Joint British Diabetes Societies Research Articles

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.

Oppurtunistic completion of the 9 diabetic care processes during inpatient admission to a mental health hospital: an audit of local practice

AimsDiabetes is more prevalent in people with mental illness than in the general population. Those with both mental illness and diabetes are more likely to have poor glycaemic control. Clients with mental illness and diabetes are less likely to receive the 9 NICE recommended annual diabetic care processes than the general population. In 2017, the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) and the Royal College of Psychiatrists released guidance recommending that inpatient psychiatric admissions should be used as an opportunity to complete diabetic care processes, and a named staff member should be responsible for this.We aimed to review local compliance with this JBDS-IP guidance, increase knowledge and improve local care for clients living with both mental illness and diabetes.MethodWe reviewed the notes of all current inpatients to general, forensic or learning disability wards at our centre and identified all patients with a known diagnosis of Diabetes. We identified which of the 9 care processes had been completed (or had the most recent result documented, or had a plan made for completion) during this admission. We identified if a named staff member was responsible for completing processes on each ward, and whether the care processes were documented in the patients’ notes.ResultWe identified 18 current diabetic inpatients at our centre (14% of inpatients). We found that none of these patients had a diabetic care processes review documented and none of these patients had had a foot check and urinary albumin performed during admission, or had the last community result identified and documented. We found that less than 15% of patients had a documented plan concerning the completion of retinal screening. One ward had a named staff member responsible for reviewing their diabetic patients’ screening. However, 6/9 care processes had been completed in the significant majority of patients (>75%).ConclusionOur centre is not compliant with the guideline audited. We have implemented a plan to increase awareness of care processes through posters, teaching (at junior and consultant level), creating documentation templates and ensuring wards nominate a staff member to review care processes. We have organised a re-audit. Organising foot examination, renal function testing and retinal screening during admission for clients who may have complicated social situations and may not be aware of (or be non adherent with) the long term management of their diabetes has the potential to significantly reduce morbidity in this client subgroup.

The Rowan Hillson Inpatient Safety Award 2019 for the best perioperative pathway for people with diabetes

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. New initiatives are urgently required to mitigate this risk.Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the sixth national Rowan Hillson Inpatient Safety Award on the theme of the best perioperative pathway for people with diabetes.Result: The winner was the team from Aneurin Bevan University Health Board led by Dr David Burckett-St Laurent for their innovative re-design of the perioperative pathway by a cross-specialty working group. The main elements of the new system were standardised patient assessment, optimisation of perioperative diabetes control, personalised diabetes management plans generated from a drop-down menu with information on usual drug treatment, pre-op/day of surgery diabetes medication modification, advice on hypoglycaemia management and sick-day rules, anaesthetic review for people with HbA1c >69 mmol/mol, secondary care diabetes review for people with suboptimal diabetes control, new inpatient charts with guidance on diabetes drug management, streamlining of time and place of admission and greater engagement and education of people with diabetes and staff looking after them. This resulted in significant improvement in outcomes and reduction in risks.The Newcastle upon Tyne NHS Foundation Trust team led by Dr Nicola Leech and colleagues received the runners-up award for their 3-year quality improvement project involving multiple specialties. The project included development of trust-wide policies and protocols, educational initiatives, targeted diabetes specialist nurse in-reach, innovative electronic whiteboard alerts for glycaemic control and electronic hypo alerts. The result was a reduction in insulin errors and hypoglycaemia on surgical wards by over 50%, a reduction in Datix incidents and fewer patients suffering harm events.Summary and conclusion: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

A prospective randomized trial comparing computerized columnar insulin dosing chart (the Atlanta protocol) versus the joint British diabetes societies for inpatient care protocol in management of hyperglycemia in patients with acute coronary syndrome admitted to cardiac care unit in Alexandria, Egypt

BackgroundHyperglycemia in acute coronary syndrome (ACS) is linked to raised morbidity and mortality. Insulin administration using insulin infusion protocols (IIP) is the preferred strategy to control hyperglycemia in critically ill patients. To date, no specific IIP has been identified as the most efficient for achieving glycemic control. Aimto compare glycemic achievements (safety) (primary objective), and coronary and other clinical outcomes (efficacy) (secondary objective) by hyperglycemia management in Cardiac Care Unit (CCU) using computerized Atlanta Protocol (Group (I)) versus paper-based Joint British Diabetes Societies (JBDS) For Inpatient Care Protocol (Group (II)). Patients and methodsThe study was done on 100 ACS patients admitted to Alexandria Main University hospital CCU with RBG >180 mg/dL. They were randomized into the 2 groups in a 1:1 ratio. CBG was measured hourly for 72 hours and was managed by IV insulin infusion. ResultsGroup (I) showed statistically significant less mean time for target BG achievement (3.52 ± 1.53hours), lower incidence of Level 1 hypoglycemia (2%) than Group (II) (4.76 ± 2.33 hours, 22%, p = 0.013, 0.002 respectively) and statistically significant less mean number of episodes above the glycemic target after its achievement than Group (II) (p < 0.001). Regarding Level 2 hypoglycemia the difference was not significant statistically. ConclusionBoth protocols successfully maintained target BG level with low incidence of clinically significant hypoglycemia, however, the computerized Atlanta protocol achieved better glycemic outcomes. We recommend the use of the computerized Atlanta protocol in CCU rather than JBDS for Inpatient Care Protocol whenever this is feasible.

Surveillance of diabetes with inpatients on glucocorticoids: are the JBDS audit standards being met?

AbstractGlucocorticoids (steroids) are widely prescribed in hospital inpatients but are known to be associated with the development or worsening of hyperglycaemia. Hyperglycaemia in inpatients is associated with adverse outcomes. The Joint British Diabetes Societies (JBDS) for Inpatient Care have produced guidelines on the management of steroid induced diabetes, or steroid worsened diabetes, but it is unknown how well these are followed.We conducted a single centre cross‐sectional survey to assess the prevalence of glucocorticoid use among adult – non‐COVID – patients at our institution. We wanted to assess whether glucose measurements were being taken and, if so, how frequently.We found that 59 (6.8%) of our inpatient population were on glucocorticoids. Of these 59, 14 (23.7%) had a previous diagnosis of diabetes, and only 21 (35.6%) had any glucose monitoring during the prior 24 hours. Thirteen of these 21 people (61.9%) had diabetes, and only half of these had glucose monitored at least four times per day. Only 19 of the 59 people on glucocorticoids (32.2%) had had an HbA1c measured in the preceding three months.Our data show that the audit standards set in the JBDS guidelines for management of glucose in people on glucocorticoids were generally not met. More work needs to be done to educate ward staff to improve the care for this potentially vulnerable group. Copyright © 2021 John Wiley &amp; Sons.

Diabetes: a major risk factor in trauma and orthopaedic surgery.

Diabetes mellitus is a growing epidemic and places a great burden on healthcare services in the UK. Trauma and orthopaedic surgeons find themselves dealing with patients with diabetes on an increasingly regular basis. Any level of surgical trauma can lead to a physiological stress response involving the hypothalamic-pituitary-adrenal axis. The resultant hormone releases can have negative effects on glucose homeostasis. General risks of operating on patients with diabetes include endothelial dysfunction, postoperative sepsis, impaired wound healing and cerebral ischaemia. Polytrauma patients with diabetes have a significantly greater risk of mortality than patients who do not have diabetes. Non-union of fractures is more common in patients with diabetes, as are deep-seated postoperative infections. National guidelines from the Joint British Diabetes Societies for Inpatient Care advise how to manage patients with diabetes in the perioperative period. Trauma and orthopaedic surgeons must be aware of these increased risks of operating and ensure that patients are involved in surgical decision making.

The Rowan Hillson Inpatient Safety Award 2018 for the best inpatient diabetes educational programme for healthcare professionals

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to mitigate this risk.Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the fifth national Rowan Hillson Inpatient Safety Award on the theme of the best inpatient diabetes educational initiative to improve patient safety in hospitals.Result: The winner was Kath Higgins and the team from the University Hospitals of Leicester NHS Trust for their ITS Diabetes – Inpatient Diabetes Training &amp; Support programme – an educational toolkit accessible to medical, nursing and pharmacy staff. Components included face-to-face training, e-learning module, monthly newsletter social media communications with competency document and flashcards. The initiative reduced insulin errors and in-hospital diabetic ketoacidosis. There were two teams in second position. Michael Lloyd and colleagues from St Helens and Knowsley Teaching Hospitals NHS Trust received the award for their individualised and shared insulin prescribing error feedback system, Safe Insulin TipS (SIPS), and multi-professional simulation-based training. Ruth Miller and colleagues in North West London were commended for the project to implement Diabetes 10 Point Training in Acute Hospitals across North West London. This clinically-based teaching programme provided quick training specifically designed for all hospital settings to address the commonest diabetes errors.Conclusion: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

Joint British Diabetes Societies for Inpatient Care (JBDS-IP) Clinical Guideline Inpatient care of the frail older adult with diabetes: an Executive Summary.

We present an Executive Summary of a guideline produced by a Joint British Diabetes Societies for Inpatient Care Writing Group for managing frail older inpatients with diabetes. This represents a multidisciplinary stakeholder consensus document providing more than 100 recommendations in eight areas: functional assessment and detection of frailty; preventative care: assessing risk factors and avoiding hospital admissions; general inpatient management principles; managing therapy choices for the frail older inpatient with diabetes; managing associated comorbidities and concerns; pre-operative assessment and care; discharge planning and principles of follow-up; and end of life care. The document is intended to guide effective clinical decision-making in an inpatient setting and is supported by four appendices: Appendix 1, STOPPFRAIL criteria; Appendix 2, Acute care toolkit 3-Royal College of Physicians; Appendix 3, a description of physical performance and frailty measures for routine NHS application; and Appendix 4, Inpatient Frailty Care Pathway-template. This document is expected to enhance clinical outcomes and overall health status for this vulnerable inpatient population of older people with diabetes. The full version of the guideline, including the appendices, can be found at https://abcd.care/sites/abcd.care/files/resources/Inpatient_Care_of_the_Frail_Older_Adult.pdf.

Guidelines for the management of diabetes in care homes during the Covid-19 pandemic.

The National Diabetes Stakeholders Covid‐19 Response Group was formed in early April 2020 as a rapid action by the Joint British Diabetes Societies for Inpatient Care, Diabetes UK, the Association of British Clinical Diabetologists, and Diabetes Frail to address and support the special needs of residents with diabetes in UK care homes during Covid‐19. It was obvious that the care home sector was becoming a second wave of Covid‐19 infection and that those with diabetes residing in care homes were at increased risk not only of susceptibility to infection but also to poorer outcomes. Its key purposes included minimising the morbidity and mortality associated with Covid‐19 and assisting care staff to identify those residents with diabetes at highest risk of Covid‐19 infection. The guidance was particularly created for care home managers, other care home staff, and specialist and non‐specialist community nursing teams. The guidance covers the management of hyperglycaemia by discussion of various clinical scenarios that could arise, the management of hypoglycaemia, foot care and end of life care. In addition, it outlines the conditions where hospital admission is required. The guidance should be regarded as interim and will be updated as further medical and scientific evidence becomes available.

‘Diabetes at the front door’: meeting the needs of diabetes patients in emergency

The Joint British Diabetes Societies Inpatient Care Group has produced a comprehensive and practical aid for the non‐specialist that covers the medical emergencies most likely for people with diabetes. Steve Chaplin reports.

Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group.

People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.

A regional quality improvement project to improve the standards of care for people with diabetes who are on maintenance haemodialysis

People with end-stage renal disease (ESRD) caused by diabetes account for 29.4% of people on maintenance haemodialysis (MHDx). When taking into account those with diabetes not causing ESRD, this figure rises up to 40% in some units.1 People with diabetes and kidney disease are at a particularly high risk of complications such as non-traumatic lower extremity amputation, cardiovascular events and death, with overall survival on MHDx in people with diabetes being approximately half that of their non-diabetic peers (3.7 vs 7.0 years).2–4 In 2016, guidelines were published by the Joint British Diabetes Societies in conjunction with the Renal Association, aimed at …

Characterization of variable presentations of diabetic ketoacidosis based on blood ketone levels and major society diagnostic criteria: a new view point on the assessment of diabetic ketoacidosis.

AimWe aimed to evaluate the clinical utility of blood ketone measurement and to test the performance of the diagnostic criteria for diabetic ketoacidosis (DKA) issued by the American Diabetes Association, the Joint British Diabetes Societies, and the American Association of Clinical Endocrinologists and the American College of Endocrinology.MethodsThis retrospective analysis included 278 patients with suspected DKA who were hospitalized at 4 university hospitals and aged ≥16 years with a blood glucose level of >200 mg/dL and a blood ketone level of ≥1.0 mmol/L as well as other biochemical data. The patients were categorized into four subgroups (ketosis, typical DKA, atypical DKA, and DKA + lactic acidosis). Atypical DKA in each analysis was defined by our supplementary criteria if the biochemical data did not meet each set of diagnostic criteria from the aforementioned societies.ResultsBlood ketone levels in patients with diabetic ketosis and those with DKA varied widely, 1.05–5.13 mmol/L and 1.02–15.9 mmol/L, respectively. Additionally, there were significant discrepancies between the guidelines in the diagnosis of DKA. Thus, the proportion of patients with atypical DKA ranged from 16.5% to 42.4%. Notably, the in-hospital mortality was comparable between patients with typical and atypical DKA, with a very high mortality in patients with DKA + lactic acidosis (blood lactate >5 mmol/L).ConclusionsOur results showed that considering variable presentations of DKA, blood ketone data need to be interpreted cautiously along with other biochemical data and suggested that a new system is required to better characterize DKA.

Variable rate insulin infusions on medical and surgical wards: are we getting it right?

A quality improvement project undertaken at University Hospital Birmingham to improve the management of patients on variable rate intravenous insulin infusions (VRIII) to allow a consistent standard of care in keeping with Joint British Diabetes Societies guidelines. An initial baseline of data was identified from the database; any episode where a patient was started on a VRIII over a 10-week period from 1 September to 10 November 2016. ITU patients and those on a scale for less than 1 hour were excluded. …

Inpatient hypoglycaemia; should we should we focus on the guidelines, the targets or our tools?

In their thought‐provoking commentary, Levy et al. [1] explore the possible unintended consequences of United Kingdom (UK) guideline targets on the high frequency of hypoglycaemia in people with diabetes who are hospitalized. The authors cite the National Institute for Health and Care Excellence (NICE) and the Joint British Diabetes Societies (JBDS) guidelines pertaining to inpatient, surgical and pregnancy diabetes care. These guidelines suggest using lower limits of glucose targets varying from 4.0 to 6.0 mmol/l [2–4]. Levy et al. propose a lower glucose limit of 5 mmol/l with the catchphrase ‘stop at 5 and keep the inpatient alive’.

The best joint pharmacy and diabetes team initiative to improve insulin and prescribing safety in hospital

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to address this risk.Methods: The Joint British Diabetes Societies for In-Patient Care (JBDS-IP) organised the third national Rowan Hillson Insulin Safety Award on the theme of the best joint pharmacy and diabetes team initiative to improve insulin and prescribing safety in hospital.Results: There were two winners (Derby and Sheffield teams) and one runner up (St George’s Hospital team). The Derby team won by showing improvements in NaDIA-reported data on medication, prescription, glucose management and insulin errors by a combination of electronic prescribing, staff education and regular audits. The Sheffield team improved self-administration of insulin by a pharmacist-led programme. The St George’s Hospital team improved patient safety by a dedicated pharmacist-supported programme for peri-operative patients.Conclusions: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

The Rowan Hillson Inpatient Diabetes Safety Award 2017 for the best digital initiative

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to address this risk.Methods: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the fourth national Rowan Hillson Insulin Safety Award on the theme of the best digital initiative to improve insulin and prescribing safety in hospital.Results: The winner was Western General Hospital team (Edinburgh). The team created diabetes dashboards which helped collect high quality accurate data on capillary blood glucose from patients admitted to the hospital and deliver specific and concise messages to various wards. The team from King’s College Hospital secured runner-up prize for their initiative which enabled reduction in hypoglycaemia during treatment of hyperkalaemia by adding a personalised dose of dextrose to insulin infusion.Conclusions: These and similar innovations need to be developed, promoted and shared to improve patient safety in hospitalised patients with diabetes.

Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings.

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Careguidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes.

Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group.

Glucocorticoids (steroids) are widely used across many medical specialities for their anti-inflammatory and immunosuppressive properties. However, one of their major side effects is the development of hyperglycaemia. It is well recognized that high glucose levels in people with diabetes in hospital are associated with harm and increased lengths of hospital stay. The use of glucocorticoid (steroid) treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control, and this may be termed 'steroid-induced hyperglycaemia', and will warrant temporary additional, and more active, glycaemic management. A rise in glucose may occur in people without a known diagnosis of diabetes, and this may be termed 'steroid-induced diabetes'. There is a lack of evidence to guide how people with hyperglycaemia should be managed, and much of the guidance given here is a consensus based on best practice collated from around the United Kingdom. Where evidence is available, this is referenced. These guidelines on the management of people with diabetes treated with steroids has been adapted specifically for Diabetic Medicine. The full version of the guidelines can be found on line at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group.

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

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, withcomplex comorbidities, and are at high risk of adverse cardiovascular outcomes, 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 professionalsproviding 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 end-stage renal failure require improved delivery of care to overcome organizational 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 people with diabetes on maintenance haemodialysis. The guidelines are 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 people with diabetes to promote empowerment and self-management.