Diabetes Specialist Team Research Articles

Diabetes medication pharmacology

Diabetes medication pharmacology

The impact of glycaemic variability on the surgical patient.

Diabetes is the most prevalent long-term metabolic condition and its incidence continues to increase unabated. Patients with diabetes are overrepresented in the surgical population. It has been well recognized that poor perioperative diabetes control is associated with poor surgical outcomes. The outcomes are worst for those people who were not recognized as having hyperglycaemia. Recent work has shown that preoperative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimize the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home. The early involvement of the diabetes specialist team is important if the glycated haemoglobin is more than 8.5%, and advice sought if the preoperative assessment team is not familiar with the drug regimens. To date the glycaemic targets for the perioperative period have remained uncertain, but recently a consensus is being reached to ensure glucose levels remain between 108 and180 mg/dl (6.0 and 10.0 mmol/l). There have been a number of ways to achieve these - primarily by manipulating the patients' usual diabetes medications, to also allow day of surgery admission. glycaemic control remains an important consideration in the surgical patient.

Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association

Diabetic nephropathy remains the principal cause of end-stage renal failure (ESRF) in the UK, as elsewhere in the developed world, and its prevalence is set to increase. People with diabetes and ESRF on maintenance haemodialysis are a highly vulnerable group, often with complex comorbidities, who are at high risk of adverse cardiovascular outcomes, which is the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and ESRF require improved delivery of care to overcome organisational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of the diabetes patient on maintenance haemodialysis. The guideline is based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and patients to promote patient empowerment and self-management.

Care Quality Commission and diabetes: a new review of community services

Care Quality Commission and diabetes: a new review of community services

Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists

### Key points Diabetic ketoacidosis (DKA) is a medical emergency. The diagnostic triad is: 1. Ketonaemia ≥3.0 mmol litre−1 or significant ketonuria (more than 2+ on urine sticks) 2. Blood glucose >11.0 mmol litre−1 or known diabetes mellitus 3. Bicarbonate <15.0 mmol litre−1, venous pH <7.3, or both. DKA can occur in both type 1 and type 2 diabetes mellitus and, although preventable, it remains a frequent and life-threatening complication. Errors in the management of DKA are not uncommon and are associated with significant morbidity and mortality. The majority of mortality and morbidity in DKA are attributable to delays in presentation and initiation of treatment. Rapid recognition and treatment of DKA is critical. To overcome these concerns and to highlight current management strategies, the Joint British Diabetes Societies (JBDS) published guidelines in 2010. This was updated in consultation with the Intensive Care Society in September 2013.1 This article will review the pathophysiology of DKA and highlight the modern management of DKA that is relevant for anaesthetists. A summary of the JBDS guidelines pertinent to intensivists has been published.2 In England in 2010, there were 14 375 admissions to …

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014.

To examine, in a national survey, the outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. Data were collected in a standardized form covering clinical and biochemical outcomes, risk and discharge planning. The form was sent to all UK diabetes specialist teams (n = 220). Anonymized data were collected on five consecutive patients admitted with DKA between 1 May 2014 and 30 November 2014. A total of 283 forms were received (n = 281 patients) from 72 hospitals, of which 71.4% used the national guidelines. The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. The median times to starting 0.9% sodium chloride and intravenous insulin were 41.5 and 60 min, respectively. The median time to resolution was 18.7 h and the median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred, with 27.6% of patients developing hypoglycaemia and 55% reported as having hypokalaemia. There were also significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 h, but 95% were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information. Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk.

Collaborative diabetes virtual clinics – a service evaluation and clinical audit

AbstractBackground: Diabetes management in primary care is becoming increasingly complex. Integrated working between primary and specialist care teams is important in addressing this complexity. Diabetes virtual clinics (DVC) provide an opportunity for the diabetes specialist team to work collaboratively with the primary care team.Aim: To evaluate the impact of a DVC on the clinical management and care outcomes of patients in primary care settings.Methods: A prospective clinical audit of DVC patients was performed in seven general practices comparing data, at baseline and at 6 months. The audit measured changes in care provision and clinical performance. The primary audit standard was that 50% of cases with a baseline glycated haemoglobin (HbA1c) ≥58 mmol/mol (7.5%) would optimise HbA1c by a clinical significant reduction of 6 mmol/mol (0.4%).Results: The audit examined 113 cases that were exposed to the DVC. Data were available on 73 cases at 6 months. The main theme for case discussion was treatment mod...

Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go?

Background: The Joint British Diabetes Society (JBDS) consensus guideline published in 2010 has provided the framework for the effective management of diabetic ketoacidosis (DKA) in adults in the UK. Methodology: A retrospective study of 50 patient episodes admitted to our teaching hospital between February and December 2012, with a discharge diagnosis of DKA. Results: Twenty-seven (54%) patients were male, mean (SD) age was 43 (21) years and duration of diabetes was 11 (9) years. In the first 60 minutes from diagnosis, median (interquartile range [IQR]) time to fixed rate intravenous insulin infusion (FRIII) was 49 (29–110) minutes and to intravenous fluids was 19 (0–42) minutes. During ongoing management, 46% of patients developed hypokalaemia and, of those, in 70% potassium supplementation was not prescribed as per protocol. Forty percent of patients experienced hypoglycaemia in the first 24 hours, of whom 80% had 10% dextrose prescribed appropriately according to protocol. Median time to hypoglycaemia from diagnosis was 12 hours 54 minutes. Median (SD) time to resolution of DKA was 12 hours 6 minutes. Eighty six percent of patients were reviewed by the diabetes specialist team during admission. No deaths due to DKA or complications of its management were reported. Median length of hospital stay was two days. Conclusions: Adherence to the JBDS DKA guideline was good in the immediate stage of treatment. Inadequate metabolic monitoring, fluid management and iatrogenic hypoglycaemia remain areas of concern. A high proportion of patients received diabetes specialist nurse input with reduced length of stay and no recorded mortality. Our recommendations as a result of this audit include a strengthened programme of teaching and education for nursing and medical staff, focus on metabolic monitoring and improved patient contact after hospital discharge.

Co‐commissioning: the architecture of integration

Co‐commissioning: the architecture of integration

Insulin for the uninitiated

Insulin therapy is important in many patients with diabetes, but the UK National Diabetes Inpatient Audit (NaDIA) suggests that insulin therapy in hospital is poorly monitored and managed. Although most hospitals should have access to an inpatient diabetes specialist team, it is important for the non-specialist clinician to be aware of the indications for insulin therapy, types of insulin and insulin regimens, methods of adjusting insulin doses and the need for care with insulin prescribing. Here, we demystify issues around insulin therapy.

Managing hyperglycaemia in patients with diabetes on enteral nutrition: the role of a specialized diabetes team.

Hyperglycaemia is commonly observed in patients with diabetes mellitus (DM) while receiving enteral nutrition (EN) in hospital, and hyperglycaemia has been shown to be associated with poor clinical outcomes. The aim of this study was to assess the glycaemic status of patients with DM who received EN during hospital admission and evaluate the impact of intervention by a specialist diabetes team (SDT) on glycaemic control and clinical outcomes of these patients. A retrospective review of patients with DM who required EN during hospital admission was conducted. We compared patient characteristics, glycaemic profile and clinical outcomes between patients who were managed by SDT and those who were managed by the admitting team. Seventy-four patients with DM on EN were included in this study, of whom 27 were managed by SDT while on EN. Compared with patients managed by the admitting team, those who were reviewed by SDT had better glycaemic control during the period of EN as well as during the 24 h after EN was ceased. These patients also had shorter length-of-stay in hospital and lower in-patient mortality. Our findings confirmed that there was a role for SDT in managing patients with DM who received EN during their hospital admission. These patients had improved glycaemic control while receiving EN and had better clinical outcomes. Further prospective studies will be required to validate the findings of this study.

Commissioning and the future of diabetes care

The creation of clinical commissioning groups has provided a unique opportunity for diabetes specialist teams and other stakeholders to collaborate directly with local commissioners to rationalise and improve diabetes care provision. We describe here the process by which the diabetes service in the Vale of York has been redesigned and a community diabetes service has been commissioned to help embed the new model of care. The process has involved getting key personnel in place to identify and drive change, creation of a model of care that is simple, removes artificial barriers and is based on clinical need rather than financial structures. Engaging and listening to stakeholders, particularly patients, was critical to the development as was participation of influential board level representatives to act as champions. Facilitative negotiation of the content and provision of the service helped build the business model to complement the clinical model. Developing a unified brand and image that would associate both commissioner and provider helped cement the alliance and provide patients with a single needs-based service.

Inpatient diabetes: do‐it‐yourself electronic referral system to support and enhance the Think Glucose project

AbstractThe national Think Glucose project utilises a ‘traffic light’ system to guide which patients should be referred to the inpatient diabetes specialist team (IPDST). Previously, referral to the IPDST required phone, fax or internal post, with their built‐in delays and patients being missed.We used our hospital trust's investigation‐ordering system to develop an electronic ‘Think Glucose Assessment’ form. The quick and easy form incorporates simple tick boxes to select which ‘traffic light’ points apply to the patient concerned. Once submitted, the form appears instantly in a generic NHS email account accessible by the IPDST. This facilitates daily IPDST ward round lists. Over the year following implementation the number of patients seen by the IPDST increased from 83 per month to 452 per month, while at the same time ensuring those seen complied with the national ‘traffic light’ criteria. All hospitals with electronic investigation‐ordering systems could easily emulate our system.

MANAGEMENT OF DIABETES IN PALLIATIVE CARE

BackgroundOf the half a million people who die in the United Kingdom each year, approximately 6–9% will have Diabetes Mellitus (DM). The 2011 position statement regarding diabetes management at the...

Diabetes care for the most vulnerable in society – the views of professionals working in care homes and domiciliary care using focus group methodology

Using focus group methods, we report that the main concerns of health care professionals working in care homes and in the domiciliary sector are as follows: Poor communication with all other health care agencies, including hospital, primary care and mental services The need for training, specifically in diabetes and dementia Currently available e-learning was not found to be useful Poor support from the specialist diabetes team

Supporting children and young people diagnosed with type 2 diabetes in school

Obesity in childhood increases the risk of developing type 2 diabetes (T2D). Those children diagnosed with T2D are more likely to die young due to the increased risks associated with cardiovascular disease and obesity. This article aims to: support practitioners working in schools and the community to identify those children and young people at greatest risk of developing T2D, encourage early referal to a specialist diabetes team and discuss the support children diagnosed with T2D may need in the school setting through a case study.

Procedures and medications to help patients control their diabetes

Two of the most common acute and potentially life-threatening complications of diabetes mellitus are diabetic ketoacidosis and hyperosmolar hyperglycaemic state. Both conditions are characterised by hyperglycaemic states, but nurses should be aware of important differences so the correct condition and treatment can be identified. Treatment includes immediate referral to specialist diabetes teams and possible transfer to intensive care. This article outlines the similarities and differences in the symptoms and treatment of the conditions, and discusses prevention strategies.

Inpatient diabetes care: complexity, resilience and quality of care

It is estimated that 10---15 % of UK hospital inpatients have diabetes. Poor glycemic control is a care quality problem that has been linked to organizational factors such as inadequate training, inadequate protocols, problems with communication and teamwork, and difficulty coordinating mealtimes. Interventions using specialist diabetes teams have been effective in addressing some of these problems and have led to increased staff and patient self-efficacy and reduced length of stay. The aim of this study was to investigate how inpatient diabetes care is delivered and how resilience is created and/or breaks down, and to identify the implications for quality improvement. In-depth interviews (n = 32) with diabetes specialist and non-specialist staff were conducted in an acute medical admissions environment in an 850-bed teaching hospital. The Critical Decision Method, a content-orientated knowledge elicitation technique, was adapted to guide interview schedules, which explored key decisions, gaps and discontinuities in care and strategies for work system improvement. Care is delivered through the coordination of a multilayered team of different professionals. Specialists provide expertise and problem solving through case-based reasoning using problem-solving skills acquired through past experience. Ward staff focus on processes and immediate patient needs and are more reliant on decision protocols. Gaps in care can occur and result in delays in referring to specialists and clinical inertia. Specialists are a key source of resilience in the system and bridge gaps by acting reactively to problems, proactively monitoring and anticipating problems, providing staff education, and patient support and education. Opportunities for supporting clinicians to bridge gaps in care were identified.

The Effect of Diabetes on Hospital Readmissions

Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Diabetes, similar to other chronic medical conditions, is associated with increased risk of hospital readmission. Risk factors include previous hospitalization, extremes in age, and socioeconomic barriers. Preliminary studies suggest that acute and/or chronic glycemic control may be of importance when diabetes is the primary diagnosis or when it is a comorbidity. Very limited evidence from prospective randomized controlled trials aimed at improving glycemic control is available. However, whether one concludes that inpatient or outpatient glycemic control is partly responsible for reduced hospitalizations, attention to glycemic control in the hospital may facilitate sustained glycemic control post-discharge. Limited prospective and retrospective evidence suggest that the involvement of a diabetes specialist team may improve readmission rates, but attention to more generalized comprehensive approaches may also be worthwhile. Prospective interventional studies targeting interventions for improving glycemic control are needed to determine whether glycemic control impacts readmission rates.

Ensuring people with diabetes stay out of hospital

Ensuring people with diabetes stay out of hospital