Nurse-Led Virtual Clinic In The Diabetes Antenatal Service
Current guidelines state that women with diabetes should be offered contact with their diabetes team every 1-2 weeks throughout their pregnancy. Gestational Diabetes (GDM) accounts for the vast majority of women attending antenatal clinics (ANCs). Both forms of diabetes can affect outcomes for both fetus and mother.
Research confirms that good blood glucose control during pregnancy reduces the risk of maternal and fetal complications. As there is a link between excessive maternal weight and GDM, good antenatal care for these women also represents an important public health opportunity. Education on diet and lifestyle interventions to control blood glucose could reduce their future risk of developing type 2 diabetes.
The diabetes antenatal clinics have been routinely overbooked, with lengthy waits to see doctors. Complex patients often have inappropriately brief appointments due to the volume of patients. There is a clear need to develop innovative ways to meet increasing demand in the face of fixed capacity whilst making the most of opportunities to make the service more patient-centred.
This project aimed to develop virtual ANC clinics that can remotely monitor and control blood glucose levels and reduce the need for routine hospital appointments.
- What was the approach?
A multidisciplinary project team was convened, consisting of diabetes specialist nurses, a diabetologist, administrative staff and clinical management representatives. Prior to the project’s start, the diabetes and obstetric teams process-mapped the antenatal pathway and identified up to five appointments in a typical GDM pregnancy where no face to face obstetric contact is needed. These appointments would be replaced by "virtual" diabetes specialist nurse-led appointments.
The project team scoped out the various technological solutions that could support a virtual clinic. At the centre of the virtual clinics were remote glucose meters and an app for sharing results with clinical staff. The team agreed to use the One Touch Verio Flex meter and the linked One Touch Reveal app. The team then undertook a privacy impact assessment, coordinated a data sharing agreement between Lifescan (meter company) and NHS Lothian and obtained Caldicott Guardian permission for Email and phone contact as part of a virtual clinic. This process required the development of detailed procedures with information sheets and a consent form.
The clinic engaged with women to see whether they would be willing to begin virtual appointments. The team then gathered baseline patient and staff satisfaction questionnaires. A database was set up to log data throughout the pilot.
Over the span of the project the team met every four to six weeks to feedback on progress. This allowed for multiple PDSA cycles to support improvements. Through this review process the GDM information leaflet was updated and there was refinement of the education process which supported women to set up the meter and app at home with minimal instruction. The outcome of this was to give a stronger focus on GDM during the group education sessions rather than on the technology required for the virtual clinic. Small tests of change established that Email was an effective means of communication if the nurse simply needed to confirm that all readings were to target, but that the phone saves time if readings are out of target and a change in treatment might be needed.
Over the 12 month implementation phase, four diabetes specialist nurses delivered 608 virtual appointments across three hospital sites.
- What was the impact?
The key outcomes from this project were:
- to achieve a reduction in patient numbers in our face to face diabetes antenatal clinics
- improve patient and staff satisfaction, and
- maintain quality of care
Patient numbers seen in virtual antenatal clinics (ANCs)
Over the 30 weeks that the virtual ANCs were delivered, the number of appointments per week across the three sites continued to rise, with no obvious sign of plateauing. The median number of weekly appointments offered between weeks 20 and 30 was 27 per week, while the median number of appointments per week from weeks 25 to 30 was 32 per week.
Patient numbers in face to face ANCs
From January 2016 to July 2018, the number of appointments in the face to face clinic rose year on year. When virtual clinics commenced in January 2019, clinic numbers were still higher than they had been in January of the last three years. By March 2019, numbers in the face to face clinic had fallen below 2018 and 2017 levels and in May and June, numbers fell to below 2016 levels.
Patient and staff satisfaction
Out of 16 patients, 12 (75%) were very satisfied, compared to just 48% on the baseline survey. Three patients identified waiting time as an area for improvement (19% of respondents versus 23% on baseline data) and none of them identified crowded waiting rooms as an area for improvement.
Quality of care
29 women completed questionnaires on the virtual ANC. Only two identified any difficulties with the blood glucose meter and only one had any difficulty with the app. Of these 29 women, 25 (86%) had had at least one virtual appointment. None of the women thought that the virtual ANC should be discontinued. Only one thought the clinic needed any changes and suggested being more explicit about the time when the nurses would get in touch for her virtual consultation. 96% of women who used the virtual clinic thought it should continue unchanged
A selection of some quotes on the virtual ANC, demonstrating the positive impact on the women’s quality of life:
- “So much easier…the virtual clinic reduces the number of times I need to come up to hospital”
- “It’s not great having to wait for hours in the clinic waiting to be seen”
- “I have two other children …the virtual clinic makes it so much easier for me”
- “Using email is brilliant”
- “I don’t drive…it’s really not good having to come up to the hospital as often as I do”
- What was the learning?
- Any clinic using virtual technology requires significant set-up time in order to ensure appropriate information governance. This would need to be taken into account by anyone considering a similar project
- It is possible to reduce face to face consultant appointments by use of a virtual clinic led by specialist nurses. This was associate with improved satisfaction scores for both women and staff
- Virtual clinics were highly acceptable to patients, who enjoyed the convenience of fewer appointments.
- The majority of patients found it straightforward to download and use an app on their phone which would Bluetooth their blood glucose data to their clinic. However, this was a young patient group (of child-bearing age) so the findings of this pilot may not translate to an older patient group.
There are plans to share our learning in a number of areas:
- Out patient and Associated Services Clinical Management Group and Diabetes Senior Management Team: both these groups have been kept up to date on progress and final verbal reports will be shared with both groups
- Clinical Change Forum: present this project in the November 2019 Clinical Change Forum at the Western General Hospital.
- Conferences: submit abstracts to the Diabetes UK annual professional conference in March 2020, FEND (Foundation of European Nurses in Diabetes) in September 2020 and the national NHS Scotland QI conference in 2020.
- Lothian Diabetes Managed Clinical Network: data will be presented at a future MCN meeting.
- Annual Lothian Diabetes Obstetric meeting: data to be presented January 2021.
- What are the next steps?
The team has been considering how to sustain the project now that the ihub funding has come to an end. Internal efficiencies within our unit mean that there are enough glucose meters, test strips and funding for DSN time to continue the project until the end of 2019. There are plans to:
- Submit a paper to the Outpatient and Associated Services Clinical Management Group and subsequently to the Lothian Senior Management Team to seek ongoing financial support to embed this virtual clinic in our core work.
- Upscale the clinic, which has focused on the more straightforward patient group with GDM. We plan to include patients with type 2 diabetes and may also expand to type 1 diabetes.
- Apply to the Edinburgh and Lothian Health Foundation fund, which is currently offering to support projects which relate to the Royal Infirmary of Edinburgh and the Simpson maternity hospital, which fits well with the virtual clinic’s remit.