus (9.4 per cent) which is very helpful to inpatients with diabetes.

## Care Improvement Initiatives: Epr And Ep

Findings The proportion of hospital sites fully-utilising EP 
has increased since 2017, from 32 to 45 per cent.

The proportion of hospital sites fully or partially utilising EPR 
has increased since 2017, from 71 to 82 per cent.

## Care Improvement Initiatives: Epr And Medication Errors

Error type1
Significant difference (p <0.05)
EPR used
EPR not used
Less likely
More likely
Less likely
More likely
No difference
No difference
Less likely
More likely

Notes: * = statistically significant at the 0.05 level (EPR used vs. EPR not used in audit year).  n = not statistically significant (EPR used vs. 

EPR not used in audit year). 1. *Medication error* = any prescription or glucose management error. See Medication errors: Definitions for explanation of error types. 2. See Glossary: Healthcare technologies for information on EPR.

Finding

Inpatient drug charts are less likely 
to contain medication, prescription and insulin errors if EPR is used. 

## Care Improvement Initiatives: Ep And Medication Errors

Significant difference (p <0.05)
More likely
More likely
More likely

Notes: * = statistically significant at the 0.05 level (EP used vs. EP not used in audit year). n = not statistically significant (EP used vs. EP 
not used in audit year). 1. *Medication error* = any prescription or glucose management error. See Medication errors: Definitions for explanation of error types. 2. See Glossary: Healthcare technologies for information on EP.

Finding

## Care Improvement Initiatives: Remote Bgm Findings

•
The proportion of hospital sites fully-utilising remote BGM has 
increased by 17 percentage points since 2017 and has more than 
doubled since 2013 (from 35 to 71 per cent).
•
However almost **1 in 5** hospital sites do not utilise remote BGM (18 
per cent).
"Web-linked blood glucose (BG) and ketone meters should be actively used to alert the diabetes inpatient team to out of range glucose values and to monitor glucometrics across the trust and at ward level 
(**remote BGM**)."
Making Hospitals Safe for People with Diabetes1, 
2018

## Care Improvement Initiatives: M&M

Notes: 1. If the hospital site does not hold a diabetes M&M meeting, they may hold a general M&M meeting where diabetes is discussed. 

This information has not been collected for 2019.

•
The proportion of hospital sites 
having diabetes M&M meetings 
has **increased** since 2017.
•
Almost **two-thirds** of hospital 
sites hold diabetes M&M meetings.

14
Increase
24
Increase
- 2019
40
Increase

## 5. Key Messages: Staffing Levels Findings

•
Staffing levels for almost all professions have **increased** for 
inpatients with diabetes since 2015 and 2017. 
•
However, improvements are sometimes from a low starting 
point (e.g. less than 1 minute per inpatient per day of podiatrist 
and dietitian time in 2015) and diabetes specialist pharmacist 
hours have actually **decreased**.
•
Almost **one fifth** of hospital sites report no dedicated diabetes 
inpatient specialist nurses (DISNs) (18 per cent).
•
Inpatient dietetic provision, although improved, is still too low
(only 35 per cent of hospital sites).

## Clinical Comment

Despite recent positive increases in staffing levels, NaDIA has found that staffing deficiencies remain, with access to specialist diabetes dietitians and pharmacists a particular problem. This is especially important in the context of continually rising patient numbers.

Recommendation 3: All trusts should have a dedicated multi-disciplinary team of specialist diabetes inpatient practitioners as indicated in the NHS Long Term Plan. Trusts should work towards providing base level specialist diabetes cover at weekends where this does not exist.

## Staffing Levels: Results

Profession
Hours per week of 
inpatient care per 
inpatient with diabetes
2015
2017
2019
Diabetes inpatient specialist nurse (DISN)
0.51
0.63
0.79
Diabetes specialist nurse 
(DSN)
0.17
0.22
0.39
Any diabetes specialist nurse (DISN and DSN)
0.68
0.85
1.18
Diabetes consultant
0.19
0.29
0.38
Podiatrist
0.11
0.16
0.26
Specialist diabetes dietitian
0.03
0.04
0.07
Non-specialist dietitian
0.07
0.05
0.14
Any dietitian
0.10
0.09
0.22
Diabetes specialist 
pharmacist
0.03
0.07
0.05

Notes:
1. The stated figures are derived from the total number of Bedside Audit forms divided by the total number of hours of inpatient care per week. The NaDIA team acknowledge the difficulty of estimating staff hours. Caution is therefore advised when interpreting staffing levels, particularly at hospital site level.

At national level, staffing levels for almost all professions have **increased** for inpatients with diabetes since 2015 and 2017:

| -                                  | DISN hours per inpatient have    |
|------------------------------------|----------------------------------|
| increased                          |                                  |
| from 0.63 in 2017 to 0.79 in 2019. |                                  |
| -                                  | Diabetes Consultant hours have   |
| increased                          |                                  |
| from 0.29 in 2017 to 0.79.         |                                  |
| -                                  | Podiatrist hours have            |
| increased                          |                                  |
| from 0.16 in                       |                                  |
| 2017 to 0.26.                      |                                  |
| -                                  | Dietitian hours have             |
| increased                          |                                  |
| from 0.09 in                       |                                  |
| 2017 to 0.22.                      |                                  |

However, some of the increases are from a low starting point (e.g. less than 1 minute per inpatient per day of podiatrist and dietitian time in 2015). And diabetes specialist pharmacist hours have decreased from 0.07 in 2017 to 0.05 in 2019.

## Staffing Levels: Delivery Of Diabetes Care

| 2010                     | 2013                    |   2015 |
|--------------------------|-------------------------|--------|
| sites with:              |                         |        |
| 31.5                     | 30.2                    |   29.3 |
| 25.9                     | 18.2                    |        |
| -                        | no diabetes inpatient   |        |
| specialist nurse         |                         |        |
| (DISNs)                  |                         |        |
| 1                        |                         |        |
| 67.3                     | 71.4                    |   71.8 |
| 72.0                     | 64.6                    |        |
| -                        | no specialist inpatient |        |
| dietetic provision for   |                         |        |
| inpatients with diabetes |                         |        |
| 26.8                     | 33.3                    |   25.5 |
| 32.3                     | 18.2                    |        |
| -                        | no inpatient podiatry   |        |
| service for inpatients   |                         |        |
| with diabetes            |                         |        |
| -                        | 88.0                    |   83   |
| 75.7                     | 74.0                    |        |
| -                        | no inpatient specialist |        |
| pharmacy service for     |                         |        |
| inpatients with diabetes |                         |        |

•
The proportion of hospital sites with no DISNs has **dropped** by 8 
percentage points since 2017.
•
However, more than a **sixth** of hospital sites have no DISNs (18 per 
cent). **Two-thirds** of these hospital sites also had no DISNs in 20172.
* There was no audit collection or report in 2014, so 2014 data is not available.

The need for DISNs in hospitals is emphasised in the **NHS Long term plan**2:
"…for those who periodically need secondary care support we will ensure that all hospitals in future provide access to multi-disciplinary foot care teams (MDFTs) and DISN teams to improve recovery and to reduce lengths of stay and future readmission rates."

## 6. Key Messages: Access To The Diabetes Team Findings

•
The proportion of inpatients with diabetes seen by 
the diabetes team where appropriate1 has 
increased since 2010 (from 54 to 75 per cent).
•
A **higher** proportion are seen by the diabetes team1
when 7 day diabetes inpatient specialist nurse (DISN) cover is provided (78 per cent compared to 72 per cent).
Notes: 1. Based on the 'Think Glucose Criteria' criteria. 

See Glossary: Referral to the diabetes team.

Clinical comment: GIRFT has found that in some hospitals, staff only become aware that a patient had diabetes when a problem occurs, which can result in serious and life-threatening harms. However, NaDIA has found that only **36 per cent** of hospital sites have an electronic system to identify and notify the diabetes team of all people with diabetes on admission.

Diabetes ID system?

diabetes team. This should be an electronic system, integrated with web-linked blood glucose meters which provide an alert system for staff when any out-of-range reading is recorded.

## Access To The Diabetes Team: Results

Based on the 'Think Glucose Criteria'1, on the audit day it was appropriate for 41 per cent of inpatients to have been referred to the diabetes team, six percentage points lower than in 2011.

| Comparison   | Significant difference    |
|--------------|---------------------------|
| (p <0.05)    |                           |
| Type 2       | Type 1                    |
| (insulin)    | (non insulin)             |
| 2010 to 2019 |                           |
| Up           |                           |
| ▲            |                           |
| Up           |                           |
| ▲            |                           |
| Up           |                           |
| ▲            |                           |
| Up           |                           |
| ▲            |                           |
| Up           |                           |
| ▲            |                           |
| 2017 to 2019 |                           |
| Up           |                           |
| ▲            |                           |
| Up           |                           |
| ▲            |                           |
| No change    |                           |
| -            |                           |
| No change    |                           |
| -            |                           |
| Up           |                           |
| ▲            |                           |

Notes: * = statistically significant at the 0.05 level (vs. current audit year). 

n = not statistically significant (vs. current audit year). 

1. Based on the 'Think Glucose Criteria'. See Glossary: Referral to the diabetes team.

Findings
Type 2 
Total

More inpatients are being seen by the diabetes team where appropriate1, reaching 86 per cent in those with type 
1 diabetes.

## Access To The Diabetes Team 7 Day Disn Provision

| Percentage of hospital sites with:   | 2015                                |
|--------------------------------------|-------------------------------------|
| -                                    | 7 day diabetes inpatient specialist |
| nurse (DISN) provision               |                                     |
| 7.0                                  |                                     |
| 9.5                                  | 17.1                                |
| -                                    | 7 day Diabetes Physician access     |
| -                                    |                                     |
| 25.9                                 | 23.8                                |
| -                                    | Both of the above                   |
| -                                    |                                     |
| 4.8                                  | 8.3                                 |
| Percentage of patients:   | 7 day DISN provision?     |
|---------------------------|---------------------------|
| Yes                       | No                        |
| -                         | seen by the diabetes team |
| where appropriate         |                           |
| 78.2                      | *                         |
| Significant difference    |                           |
| (                         |                           |
| p                         |                           |
| <0.05)                    |                           |
| 7 day DISN                | No 7 day DISN             |
| Higher                    |                           |
| ▲                         |                           |
| Lower                     |                           |
| ▼                         |                           |

Comment Important aspects of DISN care are not captured in this metric. For example, weekend DISN teams provide reviews of those admitted during the week and identified to be at high risk of metabolic decompensation
* There was no audit collection or report in 2014, so 2014 data is not available.

Notes: * = statistically significant at the 0.05 level ('Yes' vs. 'No' in audit year). n = not statistically significant ('Yes' vs. 'No' in audit year). 

1. Based on the 'Think Glucose Criteria'. See Glossary: Referral to the diabetes team.

•
Since 2015, 7 day DISN provision has more than 
doubled; an increase of 10 
percentage points (from 7 to 17 per cent).
•
However there has been a 
decrease in the proportion of 
hospital sites with 7 day Diabetes Physician access.
•
A **higher** proportion of 
inpatients are seen by the diabetes team where appropriate when 7 day DISN cover is provided (78 per cent compared to 72 per cent).

## Access To The Diabetes Team Diabetes Team Working And Support Systems

| 2019   | Percentage of diabetes inpatient teams    |
|--------|-------------------------------------------|
| with:  |                                           |
| -      | an office which facilitates team working  |
| 74.0   |                                           |
| Percentage of hospital sites with:                               | 2019                                                                |
|------------------------------------------------------------------|---------------------------------------------------------------------|
| -                                                                | an electronic system to identify and notify the inpatient diabetes  |
| team of all people with diabetes on admission                    |                                                                     |
| 35.9                                                             |                                                                     |
| 63.0                                                             |                                                                     |
| -                                                                | a system to help non-specialist staff identify and prioritise those |
| with diabetes that need reviewing by the inpatient diabetes team |                                                                     |

•
Almost **three-quarters** of diabetes inpatient teams have an office which facilitates team working (74 
per cent).
•
Take-up of automated systems to identify and notify the diabetes team to new diabetes admissions is 
low (**35.9 per cent**), probably reflecting the fact that only about 50 per cent of hospital sites have 
electronic medical records. 
•
Only **63.0 per cent** of hospital sites have systems to triage those needing a diabetes review.

## 7. Key Messages: Surgical Care

CBG levels recorded in all 4 areas?

•
On the audit day in 2019, **4 out of 5** elective 
surgery inpatients had been prioritised in the surgical list (80 per cent).
•
Only **2 out of 5** of the surgical inpatients 
audited in 2019 had their capillary blood 
glucose1 (CBG) levels recorded at all 
recommended stages of the perioperative
pathway2 (43 per cent): At sign-in and sign-out stages of the surgical safety 
checklist, during surgery, in theatre recovery, on arrival on the ward. 
•
Emergency surgery inpatients were **less likely** to have their CBG levels 
recorded than elective surgery inpatients (41 vs 47 per cent).

## Recommendation 5: All Hospital Trusts Should Have Clear, Audited Perioperative Pathways From Pre-Assessment Through To Discharge. These Should Be Broadly In Line With Ncepod Recommendations. Surgical Care: Diabetes Management

| Care structure                                                                        |   Yes? |
|---------------------------------------------------------------------------------------|--------|
| Is there a                                                                            |        |
| team                                                                                  |        |
| responsible for organising                                                            |        |
| perioperative diabetes care                                                           |        |
| ?                                                                                     |   30.9 |
| Is there a standardised                                                               |        |
| process                                                                               |        |
| for                                                                                   |        |
| pre-operative diabetes care                                                           |        |
| covering diabetes                                                                     |        |
| control, blood pressure and management of comorbidities?                              |        |
| 61.3                                                                                  |        |
| Is there a                                                                            |        |
| referral pathway                                                                      |        |
| to ensure                                                                             |        |
| elective patients                                                                     |        |
| who need pre-admission                                                                |        |
| optimisation of diabetes control are seen by an appropriate health care professional? |        |
| 65.7                                                                                  |        |

* There was no audit collection or report in 2014, so 2014 data is not available.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). 

n = not statistically significant (vs. current audit year).

Per cent

| -                                   |
|-------------------------------------|
| 3 out of 10                         |
| hospital sites have                 |
| a team responsible for organising   |
| perioperative diabetes care (31 per |
| cent).                              |

•
There were 18 per cent fewer 
surgical inpatients in the 2019 audit compared to 2015 (2,035 vs 2,495), with drops in both elective (1,033 to 819) and emergency surgical inpatients (1,462 to 1,216).

## Surgical Care: Cbg Recording And Surgical Prioritisation

| Elective                          | Emergency   | Total    | Are the CBG levels   |
|-----------------------------------|-------------|----------|----------------------|
| 1                                 |             |          |                      |
|                                   |             |          |                      |
| recorded                          |             |          |                      |
| in the following areas:           |             |          |                      |
| Per cent                          | Per cent    | Per cent |                      |
| At sign-in and sign-out stages of |             |          |                      |
| the surgical safety checklist     |             |          |                      |
| 2                                 |             |          |                      |
| 66.3                              | n           | 63.6     | n                    |
| In anaesthetic charts - during    |             |          |                      |
| surgery                           |             |          |                      |
| 3                                 |             |          |                      |
| 62.2                              | *           | 54.9     | *                    |
| In theatre recovery               | 72.6        | n        | 68.9                 |
| On arrival on the ward            | 85.8        | n        | 85.6                 |
| All of the above                  | 47.0        | *        | 40.6                 |
| Care process                                             |
|----------------------------------------------------------|
| For elective cases, was the patient prioritised to avoid |
| prolonged starvation                                     |
| 4                                                        |
| ?                                                        |
| 80.2                                                     |

Notes: * = statistically significant at the 0.05 level (vs. other admission type).  n = not statistically significant (vs. other admission type). 

1. The concentration of glucose in the blood. 2. e.g. WHO safety checklist. 3. If operation >1hr. 4. usually to the first third of the list. 5. 

Findings
•
Only **4 out of 10** of the 
surgical inpatients audited in 2019 (43 per cent) had met the NCEPOD recommendation5 of having 
CBG levels recorded in all four clinical areas.
•
Emergency surgery 
inpatients were less 
likely to have their 
CBG levels recorded.
Per cent
•
4 out of 5 elective 
surgery inpatients had been prioritised in the surgical list (80 per cent).

## 8. Key Messages: Patient Experience Findings

•
Inpatient perception of meal choice and timing 
dropped in 2015 and has not recovered.
•
Inpatient perception of staff knowledge and 
ability to answers questions on diabetes has not changed compared to 2010.
•
The proportion of inpatients who were satisfied with staff awareness of their diabetes has 
worsened since 2010.
•
There has been **no change** in measures relating to inpatient empowerment: 
self-management, self-administration and involvement in care planning
Clinical comment: Inpatients should be empowered to take control of their diabetes as much as possible, and patient expertise in their own diabetes care should be harnessed. However the NaDIA Patient Experience has found no increase in inpatient reported selfmanagement, and the NaDIA Hospital Characteristics survey has found a large reduction in the percentage of hospital sites with a policy or guideline for self-management of diabetes.

Recommendation 6: All trusts should have and promote a self-management policy, which supports patients who want to self-manage their diabetes to safely do so while in hospital, as clinically appropriate and in line with wider NHS England and NHS Improvement policies on inpatient self-management.

## Patient Experience: Summary

| Inpatients…                 | 2010                               | 2013   | 2015   |   2017 | 2019   |
|-----------------------------|------------------------------------|--------|--------|--------|--------|
| Significant difference      |                                    |        |        |        |        |
| (                           |                                    |        |        |        |        |
| p                           |                                    |        |        |        |        |
| <0.05)                      |                                    |        |        |        |        |
| 2010 to 2019                | 2017 to 2019                       |        |        |        |        |
| -                           | Aware of diabetes team             |        |        |        |        |
| 1                           |                                    |        |        |        |        |
| -                           | -                                  | -      | -      |   51.8 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| Inpatients satisfied with…  |                                    |        |        |        |        |
| -                           | Involvement in care planning       |        |        |        |        |
| 1                           |                                    |        |        |        |        |
| -                           | -                                  | -      | -      |   62.6 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Extent that ward staff respected   |        |        |        |        |
| wishes around diabetes care |                                    |        |        |        |        |
| 1                           |                                    |        |        |        |        |
| -                           | -                                  | -      | -      |   91.1 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Control over blood sugar           |        |        |        |        |
| management                  |                                    |        |        |        |        |
| 1                           |                                    |        |        |        |        |
| -                           | -                                  | -      | -      |   70.1 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Ability to self-administer insulin |        |        |        |        |
| 87.6                        | n                                  | 86.3   | 87.0   |   88.4 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Meal choice                        |        |        |        |        |
| 64.0                        | *                                  | 63.7   | 54.3   |   53.8 | n      |
| Down                        |                                    |        |        |        |        |
| ▼                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Meal timing                        |        |        |        |        |
| 67.6                        | *                                  | 70.2   | 62.2   |   62.6 | n      |
| Down                        |                                    |        |        |        |        |
| ▼                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Staff awareness of patient's       |        |        |        |        |
| diabetes                    |                                    |        |        |        |        |
| 87.7                        | *                                  | 82.1   | 84.3   |   81.9 | n      |
| Down                        |                                    |        |        |        |        |
| ▼                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Staff knowledge of diabetes        |        |        |        |        |
| 64.7                        | n                                  | 67.5   | 65.5   |   64.6 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Staff ability to answer questions  |        |        |        |        |
| on diabetes                 |                                    |        |        |        |        |
| 88.4                        | n                                  | 86.2   | 87.5   |   85.9 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| -                           | Overall care for diabetes          |        |        |        |        |
| 83.7                        | n                                  | 86.1   | 84.3   |   83.4 | n      |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |
| No change                   |                                    |        |        |        |        |
| -                           |                                    |        |        |        |        |

Findings
•
Inpatient perception of meal choice and timing and staff awareness of 
their diabetes have **worsened** since 2010.
•
There has been **no change** in measures relating to inpatient 
empowerment: self-management, self-administration and involvement 
in care planning.
Notes: * = statistically significant at the 0.05 level (vs. current audit year), deft = 2. n = 
not statistically significant (vs. current audit year), deft = 2. 1. Changes to the 2017 
Patient Experience questionnaire means that historic results are not comparable. 

## Patient Experience: Self-Management And Self-Administration Findings

•
The proportion of hospital sites with a policy or guideline for self-management of diabetes 
has **fallen** (from 63 per cent in 2015 to 46 per cent in 2019).
•
35 per cent of hospital sites still do not have a policy or guideline for self administration of 
diabetes medication.

## Glossary: Nadia Data Collection Data Collection

Each participating hospital identified all inpatients with diabetes and distributed questionnaires accordingly. Where the patient was able and willing a **Patient Experience** (PE) form was completed, as well as a Bedside Audit (BA) form which provided information on the patient's medical treatment taken from the patient's notes. The hospital team also completed a **Hospital Characteristics** (HC) questionnaire providing information on the hospital's resources and staffing structure.

Which patients are included in the audit? A patient was included in the inpatient audit (NaDIA) if they had been admitted to a hospital bed for 24 hours or more. Patients on an Obstetric or Paediatric ward were excluded from this audit. Mental Health wards were also excluded due to the high prevalence of long stay patients. Other exclusions included:


Patients who were hyperglycaemic but not yet formally diagnosed with diabetes

Accident and Emergency

Day case ward

Day surgery unit patients

Observation ward (if patients had been admitted for less than 24 hours)

Surgical short stay unit (if patients had been admitted for less than 24 hours)

Palliative care centres

Community hospitals

## Glossary: Diabetes Type

Diabetes is a serious life-long health condition that causes a person's blood glucose (sugar) 
level to become too high. This occurs when there is not enough of the hormone insulin to manage blood glucose (BG) levels effectively. If untreated, diabetes leads to serious illness and death.

## There Are Two Main Diabetes Types:

•
Type 1 diabetes develops when the insulin-producing cells in the body have been 
destroyed and the body is unable to produce any insulin. 
Type 1 diabetes accounts for about 10 per cent of all adults with diabetes (7 per cent of inpatients with diabetes) and is treated by daily insulin doses. Type 1 diabetes can develop at any age but usually appears before the age of 40, and especially in childhood1.

## Inpatients With Diabetes T1

•
Type 2 diabetes develops when the insulinproducing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly (known as insulin resistance). 
Type 2 diabetes usually appears in people over the age of 40, though it may appear at any age. Type 2 diabetes accounts for around 90 per cent of adults with diabetes 
(around 93 per cent of inpatients with diabetes)2.

## T2 & Other Glossary: Diabetes Treatments

There are a number of treatments available to help manage and control diabetes. 

All patients are different, so treatment will vary depending on individual needs1.

•
Insulin: Everyone with type 1 diabetes, and some people with type 2 
diabetes, need to take insulin to control blood glucose (BG) levels1.
•
Tablets: Some people with type 2 diabetes (and a minority with type 1 
diabetes) use tablets to help control their BG levels1. Common tablet 
treatments include Biguanide (Metformin) and Sulphonylureas. 
•
Lifestyle: Type 2 diabetes can sometimes be controlled through healthy 
eating and increased exercise. However type 2 diabetes is a progressive condition, and over time people with type 2 diabetes may need medication (insulin or tablets) to help manage their BG levels.
For NaDIA analysis, inpatients with type 2 diabetes are grouped into three sub-categories based on their treatment type:

•
Type 2 (insulin)
•
Type 2 (non insulin)
•
Type 2 (diet only)
Inpatients with type 1 diabetes are reported as a single group.

## Glossary: Healthcare Providers

NaDIA data is collected and submitted by healthcare professionals that work on applicable hospital wards in England and Wales (Wales did not participate in 2019).

For NaDIA Hospital Level Analysis, data is aggregated by **NaDIA hospital site**, which may be an **NHS trust**, Welsh **Local Health Board** (LHB), an individual hospital or a grouping of hospitals that have chosen to have their results aggregated together.

Commissioners decide what health services are needed and ensure that they are provided. Clinical Commissioning Groups (CCGs) in England and LHBs in Wales are responsible for commissioning healthcare services.

The National Institute for Health and Care Excellence (**NICE**) produces guidelines for the treatment of diabetes. All diabetes inpatient services should follow these guidelines, so that people with diabetes receive the best possible healthcare.

## Glossary: Healthcare Professionals

A wide variety of healthcare professionals are involved in the care of inpatients with diabetes, including (but not restricted to) the following professions:

•
Diabetes consultants are senior hospital physicians who diagnose and treat 
patients with diabetes. Diabetes consultants are specialists in diabetology and endocrinology (the specialism concerning the glands and hormones).
•
Diabetes specialist nurses (DSN) work to meet the needs of people with 
diabetes and provide experience and expertise as part of dedicated diabetes 
teams. DSNs work wholly in diabetes care. A diabetes specialist inpatient 
nurse (DISN) provides hospital inpatient care1.
•
A **dietitian** is a healthcare professional with expertise in diet and nutrition. A 
specialist diabetes dietitian advises people with diabetes on the most 
suitable diet to control and manage their diabetes.
•
Podiatrists are healthcare professionals that specialise in 
conditions of the feet and lower limbs. This includes the prevention, management and treatment of foot complications commonly experienced by people with diabetes (e.g. diabetic foot disease).
•
Diabetes specialist pharmacists are healthcare professionals 
that specialise in the safe and effective management of medication for controlling and treating diabetes.

## Glossary: Healthcare Teams

"Specialists involved in the delivery of diabetes care must work in multi-disciplinary foot care teams (MDFTs) for care to be truly effective. They should have received extensive training accredited at a national level."

## Diabetes Uk1

Healthcare professionals form multi-disciplinary specialist teams in hospitals to co-ordinate diabetes care, including (but not restricted to):

•
Inpatient specialist diabetes teams or **MDiTs** co-ordinate diabetes care in 
hospitals. Diabetes teams usually consist of diabetes consultants, diabetes specialist (inpatient) nurses (DSN/DISN), podiatrists and dietitians, who will
also work with other specialists who might also form part of the team (e.g. pharmacists and clinical psychologists).
•
Inpatient **MDFTs** co-ordinate diabetes foot care in hospitals. MDFTs meet weekly 
and consist of a diabetes consultant (diabetologist), a podiatrist with skills in managing the diabetic foot and a surgeon (general, orthopaedic or vascular surgeon). MDFTs will also work with other specialists who might be incorporated into the team (e.g. DSN/DISNs, podiatrists, interventional radiologists, microbiologists, tissue viability nurses). 82 per cent of hospital sites have MDFTs.
•
65 per cent of hospital sites host regular diabetes mortality and morbidity (M&M) **meetings** for healthcare professionals to discuss patient deaths and 
adverse incidents relating to diabetes. At M&M meetings staff can discuss 
incidents in detail, report problems and share lessons to prevent the recurrence of adverse incidents. 

## Glossary: Referral To The Diabetes Team

When should the patient be referred to the diabetes team?

•
Patient request
•
Sepsis
•
Vomiting
•
Foot ulceration
•
Unable to self-manage
•
Impaired consciousness
•
Newly diagnosed type 1 diabetes
•
Newly diagnosed type 2 diabetes
•
Parenteral or enteral nutrition
Derived from the 'Think Glucose Criteria' developed by the NHS Institute for Innovation Think Glucose1

•
Severe hypoglycaemia
•
Recurrent hyperglycaemia
•
Acute coronary syndrome
•
Previous problems with diabetes as inpatient
•
Intravenous insulin infusion for over 48 hours
•
Intravenous insulin infusion with glucose outside limits
•
Diabetic ketoacidosis (DKA)
•
Hyperosmolar hyperglycaemic state (HHS)
•
Admission for urgent or major elective surgical procedure
•
End of life care

## Glossary: Healthcare Technologies

Hospitals may use some or all of the following healthcare technologies which support inpatient care:

•
An **electronic patient record** (EPR) is a computer system 
designed to collect and store patients' clinical and health information in one place, replacing paper-based health records and multi-platform data collection. Hospital staff involved in patient care 
can access and update the EPR system at different points in the patient's care. A variety of EPR systems are used. More than one 
third of hospital sites fully-utilise an EPR system (37 per cent).
•
Hospital **electronic prescribing** (EP) is a computer system 
designed to allow prescriptions to be sent to pharmacies through IT systems, rather than through paper prescriptions. More than 4 
out of 10 hospital sites fully-utilise an EP system (45 per cent).
•
Remote blood glucose monitoring (BGM) tools allow remote 
access to the measurement of patient blood glucose (BG) levels. Results can be transmitted to patients and caregivers in real time, providing an early warning if BG levels are outside the expected levels. More than 7 out of 10 hospital sites fully-utilise 
remote BGM (71 per cent).

## Glossary: Inpatient Diabetic Foot Care

People with diabetes are at much greater risk of developing problems with their feet (**diabetic foot disease**), due to the damage raised blood sugars can cause to sensation (neuropathy) and circulation (ischaemia). If left untreated, these problems can cause foot lesions 
(ulcers) and infections and, at worst, may lead to amputations1.

About 9 per cent of inpatients with diabetes are admitted to hospital with active diabetic foot disease, around half of which are admitted for diabetic foot disease.

On admission to hospital, inpatients with diabetes may undergo a specific diabetic foot risk examination for ulceration, in addition to general pressure sore checks such as the Waterlow score. 

Hospitals may follow foot care examination initiatives such as 'Putting Feet First'2 or NICE inpatient foot guidance3 and may also have **tools or systems** in place to increase the number of inpatients with diabetes that have a specific diabetic foot risk examination. Inpatients with active diabetic foot disease or at a high risk of developing foot problems should be assessed by the **multi-disciplinary foot care team** (MDFT - see Glossary: Healthcare Teams) as soon as possible following admission. 82 per cent of hospital sites have MDFTs.

If inpatient foot care is not effective, hospital-acquired diabetic **foot lesions** can arise. Foot lesions are associated with great patient distress, risk of amputation, increased mortality and high cost. Whilst under a hospital's care, no patient should deteriorate enough so that they develop a new instance of a foot lesion.

## Glossary: Medication Errors

Hospital inpatients have **drug charts** to record their prescribed medication. Some entries contain medication errors, which have the potential to cause or contribute towards patient harms (see Glossary: 
Patient harms). Medication errors can be categorised by incident type (prescription or glucose management) and medication type (insulin or **OA-DA**1). A summary is shown in the table below:

Error description1
Error type
Insulin not written up Name of insulin incorrect Number (dose) unclear Unit abbreviated to 'u' or written unclearly
Insulin or prescription chart not signed by prescriber Insulin not signed as given Insulin given/prescribed at the wrong time OA-DA not signed as given OA-DA given/prescribed at the wrong time
Wrong dose OA-DA not written up Insulin not increased when persistent BG >11 mmol/L and better glycaemic control appropriate for this patient
Insulin not reduced if unexplained BG <4 mmol/L Inappropriate omission of insulin after episode of hypoglycaemia No action taken when persistent BG >11 mmol/L and better glycaemic control appropriate OA-DA not reduced if unexplained BG <4 mmol/L
Inappropriate omission of OA-DA after episode of hypoglycaemia

## Glossary: Patient Harms

There are a variety of patient harms that people with diabetes may develop in hospital. 

These potentially life-threatening events are entirely preventable and strenuous efforts must be taken to avoid them.

A **hypoglycaemic episode** (a hypo) is a potentially dangerous drop in a patient's blood glucose 
(BG) to below 4.0 mmol/L. 'Normal' BG (normoglycemia) is typically between 4.0 and 8.0 mmol/L.

•
A 'mild' hypoglycaemic episode involves a BG level of between 3.0 and 3.9 mmol/L. 
•
A 'severe' hypoglycaemic episode involves a BG level of less than 3.0 mmol/L.
A **hypoglycaemic episode requiring injectable rescue treatment** occurs in severe cases of hypoglycaemia when the patient is unconscious and cannot take sugar by mouth. Rescue treatment is applied using an injection of glucose or Glucagon.

A patient whose BG levels are properly managed should never experience a severe hypoglycaemic episode or require rescue treatment during their hospital stay.

Diabetic ketoacidosis (DKA) mainly occurs in people with type 1 diabetes when a severe lack of insulin means the body cannot use glucose for energy and the body starts to break down other body tissue, releasing ketones as an alternative energy source. This can lead to ketoacidosis if the levels are too high. The development of DKA after admission suggests that the inpatient's insulin treatment was omitted, or insufficient levels of insulin were provided, for an appreciable time. DKA is a potentially life-threatening emergency which should not develop in hospital.

Hyperosmolar hyperglycaemic state (HHS) mainly occurs in people with type 2 diabetes who experience very high BG levels (often over 40mmol/L). It can develop over a course of weeks through a combination of illness (e.g. infection) and dehydration. HHS is a potentially lifethreatening emergency which should not develop in hospital.

Patients with diabetes are at a higher risk of developing **foot lesions** (ulcers) because of associated blood flow (ischaemia) and nerve problems (neuropathy). No patient should deteriorate enough while under a hospital's care that they develop a new foot lesion.

## Glossary: Nadia-Harms

NaDIA-Harms is a continuous audit of inpatient harms that runs parallel to the annual NaDIA snapshot covered in this report. 

Why is NaDIA-Harms necessary?: The snapshot nature of the annual NaDIA collection, coupled with the relatively low incidence of the four inpatient harms, means that continuous collection via NaDIA-Harms is needed to allow robust monitoring at **local level**, and contribute to the drive to lower the incidence of these serious inpatient harms. In time, the NaDIA-Harms audit will enable NHS trusts to identify and analyse local occurrences of these key inpatient harms, supporting local **quality improvement** (QI) work. By collecting patient identifiers in NaDIA-Harms, the audit can harness the power of the core National Diabetes Audit 
(NDA) via **data linkage**, allowing case-mix adjusted **benchmarking** to be reported and riskadjusted long term outcomes identified. Additionally, national characterisation of which patients are at **highest risk** will inform the development of better preventive care.

## Nadia-Harms Case Ascertainment

Comparability: In the latest NaDIA-Harms report, the NaDIA 
snapshot figures in slides 14, 15 and 16 have been used to produce an estimate of NaDIA-Harms case ascertainment, which ranges from 20 per cent (DKA) to just 6 to 8 per cent (others). Given these relatively low completeness levels, it is envisaged that the NaDIA snapshot will continue to collect data on inpatient harms over the next few years as participation in NaDIA-Harms improves. 

The latest NaDIA-Harms report covering May 2018 to October 
2019 is here: http://digital.nhs.uk/pubs/nadia-harms2019. 

## Glossary: Patient Experience

To find out whether the **patient experience** was favourable, the audit collects patient feedback on the following measures:

| NaDIA Measure                                               |
|-------------------------------------------------------------|
| - Involvement in care planning                              |
| Inpatients should be empowered to become involved in        |
| their care planning as much as possible. Patient expertise  |
| in their diabetes care should be harnessed.                 |
| - Extent that preferences for diabetes                      |
| treatment taken into account                                |
| Patient preferences for their diabetes treatment should be  |
| accommodated where possible.                                |
| - Ability to take control of their diabetes                 |
| Inpatients should be empowered to take control of their     |
| diabetes as much as possible. Patient expertise in their    |
| diabetes care should be harnessed.                          |
| - Ability to self-administer insulin                        |
| - Meal choice                                               |
| The timely provision of suitable food is integral to good   |
| diabetes management.                                        |
| - Meal timing                                               |
| - Staff awareness of diabetes                               |
| Staff need to know which patients have diabetes to ensure   |
| the appropriate treatment is given.                         |
| - Staff knowledge of diabetes                               |
| Staff expertise in diabetes is essential to ensure the      |
| appropriate treatment is given and patient questions can be |
| addressed.                                                  |
| - Staff ability to answer questions on                      |
| diabetes                                                    |
| - Overall care for diabetes                                 |
| Patients overall perception of their diabetes care during   |
| their hospital stay is a useful measure of the patient      |
| experience as a whole.                                      |

## Glossary: Acronyms

BA form = NaDIA Bedside Audit form

mmol/L = millimole (one thousandth of a mole) 
per litre

BG = blood glucose

CCG = Clinical Commissioning Group DISN = diabetes inpatient specialist nurse
NCAPOP = National Clinical Audit Patient 
Outcomes Programme
DKA = diabetic ketoacidosis DSN = diabetes specialist nurse
NCVIN = National Cardiovascular Intelligence 
Network
EP = electronic prescribing

EPR = electronic patient records

Excellence

HC form = NaDIA Hospital Characteristics form

HHS = hyperosmolar hyperglycaemic state

PE form = NaDIA Patient Experience form

HQIP = The Healthcare Quality Improvement Partnership QOF = Quality and Outcomes Framework

IVII = intravenous insulin infusion JBDS-IP = Joint British Diabetes Societies for
Inpatient Care group
LHB = Welsh Local Health Board
M&M meeting = mortality and morbidity meeting MDFT = multi-disciplinary foot care team

## Additional Information: Summary

The following documents are available from http://digital.nhs.uk/pubs/nadia2019

- A one page executive summary of this report. - A PowerPoint version of this report. - Deep-dive reports on individual chapters, including  
report chapters as standalone publications (pdf and 
PowerPoint).
- Hospital site level 2010-2019 charts and data - Supporting data in Excel format - Data Quality Statement - Methodology

## Additional Information: References

Diabetes UK (2010): Commissioning specialist diabetes service for adults with diabetes: https://www.diabetes.org.uk/resourcess3/2017-09/defining%2520specialist%2520diabetes%2520service%2520for%2520adults%2520with%2520diabetes.doc Diabetes UK: Diabetes and foot problems: https://www.diabetes.org.uk/Guide-to-diabetes/Complications/Feet/ Diabetes UK: Diabetes treatments: https://www.diabetes.org.uk/Diabetes-the-basics/Diabetes-treatments/ Diabetes UK (2018): Making hospitals safe for people with diabetes: https://www.diabetes.org.uk/resources-s3/2018-10/Making Hospitals safe for people with diabetes_FINAL.pdf Diabetes UK (2014) Position statement: Diabetes Specialist Nurses: Improving Patient Outcomes and Reducing Costs: https://www.diabetes.org.uk/Documents/Position statements/Diabetes-Specialist-Nurses_Improving-patient-outcomes-and-reducingcosts-position-statement-February2014.pdf Diabetes UK: Putting Feet First: https://www.diabetes.org.uk/putting-feet-first Diabetes UK: Testing: https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/Testing/ Diabetes UK: What is type 1 diabetes?: https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-1-diabetes/ Diabetes UK: What is type 2 diabetes?: https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-2-Diabetes/ EU General Data Protection Regulation. Article 6: Lawfulness of processing: https://www.privacy-regulation.eu/en/article-6-lawfulnessof-processing-GDPR.htm Getting It Right First Time (GIRFT): Diabetes. Forthcoming publication TBC.

Joint British Diabetes Societies for Inpatient Care (2014): The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients: http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_VRIII.pdf Lexico: Perioperative: https://www.lexico.com/definition/perioperative NCEPOD (2018): Perioperative Diabetes: https://www.ncepod.org.uk/2018pd.html NICE: Diabetic foot problems: Prevention and management: https://www.nice.org.uk/Guidance/NG19 NICE: Diabetes in adults: https://www.nice.org.uk/Guidance/QS6 NHS England: Diabetes transformation fund: https://www.england.nhs.uk/diabetes/diabetes-prevention/diabetes-transformation-fund/ NHS England (2019): NHS Long Term Plan: https://www.longtermplan.nhs.uk/ NHS England: Serious Incidents Framework: https://www.england.nhs.uk/patientsafety/serious-incident/

## Additional Information: Acknowledgements The Nadia Team Would Like To Thank All The People And Teams Who Have Worked Hard To Contribute To This Unique And Valuable Insight Into The Inpatient Care Of People With Diabetes.

Development and delivery of the NaDIA is guided by a multi-professional advisory group of clinicians and patient representatives, chaired by Gerry Rayman. The NaDIA Advisory Group members include: 

Gerry Rayman
Consultant Diabetologist and National Clinical Lead for Inpatient Diabetes (Chair)
Bob Young
NDA Specialist Clinical Lead
Neera Agarwal
Diabetes & Endocrinology Training Programme Director (Wales Deanery) Deputy Programme Director
Belinda Allan 
Consultant Diabetologist, Michael White Centre for Diabetes and Endocrinology (Hull)
Alex Berry 
Engagement Lead, Diabetes UK
Olivia Burr
Inpatient Care Lead, Diabetes UK
Anne Claydon
Nurse Consultant for Diabetes, Barts Health NHS trust
Sophie Colling
NDA Project Support Officer, Diabetes UK
Ketan Dhatariya 
Consultant Diabetologist, Norfolk and Norwich University Hospitals NHS Foundation Trust
Anne Kilvert
Consultant Diabetologist, Northampton General Hospital NHS trust
Alistair Lumb
Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust 
Michael Mason
Information Analyst, NHS Digital
Maureen McGinn
Patient representative
Julie Michalowski
Audit Manager, NHS Digital
Omar Mustafa 
Consultant Diabetologist, Kings College Hospital
Rustam Rea
Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust
Aled Roberts
Consultant Diabetologist - Wales
David Roberts
Patient Representative
Debbie Stanisstreet 
Lead Nurse for Diabetes and Endocrinology (Lister Hospital**) &** Diabetes Inpatient Specialist Nurse 
Network
Garry Tan
Consultant Diabetologist, Oxford Centre for Diabetes, Endocrinology and Metabolism 
Andrew Whitehead
Audit Coordinator, NHS Digital
Emily Watts
Inpatient Care Lead, Diabetes UK
Emilia Woch
Higher Information Analyst, NHS Digital 
Arthur Yelland
Senior Information Analyst, NHS Digital

## Prepared In Collaboration With:

The Healthcare Quality Improvement Partnership (HQIP). The National Diabetes Inpatient Audit (NaDIA) audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. 

The programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations and crown dependencies www.hqip.org.uk/national-programmes.

NHS Digital is the new name for the Health and Social Care Information Centre. NHS 
Digital managed the publication of the 2020 annual report.

Diabetes UK is the largest organisation in the UK working for people with diabetes, funding research, campaigning and helping people live with the condition.

## Supported By:

The **National Cardiovascular Intelligence Network** (NCVIN) is a partnership of leading national cardiovascular organisations which analyses information and data and turns it into meaningful timely health intelligence for commissioners, policy makers, clinicians and health professionals to improve services and outcomes.

# National Diabetes Inpatient Audit 2019 Published By Nhs Digital Part Of The Government Statistical Service

Responsible Statistician Peter Knighton, Principal Information Analyst

## For Further Information Digital.Nhs.Uk 0300 303 5678 Enquiries@Nhsdigital.Nhs.Uk

© 2020, Healthcare Quality Improvement Partnership (HQIP) This work remains the sole and exclusive property of the Healthcare Quality Improvement Partnership and may only be reproduced where there is explicit reference to the ownership of the Healthcare Quality Improvement Partnership. This work may be re-used by NHS and government organisations without permission.