Joint British Diabetes Societies Research Articles

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

1987 Capillary blood glucose testing on older inpatients at the Norfolk and Norwich University Hospital (NNUH)

Abstract Rationale Inpatient glycaemic management is a challenge in older people. Clinicians at the Norfolk and Norwich University Hospital noticed substantial numbers of finger-prick capillary blood glucose (CBG) tests being documented. This quality improvement project explored the frequency of CBG testing on older people’s medicine wards, to determine if improvements in service provision and patient safety could be made. Methods Setting: Electronic records of inpatients on geriatric medicine wards at NNUH (May-July 2023) Patient selection: Older people with recorded CBG testing Measures: Type of diabetes, medication regime and frequency of CBG testing. Staff survey of CBG monitoring knowledge. Analysis: Compliance with the Joint British Diabetes Societies for Inpatient Care guidelines for frail older adults with diabetes (February 2023). Staff knowledge. Results 240 inpatients included - 23% had type 2 diabetes. 32% had regular CBG monitoring (once daily or more). Of these patients, 70% had tests that were not compliant with guidance. In a single day, we calculated 120 CBG tests that were not clinically indicated. 43% of patients were on single-therapy treatment (not including sulphonylureas) or diet-controlled type 2 diabetes, all of whom underwent excessive testing during their inpatient stay. A staff survey of 15 ward sisters, nurses and healthcare assistants revealed no consensus on who determines frequency of CBG testing and target CBG ranges for frail, older inpatients. Conclusions Ad hoc CBG testing has resulted in potential harm to our inpatients and overuse of staff time and resources. Future work is underway to ‘Think Glucose’ and implement protocols for appropriate CBG monitoring frequencies and target CBG ranges for our inpatients.

A UK national survey of enteral feed use in people with diabetes 2022.

Enteral feeding is commonly used to manage a variety of medical conditions in hospitals. For people with diabetes this can present a specific challenge for glucose management. To address gaps in our understanding of modern enteral feeding outcomes and to help with the development of more specific guidance on maintaining glycaemic control, we conducted a national survey on the management of enteral feeding against the standards in the nationally adopted Joint British Diabetes Societies for Inpatient Care (JBDS) guidelines. A questionnaire was developed using the 2018 JBDS guideline as a template this questionnaire was sent out by email to all 220 UK specialist diabetes teams. Databases of Diabetes UK, the Association of British Diabetologists (ABCD) and the Diabetes Inpatient Specialist Nurse UK Group were used. Twenty-six hospitals responded, 11 had guidelines for the management of insulin with enteral feeding. There were three main feed regimens used: continuous 24-h feeding, a single feed with one break in 24 h, or multiple feeds in 24 h. There were five regimens in common use: premixed insulin, isophane insulin, analogue basal insulin, variable rate intravenous insulin or basal bolus insulin. Overall glucose control was poor for all regimens and combinations. Continuous feed showed better glucose control than a single feed with a break, mean (±SD) glucose 12.4 mmol/L (5.6) versus 15.1 mmol/L (6.9) p < 0.005, but no group showed optimal control. Managing diabetes control during enteral feeding remains a challenge. Our survey showed that glucose control during this treatment is suboptimal.

Clinical characteristics and severity of diabetic ketoacidosis: A cross-sectional study from a tertiary hospital in Ghana.

Diabetic ketoacidosis (DKA) is a common, severe and often fatal complication of diabetes. This study aimed to investigate the clinical characteristics and precipitants of DKA, as well as factors associated with DKA severity in Ghanaian patients. Cross-sectional study of the medical records of all 70 adult patients >18 years managed for DKA in the adult emergency room of Korle-Bu Teaching Hospital in Ghana from March 2019 to July 2019. DKA diagnosis was based on hyperglycaemia >11.0 mmol/L, ketonuria (more than 2+) plus acidaemia of (pH < 7.3) or bicarbonate (HCO3 - ) <15.0 mmol/L. However, when serum bicarbonate and pH were not available, clinical signs of acidosis, for example, Kussmaul breathing aided in the diagnosis. DKA severity was assessed based on the Joint British Diabetes Societies (JBDS) guidelines of factors suggestive of severe DKA. Multivariable logistic regression was used to determine the factors associated with DKA severity. Odds ratio and 95% confidence interval for factors associated with DKA severity were determined. The mean (±standard deviation) age, diabetes duration and blood sugar at admission were 44.06 (±16.23) years, 7.19 (±6.04) years and 26.37 (±6.70) mmol/L, respectively. Females comprised 51.4% of the study population. The most common presenting symptoms were generalised weakness (30.0%) and fever (14.3%). The major precipitants were infection (70.0%) and non-compliance (22.9%). Overall, 71.4% of participants had features suggestive of severe DKA. In a multivariable regression model, Type 2 diabetes was associated with over fourfold decreased odds of severe DKA (OR 0.23, 95% CI [0.07-0.76], p = 0.016). Patient education on prevention of DKA was documented for only 18.6% of patients before being discharged. In this study, more than 70% of the study participants had features suggestive of severe DKA, with infection being the most common precipitant of DKA. 51.4% of patients had Type 2 diabetes which was associated with a statistically lower risk of severe DKA. Female sex tended to be positively associated with DKA severity. In a setting where the venous/arterial pH and bicarbonate levels may be inaccessible and/or unaffordable, using clinical features as found in the JBDS guidelines may help categorise patients and escalate care when needed. Indeed it may be useful to validate the use of the JBDS criteria for use in such settings.

Optimal staffing for a good quality inpatient diabetes service.

Increasing numbers of people admitted to hospital have diabetes and need specialist support. To date, there is no mechanism which can help teams estimate the number of health care professionals they need to provide optimal care for people with diabetes in hospitals. The Joint British Diabetes Societies (JBDS) for Inpatient Care Group organised a survey of specialist inpatient diabetes teams in the UK for current staffing and the perception of optimal staffing using mailing lists available through their representative organisations. The results were verified and confirmed by one-to-one conversations with individual respondents and discussed in multiple expert-group meetings to agree on the results. Responses were received from 17 Trusts covering 30 hospital sites. Current diabetes specialist staffing level per 100 people with diabetes in hospital (Median, IQR) for consultants was 0.24 (0.22-0.37), diabetes inpatient specialist nurses was 1.94 (1.22-2.6), dieticians was 0.00 (0.00-0.00), podiatrists was 0.19 (0.00-0.62), pharmacists was 0.00 (0.00-0.37), psychologists was 0.00 (0.00-0.00). The teams also reported that for optimal care the total staff needed for each group (Median, IQR) was much higher; consultants 0.65 (0.50-0.88), specialist nurses 3.38 (2.78-4.59), dieticians 0.48 (0.33-0.72), podiatrists, 0.93 (0.65-1.24), pharmacists, 0.65 (0.40-0.79) and psychologists 0.33 (0.27-0.58). Based on the results of the survey, the JBDS expert group produced an Excel calculator to estimate staffing needs of any hospital site in question just by populating a few of the cells. Current inpatient diabetes staffing is much lower than needed in most Trusts who responded to the survey. The JBDS calculator can provide an estimate of the staffing needs of any hospital.

#3584 COMPLIANCE OF DIABETIC MONITORING IN PATIENTS WITH END-STAGE RENAL DISEASE ON MAINTENANCE HAEMODIALYSIS

Abstract Background and Aims Diabetic nephropathy is a major cause of end-stage kidney disease (ESKD) in the UK, accounting for nearly 30% of patients requiring dialysis and in some units over 40% of the people on dialysis have diabetes. The national reviewing and benchmarking committee (GIRFT NHS) had highlighted the disjointed and variable care received by these patients, with increasing risk of complications including blindness, foot ulcers and amputations from suboptimal care. Increased monitoring is shown to be cost-effective and co-ordination of a multi-disciplinary team focus can reduce complications especially lower limb amputation rates. Hence, we aimed to review the quality of care on our setting and compare it to national recommendations. Method We performed a cross-sectional review on patients with diabetes on haemodialysis in the satellite unit at a district general hospital to assess compliance with the Joint British Diabetes Societies (JBDS) and the UK Kidney Association (UKKA) recommendations on management of adults with diabetes. Subsequently we introduced monitoring protocols for the relevant key areas of diabetes monitoring (pre and post-dialysis glucose checks, HbA1c checks, check boxes for once weekly feet inspections, criteria for inpatient podiatry review), highlighted potential complications including hypoglycaemia, re-emphasised the importance of adequate documentation to allied healthcare teams, and updated the haemodialysis monitoring sheets. We worked with the unit manager to highlight the rationale for monitoring and provided brief education on complications to the team, and over repeated visits, gained the confidence and support of staff for the changes suggested despite an increased workload. Results We reviewed data from January to April 2021 followed by re-evaluation 12 months later after implementation of changes. Data for 25 patients were reviewed and re-assessed after a year. 7 patients passed away during this period. Initial review recognised the lack of awareness of good practice management of diabetic patients in the haemodialysis unit. Most patients have type 2 diabetes which carries a higher risk of ESKD. After a year of change in protocols there were significant improvements in monitoring parameters, with greatest improvements seen in glucose monitoring and routine feet inspections. Conclusion The review was based on care standards that included diabetes parameters as part of the recommended national care processes, and individualised treatment approach. The aims included were performing annual reviews, adequate glucose monitoring and rational glycaemic targets, and earlier targeted involvement of the diabetes specialist team. There was improvement in most of the monitoring parameters and clearer documentations from allied healthcare teams. Implementation of recommendations was initially challenging due to the COVID-19 pandemic and staff workload on the unit however with persistence we were able to obtain co-operation from the team. As expected, patients on insulin/sulphonylureas (SUs) had proper blood glucose monitoring methods. Most were on insulin, and the remaining were on SU and DPP-IV inhibitor, and those with HbA1c &amp;lt;58 mmol/mol declined. One-third of these patients used flash glucose monitoring and with increasing recognition and recommendation by the NHS hopefully more patients will benefit from this. This audit showed that simple interventions such as staff engagement and education can improve care and monitoring of patients in this population. With recovery of service provisions, more interventions can be put in place. Following this, we can reaudit amputation rates and gather patient feedback, plan interventions with the community team, and encourage involvement from general practitioners and their trainees to deliver better care to these patients. Hence, we emphasise the importance of clear protocols for the management and monitoring of each patient with diabetes mellitus in haemodialysis units to ensure care standards are met.

Part II: Interactive case: Drug‐induced endocrine disorders

Part <scp>II</scp>: Interactive case: <scp>Drug‐induced</scp> endocrine disorders

Exploring ChatGPT's Potential in Facilitating Adaptation of Clinical Guidelines: A Case Study of Diabetic Ketoacidosis Guidelines.

Background This study aimed to evaluate the efficacy of ChatGPT, an advanced natural language processing model, in adapting and synthesizing clinical guidelines for diabetic ketoacidosis (DKA) by comparing and contrasting different guideline sources. Methodology We employed a comprehensive comparison approach and examined three reputable guideline sources: Diabetes Canada Clinical Practice Guidelines Expert Committee (2018), Emergency Management of Hyperglycaemia in Primary Care, and Joint British Diabetes Societies (JBDS) 02 The Management of Diabetic Ketoacidosis in Adults. Data extraction focused on diagnostic criteria, risk factors, signs and symptoms, investigations, and treatment recommendations. We compared the synthesized guidelines generated by ChatGPT and identified any misreporting or non-reporting errors. Results ChatGPT was capable of generating a comprehensive table comparing the guidelines. However, multiple recurrent errors, including misreporting and non-reporting errors, were identified, rendering the results unreliable. Additionally, inconsistencies were observed in the repeated reporting of data. The study highlights the limitations of using ChatGPT for the adaptation of clinical guidelines without expert human intervention. Conclusions Although ChatGPT demonstrates the potential for the synthesis of clinical guidelines, the presence of multiple recurrent errors and inconsistencies underscores the need for expert human intervention and validation. Future research should focus on improving the accuracy and reliability of ChatGPT, as well as exploring its potential applications in other areas of clinical practice and guideline development.

Identifying patients with diabetes in a day‐case systemic anti‐cancer therapy population: the Belfast Regional Oncology Centre experience

AbstractPatients undergoing systemic anti‐cancer treatment (SACT) often receive short courses of high dose steroids which may cause hyperglycaemia and potentially impact negatively on clinical outcomes. In this study we aimed to ascertain the prevalence of diabetes in a day‐case SACT cohort and secondly to compare practical methods of identifying patients with diabetes in a busy oncology service.We performed two prospective snapshots of all patients attending for day‐case SACT at the Regional Oncology Centre, Belfast, over two separate week‐long periods. In the first snapshot we evaluated laboratory random serum glucose concentration. Data from 221 patients identified 14 patients with elevated random serum glucose (≥11.1mmol/L). In the second snapshot we added a patient questionnaire asking if the patient had diabetes alongside laboratory random serum glucose concentrations. We obtained 242 completed questionnaires from a potential of 299 (81% response rate) patients; 54 (22%) had known diabetes. By laboratory data, only 17 of 242 (7%) had a random serum glucose concentration ≥11.1mmol/L. All 17 would have been identified by asking the patient if they had diabetes. Diabetes is common in this cohort (22%). In a busy oncology clinic, the most effective way to identify patients with diabetes is to ask them first if they have diabetes.This study is timely given the recent publication of Joint British Diabetes Societies and United Kingdom Chemotherapy Board guidance to improve the glycaemic control of patients with cancer. Earlier diagnosis and subsequent intervention to improve glycaemic control have the potential to improve clinical outcomes. Copyright © 2023 John Wiley &amp; Sons.

Management of adults with diabetes on dialysis: Summary of recommendations of the Joint British Diabetes Societies guidelines 2022.

Diabetes is the commonest cause of end-stage kidney disease in many parts of the world, and many people on dialysis programmes live with diabetes. Such people are vulnerable to complications from their diabetes, and their care may be fragmented due to the many specialists involved. This updated guidance from the Joint British Diabetes Societies aims to review and update the 2016 guidance, with particular emphasis on glycaemic monitoring in the light of recent advances in this area. In addition, the guidance covers clinical issues related to the management of diabetes in people on peritoneal dialysis, along with acute complications such as hypoglycaemia and ketoacidosis, and chronic complications such as foot and eye disease.

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group.

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Rowan Hillson Inpatient Safety Award 2022

Introduction: The annual National Diabetes Inpatient Audit (NaDIA and NaDIA-Harms) in the UK continues to show significant problems with patient care. During the COVID pandemic patient care has been even more difficult. New initiatives are urgently required to improve inpatient safety for people with diabetes. Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the seventh national Rowan Hillson Inpatient Safety Award on the theme of “the best interventions: redesigning, rebuilding and maintaining safe inpatient diabetes care during COVID”. Result: The winner was the DEKODE team, led by Dr Punith Kempegowda from University Hospitals Birmingham NHS Foundation Trust, for their innovative quality improvement project across hospitals during COVID to improve diabetes-related ketoacidosis (DKA) management and study DKA in people with COVID. Adherence to national guidance improved in some hospitals, with falls in hypoglycaemia, and overall there was a significant improvement in awareness about DKA amongst junior doctors. The King’s College NHS Foundation Trust team, led by Adrian Li and colleagues, received the highly commended award for their innovative project of remote blood glucose (BG) monitoring across healthcare boundaries. This improved diabetes control and tackled health inequalities. Summary and conclusion: These and similar schemes need to be developed, promoted and shared to improve safety for people with diabetes admitted in hospital during COVID times.

Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non-critically ill adults: A call for further research.

To describe the gaps in knowledge for the care of people in the hospital who have dysglycaemia or diabetes. A review of the current literature and the authors' knowledge of the subject. Recent data has suggested that the prevalence of hospitalised people with diabetes is approximately three times the prevalence in the general population and is growing annually. A wealth of observational data over the last 4 decades has shown that people with hyperglycaemia, severe hypoglycaemia or diabetes, all experience more harm whilst in the hospital than those who do not have the condition. This often equates to a longer length of stay and thus higher costs. To date, the proportion of federal funding aimed at addressing the harms that people with dysglycaemia experience in hospitals has been very small compared to outpatient studies. National organisations, such as the Joint British Diabetes Societies for Inpatient Care, the American Diabetes Association and the Endocrine Society have produced guidelines or consensus statements on the management of various aspects of inpatient care. However, whilst a lot of these have been based on evidence, much remains based on expert opinion and thus low-quality evidence. This review highlights that inpatient diabetes is an underfunded and under-researched area.

Trends in rates of complications and adverse outcomes in diabetic ketoacidosis following changes to the Joint British Diabetes Societies' management guidelines

Serious complications of diabetes-related ketoacidosis (DKA) and its management with fixed rate intravenous insulin infusion (FRIII) include hypoglycaemia, hyperkalaemia and hypokalaemia. Revised Joint British Diabetes Societies for Inpatient Care (JBDS) guidelines in June 2021 recommend a reduced

The impact of changes to Joint British Diabetes Societies' diabetes-related ketoacidosis management guidelines on trends of complications and outcome

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Glucocorticoid-induced hyperglycaemia and diabetes: Call for action.

Glucocorticoid-induced hyperglycaemia and diabetes: Call for action.

A quality improvement project reducing adverse events and improving adherence to guidelines surrounding VRIII usage

Variable rate intravenous insulin infusions (VRIII) are frequently used in hospitals and incorrect use can lead to electrolyte imbalance, hypoglycaemia and adverse outcomes. The Joint British Diabetes Societies (JDBS) published...

The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care.

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes - an updated guideline from the Joint British Diabetes Society for Inpatient Care.

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of glycaemia in pregnant women with diabetes on obstetric wards and delivery units, Joint British Diabetes Societies (JBDS) for Inpatient Care Group, ABCD (Diabetes Care) Ltd. The updated guideline offers two approaches - the traditional approach with tight glycaemic targets (4.0-7.0mmol/L) and an updated pragmatic approach (5.0-8.0mmol/L) to reduce the risk of maternal hypoglycaemia whilst maintaining safe glycaemia. This is particularly relevant for women with type 1 diabetes who are increasingly using Continuous Glucose Monitoring (CGM) and Continuous Subcutaneous Insulin Infusion (CSII) during pregnancy. All women with diabetes should have a documented delivery plan agreed during antenatal clinic appointments. Hyperglycaemia following steroid administration can be managed either by increasing basal and prandial insulin doses, typically by 50% to 80%, or by adding a variable rate of intravenous insulin infusion (VRIII). Glucose levels, either capillary blood glucose or CGM glucose levels, should be measured at least hourly from the onset of established labour, artificial rupture of membranes or admission for elective caesarean section. If intrapartum glucose levels are higher than 7.0 or 8.0mmol/L on two consecutive occasions, VRIII is recommended. Hourly capillary blood glucose rather than CGM glucose measurements should be used to adjust VRIII. The recommended substrate fluid to be administered alongside a VRIII is 0.9% sodium chloride solution with 5% glucose and 0.15% potassium chloride (KCl) (20mmol/L) or 0.3% KCl (40mmol/L) at 50ml/hr. Both the VRIII and CSII rates should be reduced by at least 50% after delivery.