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Hypoglycaemia and Pre-Pregnancy Care Projects
Dr Peter Winocour - Consultant Physician and Clinical Director for Diabetes and Endocrine Services
Sarah Woodley - Clinical Nurse EducatorKaren Moore-Haines - Project Manager
East and North Herts Institute of Diabetes and Endocrinolgy (ENHIDE)
EAHSN Strategic goals:
Innovative population based transformational models of delivery
Using data to address unwarranted variations
Using proven science methods and professional networks to deliver improvement in outcomes for major chronic diseases
Engaging industry to deliver innovative interventions and systems
Developing workforce capacity and capability
Diabetes CSG – nodes
Cambridge
Norwich
Stevenage Colchester
Marcus Bailey- EoE Ambulance Trust
Dr Charles BodmerDr John ClarkeDr Martin Hadley BrownDr Clare HamblingDr Vithian KarunakaranDr Helen MurphyDr Gerry RaymanDr Rosemary TempleDr Mike StreatherDr David SimmonsProf Mike SampsonDr Peter Winocour Commissioners
Improving outcomes and reducing variance in diabetes pregnancy in the EAHSN (‘EASIPOD2’) Murphy (CUHFT) / Temple (NNUHFT)
Serious adverse outcome rates (major malformation and perinatal mortality) are about 55/1000 diabetes births, a three to fourfold higher rate than in the background maternity population.
EASIPOD programme (2007 -2009) reduced East of England adverse outcomes from 7.8 to 1.3% (p = 0.009), based on improved preconception care and is a simple primary and secondary care based preconception education programme for patients and HCP
Wide variance in outcomes driven by ethnicity, obesity, deprivation
Intervention To restart improved EASIPOD programme for all practices and all Acute Trusts
Primary end point Foetal loss and major malformation (at 6 weeks post partum)
Impact 1000 + women with diabetes deliver over 5 years in EAHSN area, and potentially 40 + prevented major foetal malformations /perinatal deaths and reduced variance in pre pregnancy care and pathways
Reducing admissions for severe acute hypoglycaemia (SAHE) in EAHSN area Sampson NNUHFT/All
Over 9,000 blue light 999 severe acute hypoglycaemia calls annually in EAHSN area .
Annual tariff-indirect cost £2.1M
Hypoglycaemia one of 5 National Clinical Performance Indicators for Ambulance Trust
High proportion of frequent fliers . Evidence base for prevention through education and action.
2 – 4 fold variance in EAHSN area for hospital conveyance , admissions and readmissions with hypoglycaemiaIntervention To develop new single point of contact service and OOH
service with enhanced case management pathways linked to new BPT, with Ambulance Trust collaboration.
Primary end point VisiCad Ambulance Trust data for Hypo
Impact A reduction of SAHE events by 20% through reducing recurrent episodes would be over 1000 SAHE admissions and contacts avoided per annum
Hypo Leaflet
Ambulance attend call out
Pt managed at the scene
Pt given Hypo leaflet
Pt info given to SPOC
3 days cooling off period for patients to opt out of being referred for follow up.
SPOC sends to hypodiabetesherts
@nhs.net
Pt taken to hospital and given hypo leaflet
Discharged Home & Check Hypo Leaflet given
Pt admitted
Pt admitted to ward
Yes
No
Yes
No
Severe Acute Hypoglycaemic Episode Pathway
14 days cooling off period for patients to opt out of being referred for follow up, if admitted to hospital
After 3/14 days patient info passed to
Identify where patients care is managed?
GPCommunity Acute Trust
Attempt to contact Patient via the telephone
to offer education
Contact GP advising unable
to contact patientAble to contact
patient
Education given and Email letter to GP advising what was
discussed.
No Yes
SPOC Pathway
EAHSN Data
Project launched mid December 2014 in Norfolk and Norwich -first referral 20/12/14
The Single Point of Contact (SPOC) within the East of England Ambulance Service (EEAS) started in East and North Herts February 2015
As of 31st August 2015 the project has received 1071 referrals, of which 116 are within East and North Herts
Total Referrals (n=1071)
Norfo
lk
Out
of A
rea
Cambr
idge
shire
Hertfor
dshi
re
Colch
este
r
Ipsw
ich
Bedfo
rdsh
ire
Wes
t Suff
olk
0
50
100
150
200
250
300
350312
156 149
116104 99
7659
East
and
Nor
th
Gender And Age (n=1071)
On average 55% of all referrals were ‘Male’ in the East of England. In East and North Herts 65% of referrals received were ‘Male’
0-9yrs 10-19yrs 20-29yrs 30-39yrs 40-49yrs 50-59yrs 60-69yrs 70-79yrs 80+yrs0
50
100
150
200
250
300 Other Regions in East of England
East and North Herts
Linear (East and North Herts)
Conveyance(n=128)
Norfo
lk
Cambr
idge
s...
Hertfor
dshi
re
Bedfo
rdsh
ire
Ipsw
ich
Out
of A
rea
Wes
t Suff
olk
Colch
este
r0
5
10
15
20
25
30
35
15%
10%19%
21%12% 8%
17%
2%
East
and
Nor
th
Medication (n=1071)
Norfolk
Out of A
rea
Cambridgesh
ire
Hertford
shire
Ipswich
Colcheste
r
Bedford
shire
West
Suffolk0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DietTabletInsulin
East
and
Nor
th
Previous Severe Hypo (n=1071)
Norfolk Cambridgeshire West Suffolk Hertfordshire Bedfordshire Colchester Ipswich Out of Area0
50
100
150
200
250
300
350
34%30%
32%42%
29%41% 40% 34%
East
and
Nor
th
Blood Glucose Levels(n=116)
0-0.9 1-1.9 2-2.9 3-3.9 >40
5
10
15
20
25
30
35
40
45
East and North Hertfordshire
36% 36%
3%
17%
6%
Loss of Consciousness
(n=1071)
Other Regions in the East of England East and North Hertfordshire0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total
Hypo Treatment for East and North Herts
(n=116)
Oral Carbs Im Glucagon IV Glucose Hypostop Other0
5
10
15
20
25
30
35
40
45
67yr old, Male, Type 1 since 1967 – under acute Lives at home with family Taking Humalog mix 25 am Insulatard pm Recent HbA1c 68 mmol/L 5 SAHE call outs over a 5 week period (March-April) First BG ranges on arrival at the scene 1.9 mmol/L – 2.5 mmol/L LOC x3 - All but one hypo occurred mid-morning All severe events treated with IV/IM treatments No entry for driving on CIPTS Had not disclosed to diabetes team
Hypo case study
Failed attempts to contact patient by DSN DSN contacted GP asked to reduce insulin Patient found to be a non-driver Insulin regime changed to Humulin M3 ECG showed ST -T wave abnormality in inferior lead Found to have strong family history IHD On-going foot complications Most recent HbA1c 46 mmol/L (7.5%)
Outcomes
Improve awareness/access to PPC for T2D women (currently 30% attend)
Improve quality of PPC for women with T1D who do not attend (currently <50% T1D who attend achieve Hba1c <7%)
Target hard to reach high risk women with T1D or T2D (previously poor outcomes)
2 Specialist Midwives to provide women with support and education. ([email protected])
Pre-Pregnancy Care Project
Steps taken so far… Contacted Practices in East and North Herts to ask to send
a PPC leaflet out to women aged between 16-45yrs (short exclusion list)
In total 2118 PPC Leaflets have to sent out by GP practices in the East of England
Visited all Tesco, Sainsbury and Asda Pharmacies Superstores in area to hand out PPC leaflet with medication
Visited a number of Health Centres/Childrens Centres to display leaflets as various clinics
Pre-Pregnancy Care Project
Any Questions?
