Diabetes Specialist Team Research Articles

Diabetes‐related distress in people with type 2 diabetes: experience from a community diabetes clinic

AbstractBackground: Diabetes distress is the term used to describe the diabetes‐specific emotional distress resulting from the challenges of managing this demanding chronic condition.Aims: This study aimed to determine the prevalence of diabetes distress and its subtypes in adults with type 2 diabetes who attended our community‐based clinics and to investigate the relationship between diabetes distress scores and demographic factors and diabetes variables (HbA1c and treatment regimen).Methods: Patients were referred to our specialist diabetes team by primary care teams. Clinical details, including current treatment regimen and recent HbA1c result, were recorded. Patients then completed the Diabetes Distress Scale (DDS) 17 questionnaire. Data from all 82 patients who attended our clinic from May 2022 to November 2022 were analysed.Results: A high level of diabetes distress (mean score of ≥3) was found in 17 patients (20.7%), and a moderate level of diabetes distress was found in 22 patients (26.8%). Patients with an HbA1c of >90mmol/mol had significantly higher mean regimen‐related distress than those with an HbA1c of <60mmol/mol (2.58±1.18 vs 1.86±0.8, respectively; p=0.03). In addition, patients with higher HbA1c had higher diabetes‐related emotional distress than those with lower HbA1c. However, this result did not demonstrate statistical significance. Conversely, patients with optimal HbA1c levels had significantly lower mean interpersonal distress scores than the rest of the cohort (1.13±0.99 vs 1.80±0.99, respectively; p=0.01).Conclusions: Diabetes distress is common among patients attending community‐based diabetes services. Further research is needed to determine the most effective strategies for reducing diabetes distress and improving clinical outcomes.

Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team

Pancreatic surgery units undertake several complex operations, albeit with considerable morbidity and mortality, as is the case for the management of complicated acute pancreatitis or chronic pancreatitis. The centralisation of pancreatic surgery services, with the development of designated large-volume centres, has contributed to significantly improved outcomes. In this editorial, we discuss the complex associations between diabetes mellitus (DM) and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis, highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services. Type 3c pancreatogenic DM, refers to DM developing in the setting of exocrine pancreatic disease, and its identification and management can be challenging, while the glycaemic control of such patients may affect their course of treatment and outcome. Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period. The incidence of new onset diabetes after pancreatic resection is widely variable in the literature, and depends on the type and extent of pancreatic resection, as is the case with pancreatic parenchymal loss in the context of severe pancreatitis. Early involvement of a specialist diabetes team is essential to ensure a holistic management. In the current era, large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery, with inclusion of provisions for optimisation of the perioperative glycaemic control, to improve outcomes. While various guidelines are available to aid perioperative management of DM, auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement. The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined, a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis. Therefore, pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams. With the ongoing accumulation of evidence, it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.

Queensland Inpatient Diabetes Survey (QuIDS): patient experience survey evaluation.

Measurement of inpatient experience can allow for treatment tailored to patient preferences and needs. The patient experience of diabetes care has not been explored in Queensland hospitals. To investigate the experiences of patients with diabetes when hospitalised using the Queensland Inpatient Diabetes Survey (QuIDS). In 2019 and 2021, patient experience surveys were collected as part of the statewide QuIDS, a cross-sectional study assessing the quality of inpatient care received by people with diabetes in Queensland, Australia. Patient responses were categorised and frequencies reported as percentages. Free text comments were analysed using thematic analysis methods. Pooled descriptive data were presented. Responses were collected from 27 hospitals in 2019 (n = 526, 52.4% of all patients with diabetes) and 35 hospitals in 2021 (n = 709, 55.5%). Overall, patients were satisfied with their inpatient diabetes care. Areas for improvement identified by surveyed patients include the choice and timing of meals, staff knowledge about diabetes and increased diabetes self-management. Access to a specialist diabetes team was also identified as being potentially underutilised. Patient comments fell into four major themes: communication, food choices, patient autonomy and education. Many patients reported positive inpatient experiences; however, patients also expressed dissatisfaction with their inpatient diabetes care. Our data provide unique insight and an opportunity to improve standards of care and service provision for inpatients with diabetes.

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.

A cluster randomised controlled trial, process and economic evaluation of quality improvement collaboratives aligned to a national audit to improve the care for people with diabetes (EQUIPD): study protocol

BackgroundPeople with type 1 diabetes and raised glucose levels are at greater risk of retinopathy, nephropathy, neuropathy, cardiovascular disease, sexual health problems and foot disease. The UK National Institute for Health and Care Excellence (NICE) recommends continuous subcutaneous ‘insulin pump’ therapy for people with type 1 diabetes whose HbA1c is above 69 mmol/mol. Insulin pump use can improve quality of life, cut cardiovascular risk and increase treatment satisfaction. About 90,000 people in England and Wales meet NICE criteria for insulin pumps but do not use one. Insulin pump use also varies markedly by deprivation, ethnicity, sex and location. Increasing insulin pump use is a key improvement priority.Audit and feedback is a common but variably effective intervention. Limited capabilities of healthcare providers to mount effective responses to feedback from national audits, such as the National Diabetes Audit (NDA), undermines efforts to improve care. We have co-developed a theoretically and empirically informed quality improvement collaborative (QIC) to strengthen local responses to feedback with patients and carers, national audits and healthcare providers. We will evaluate whether the QIC improves the uptake of insulin pumps following NDA feedback.MethodsWe will undertake an efficient cluster randomised trial using routine data. The QIC will be delivered alongside the NDA to specialist diabetes teams in England and Wales. Our primary outcome will be the proportion of people with type 1 diabetes and an HbA1c above 69 mmol/mol who start and continue insulin pump use during the 18-month intervention period. Secondary outcomes will assess change in glucose control and duration of pump use. Subgroup analyses will explore impacts upon inequalities by ethnicity, sex, age and deprivation. A theory-informed process evaluation will explore diabetes specialist teams’ engagement, implementation, fidelity and tailoring through observations, interviews, surveys and documentary analysis. An economic evaluation will micro-cost the QIC, estimate cost-effectiveness of NDA feedback with QIC and estimate the budget impact of NHS-wide QIC roll out.DiscussionOur study responds to a need for more head-to-head trials of different ways of reinforcing feedback delivery. Our findings will have implications for other large-scale audit and feedback programmes.Trial registrationISRCTN82176651 Registered 18 October 2022.

#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.

Individualized assessment and optimization of post myocardial infarction care by introducing a hybrid clinic - A DGH experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Optimal secondary prevention remains key in improving cardiovascular outcomes post myocardial infarction. Barriers to achieving timely and individualized medical optimization include unavailability of close follow up’s, compliance to secondary prevention, and more recently, the impact of COVID pandemic on outpatient face to face clinic appointments. With the recent emphasis from the European Society of Cardiology on secondary prevention in addition to optimizing lipid therapy, a dedicated service for post MI patients to address individualized risks can provide a timely opportunity to improve holistic cardiovascular care. Purpose To assess established secondary prevention practices, we initially audited 52 patients who presented with ACS between Jan 2020 and July 2020. These patients were assessed for post MI care optimization at 6 weeks post discharge. Utilizing ESC guidelines as audit targets, in our 6-week post discharge audit, we identified that there was scope of ACE-inhibitor up titration in 55.8% of the patients, beta-blocker optimization in 9.6%, Lipid lowering agents in 15.4%, mineralocorticoid receptor antagonist addition in patients with impaired LV systolic function in 5.8% of the patients. 5% of patients with new diagnosis of diabetes required referral to specialist teams for diabetic medication initiation or optimization. These results provided an opportunity to introduce a structured post MI clinic that will allow individualized risk assessment on an outpatient basis. Method We proposed a one stop hybrid clinic where all patients discharged following a myocardial infarction received a consultation 6 – 8 weeks following a discharge. These patients were sent blood forms 2-3 weeks prior to their appointment for full blood count levels, renal functions, liver profile, HBa1c levels and lipid profile. Focus of this consultation was to assess and educate the patient on risk factors (smoking, diabetes, cardiac rehab program), assess and address compliance to secondary prevention medications and finally titrate medications to maximum tolerated doses whilst achieving ESC defined targets for secondary prevention (post MI target systolic BP&amp;lt;140mmHg in non diabetics and &amp;lt;130mmHg in diabetics, LDLc &amp;lt;1.4, smoking cessation, HBa1c &amp;lt;49). Where appropriately identified, referral to lipid specialist and diabetes specialist teams were made to provide holistic multi-disciplinary management. Results To understand the Impact made by the clinic we obtained patient list through local electronic records to filter those discharged with a primary diagnosis of myocardial infarction in 2022. An audit tool was created and data collection was performed including baseline characteristics as per table 1 and interventions made Table 2. Conclusion(s) By establishing the post MI clinic we were able to demonstrate efficient individualized assessment and optimization of secondary prevention risk factors and pharmacotherapy.

The Role Of The Diabetes Specialist Team In The Modern Management Of Diabetes Mellitus: A Call For Its Implementation In Ghana

Many chronic illnesses require patient-centred care where behavioural change aimed at dealing and coping with the socio-psychological as well as the physical impact of the disease is emphasized.&#x0D; Diabetes presents such a challenge especially in the developing world where both human and material resources are limited in dealing with this complex disease. Most centres in Ghana and Africa in general, rely on overburdened practitioners who have responsibilities to other acute and chronic illnesses in addition to diabetes care.&#x0D; The Diabetes Specialist Team (DST) has become a tool in overcoming these complexities to improve care and outcomes. They work in a team with specialised and sometimes overlapping skills. Core members include Consultant physician diabetologists, specialist diabetes nurses, podiatrists, dieticians and clinical psychologists.&#x0D; The positive impact of DST is noticed in the aspects of diabetes preventive services, early diagnosis, patient education, medication use, risk factor and complication identification and management, together with in-patient care and management of special groups.&#x0D; Recognising that the needs of persons living with diabetes are under served, coupled with the fact that developing countries are expected to experience the greatest burden in terms of numbers and complications of diabetes, more resources are needed to reverse these expected grim statistics. Efforts should be made to develop and deploy DST as much as possible to provide specialised and dedicated services in the routine management of diabetes at least at the district or municipal health level. Resources are needed to maintain and snowball the impact of this approach.

Evaluating the Effectiveness of Joint Specialist Case Conferences in Improving Diabetes Control in Patients With Schizophrenia on Clozapine.

Clozapine treatment for schizophrenia is typically long-term and is associated with a high rate of diabetes. Mental health and diabetes specialist teams at a local hospital in Australia have undertaken a series of joint specialist case conferences (JSCCs) where the diabetes team works with the psychiatry team to improve diabetes management. In this retrospective cohort study conducted between 2013 and 2018, we found that glycemic control in clozapine clinics linked with JSCCs was improved significantly compared with that in the non-JSCC clinics. In the non-JSCC clozapine clinics (control), the poor glycemic control rates stayed at a similar level: 23% in 2013 and 24% in 2018. In contrast, whereas the control patients' poor glycemic rate in JSCC clozapine clinics in 2013 was 24%, it decreased markedly in 2018 to 13%. This study indicates that JSCCs can improve diabetes outcomes in a group of patients with severe mental illness.

Integrated diabetes care: The Association of British Clinical Diabetologists (ABCD) national survey report

Executive Summary A national survey on integrated diabetes services was carried out by the Association of British Clinical Diabetologists (ABCD) during the COVID-19 pandemic and has provided some very useful insights into the current state of integration to deliver a joined-up diabetes service in the UK. This survey was carried out during the second half of 2020 and explored three main areas: (1) current state of clinical integration between primary and secondary (specialist) diabetes services; (2) the state of IT integration among the diabetes IT systems and hospital-based electronic patient records (EPR) and between hospital and primary care; (3) to ascertain the membership of their views on a ‘one-stop service’ for collecting annual review data for diabetes and the potential barriers to achieve this. The results presented are a summary of the survey, while the full unedited survey report, especially on the qualitative aspects, is available to ABCD members. The survey was mailed to 518 individuals, of which 431 (83.2%) were consultants and 53 (10.2%) were specialist registrars. Of the 83 replies received, 98% were from consultants and the responses represented a total of 73 hospital diabetes services. The findings of this survey revealed that full integration of clinical services among primary care and specialist diabetes teams is uncommon, although there are good examples of clinical integration in different formats. In a number of areas, primary care and specialist diabetes services continue to work in silos despite a universal recognition that integrated services are desirable and are likely to improve quality of care. Clinical leadership, resources and buy-in from those who commission services were deemed important factors to help improve the development of integrated care systems. In hospitals with dedicated diabetes IT systems the information flow from these diabetes systems to the EPR was not universal, raising concerns that vital information about an individual’s diabetes may not be available to other hospital clinical specialities at the time of delivery of care, posing a significant clinical risk. IT integration among primary and specialist diabetes teams in England was only available in certain areas and was mostly based around the use of SystmOne. The survey also identified a diversity of opinions regarding the current arrangements of the Quality Outcome Framework (QOF), where GPs are incentivised to collect data for annual review of routine diabetes care. Many were of the opinion that annual review processes should be performed by clinical teams who are tasked to deliver diabetes care to the individual, while others felt that the status quo should continue with primary care GPs being responsible. A one-stop service for eye screening for diabetes and other annual measurements nearer to people’s homes was identified as an improvement, but several logistic barriers were identified. We recognise the limitations of any survey which expresses opinions of participants. However, we believe the present survey represents a significant proportion of diabetes units in the UK and provides insights into the current state of integrated services in diabetes. There are significant learnings for diabetes communities, and the information can be used to improve and galvanise delivery of integrated diabetes care in the UK.

The Queensland Inpatient Diabetes Survey (QuIDS) 2019: the bedside audit of practice

To assess the quality of care for patients with diabetes in Queensland hospitals, including blood glucose control, rates of hospital-acquired harm, the incidence of insulin prescription and management errors, and appropriate foot and peri-operative care. Cross-sectional audit of 27 public hospitals in Queensland: four of five tertiary/quaternary referral centres, four of seven large regional or outer metropolitan hospitals, seven of 13 smaller outer metropolitan or small regional hospitals, and 12 of 88 hospitals in rural or remote locations. 850 adult inpatients with diabetes mellitus in medical, surgical, mental health, high dependency, or intensive care wards. Twenty-seven of 115 public hospitals that admit acute inpatients participated in the audit, including 4175 of 6652 eligible acute hospital beds in Queensland. A total of 1003 patients had diabetes (24%), and data were collected for 850 (85%). Their mean age was 65.9 years (SD, 15.1 years), 357 were women (42%), and their mean HbA1c level was 66mmol/mol (SD, 26mmol/mol). Rates of good diabetes days (appropriate monitoring, no more than one blood glucose measurement greater than 10mmol/L, and none below 5mmol/L) were low in patients with type 1 diabetes (22.1 per 100 patient-days) or type 2 diabetes treated with insulin (40.1 per 100 patient-days); hypoglycaemia rates were high for patients with type 1 diabetes mellitus (24.1 episodes per 100 patient-days). One or more medication errors were identified for 201 patients (32%), including insulin prescribing errors for 127 patients (39%). Four patients with type 1 diabetes experienced diabetic ketoacidosis in hospital (8%); 121 patients (14%) met the criteria for review by a specialist diabetes team but were not reviewed by any diabetes specialist (medical, nursing, allied health). We identified several deficits in inpatient diabetes management in Queensland, including high rates of medication error and hospital-acquired harm and low rates of appropriate glycaemic control, particularly for patients treated with insulin. These deficits require attention, and ongoing evaluation of outcomes is necessary.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study.

BackgroundPeople with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.AimTo identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.Design & settingThirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).MethodFactors precipitating admissions were examined using framework analysis.ResultsThree aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services — in time and proximity — and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.ConclusionDedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Diabetes management during cardiac surgery in the UK: A survey

To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK. We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively. Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA1c preoperatively for all patients, 19% had an HbA1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy. The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306).

New Guidance on Managing Inpatient Hyperglycaemia during the COVID‐19 Pandemic

The COVID-19 pandemic has had a dramatic impact on the provision of acute inpatient care with specialists from all disciplines having to manage patients outside of their usual speciality areas. In many UK hospitals diabetes consultants and diabetes inpatient specialist nurses have been redeployed to the wards to care for COVID-19 positive or suspected cases. Consequently, clinicians relatively unfamiliar with managing hyperglycaemia have been required to do so as the usual input from diabetes specialist teams has not been possible in many areas. The National Diabetes Inpatient COVID-19 Response Group was formed to provide guidance to those involved in the care of inpatients with diabetes during this crisis. We have published in a previous issue of this journal guidance on care at the ‘front door’ aimed at emergency departments and admitting teams [1]. We now present guidance on the management of inpatient hyperglycaemia (Figure 1). We recognise that most hospitals will already have established local guidance in place. The current guidance is intended to help supplement and update existing guidance with a particular reference to supporting those less experienced in insulin use. In this respect, it is tailored to manage hyperglycaemia but as much as possible reducing the risk of overcorrection resulting in hypoglycaemia. It thus sets more liberal glycaemic targets than have been suggested in previous UK guidelines [2]. The COVID specific diabetes algorithms aim to achieve a ‘lower’ target of 6.0 mmol/L (higher than the previous of 4.0mmol/L) yet to keep blood glucose levels less than 10.0 mmol/L with up to 12.0 mmol/L being acceptable. Uniquely, it provides 3 different correction regimes for rapid acting analogue insulin based on the information available to the clinician. Firstly, if the person with diabetes knows their own ‘correction dose’ this should be used (e.g. for people with type 1 diabetes who are DAFNE trained, 1 unit reduces the blood glucose by 3.0 mmol/L). Secondly, if the total daily dose is known the correction is based on intervals of less than 50 units/day, 50-100 units/day and over 100 units/day. Finally, where none of the previous are known, the correction is based on weight with intervals of less than 50 kg, 50-100 kg and > 100 kg (for insulin naïve people or those newly presenting). The guidance recommends commencement of a basal insulin if hyperglycaemia persists after several correction doses of rapid acting insulin within a 24 hr period. The algorithm recommends a starting dose related to the person’s weight and specific issues such as age, fragility and renal function. There are then dosing regimens related to the particular basal insulin available in individual hospitals. There is also a dose adjustment regimen for the basal regimen based on the blood glucose levels immediately prior to the timing of the basal insulin. Finally, the guidance recognises that the insulin dose may need adjustment, particularly the basal insulin dose when there is a change in insulin sensitivity such as can occur with improving infection, reduction in corticosteroid treatment and in those recovering from COVID-19 related insulin resistance. Although, this guidance has been introduced for use during the present pandemic it is possible that this more judicious glucose target that has been previously advocated by some [3] and the early intervention with basal insulin may become the established guidance for the future.

1237-P: The Type 1 Diabetes Identification Initiative: Improving the Care of Inpatients with Type 1 Diabetes

Background: Specialist care may improve outcomes for inpatients with diabetes. However, research specific to type 1 diabetes (T1D) is lacking. We aimed to investigate whether automatic alerts from the Electronic Medical Record (EMR) enable prompt review of inpatients with T1D by a specialist diabetes team. Methods: The type 1 diabetes identification (“T1DI”) initiative was established to improve identification and review of inpatients with T1D by a specialist diabetes team. A specific T1DI code was entered into the EMR of patients with T1D. On subsequent admission, the specialist diabetes team received an automatic message and generated a list of inpatients requiring review. “T1DI” admissions of more than 1-day were analysed over a 1-year period (1 January-31 December 2018). The control group was T1D admissions as coded by health information services following discharge. Analysis was performed for patients admitted to units other than endocrinology to investigate review outcomes. Data was analysed using Chi2 (categorical), Wilcoxon rank sum (continuous) and random effects logistic or negative binomial regression models. Results: There were 136 admissions of adults with T1D over the study period (T1DI n=67, control n=69). The median age was 49 (IQR 33-64) years; 53% were females. Specialist diabetes team review was more common in the T1DI cohort compared to the control group (endocrinology review AOR 10.27, CI 2.26-46.55, P=0.003; diabetes education review AOR 7.22, CI 2.73-19.10, P&amp;lt;0.001). Prompt endocrinology review (no later than day 2 of admission) was more likely in T1DI inpatients (AOR 2.77, CI 1.15-6.65, P=0.023). Conclusion: The T1DI initiative was associated with improvements in occurrence and timing of specialist diabetes team review for inpatients with T1D. This initiative could be implemented in other hospitals with EMR systems, enabling more effective identification and management of T1D in the inpatient setting. Disclosure R. Loveridge: None. N. Torkamani: None. S.L. Patterson: None. L. Churilov: None. E.I. Ekinci: None.

COVID‐19: diabetes and death. A call to action

<scp>COVID</scp>‐19: diabetes and death. A call to action

Multidisciplinary healthcare teams' challenges and strategies in supporting people with type 1 diabetes to recover from disordered eating.

To examine the challenges healthcare teams face when treating people with type 1 diabetes and disordered eating and the strategies these teams have developed to facilitate effective treatment. Four semi-structured focus groups were conducted including two tertiary diabetes specialist teams and three tertiary eating disorders specialist teams between July and December 2018. Thematic analysis of the transcripts followed a six-phase process. Twenty-nine experienced healthcare professionals (16 diabetes and 13 eating disorder specialists, 16±12 years' professional experience) were interviewed. The challenges identified in treating people with type 1 diabetes and disordered eating included subthemes the 'challenges specific to the healthcare professional' (feeling not competent enough and perceived emotional burden), 'challenges pertaining to patient factors' (e.g. difficulties with engaging in therapy) and 'challenges created by the healthcare system' (time pressure and staff shortage). Healthcare professionals expressed the need for a consensus on diagnosis and the definition of disordered eating in type 1 diabetes, as well as the need for training and educational resources specific to type 1 diabetes and disordered eating. Healthcare professionals gave practical examples of strategies of communication for better patient engagement and felt that multidisciplinary working in joint clinics with the other specialty were facilitators for recovery from disordered eating. Healthcare professionals require multidisciplinary team support when treating people with type 1 diabetes and to improve their own competencies. The development of effective screening and assessment tools, educational resources and training for healthcare professionals, and developing multidisciplinary treatment pathways will be key to improving outcomes for their service users with type 1 diabetes and disordered eating.

Do patients receiving laser treatment for sight threatening diabetic retinopathy and those under the care of a consultant led multidisciplinary diabetes specialist team have better HbA1c value than those that are not under a diabetes specialist?

AbstractPurposeTo evaluate if patients with sight threatening diabetic retinopathy who undergo laser photocoagulation treatment and are under the care of a consultant‐led specialist diabetes team have a better HbA1c value than those that are not under a specialist diabetes team.MethodsRetrospective review of all patients who underwent pan laser photocoagulation (PRP) treatment or macular laser therapy between 1st January 2018 and 31st December 2018 were included in the study.ResultsWe identified 64 patients who underwent laser treatment for diabetic retinopathy in the 12‐month period, 21 female and 43 male. Of these, 36 patients (56%) had type‐2 diabetes, 12 patients (18%) had type‐1 diabetes and in 16 patients (25%), this was undocumented. In terms of type of laser therapy, 50 (78%) underwent PRP and 14 (22%) underwent macular laser. 33 patients (51%) who underwent laser treatment were under the care of a specialist diabetes team within 1 year of receiving treatment. The average HbA1c value of patients who were under a diabetes specialist was 80.9 mmol/mol (9.6%), versus those who were not under a diabetes specialist was 72.7 mmol/mol (8.8%).ConclusionOur study showed that amongst patients who underwent laser treatment for sight threatening diabetic retinopathy, majority underwent pan retinal photocoagulation for proliferative disease rather than macular laser for maculopathy. This observation is expected, as macular laser is less commonly practiced since the advent of anti‐VEGF therapy for diabetic maculopathy. Surprisingly, the HbA1c values on average were better in those who were not under a specialist diabetes team compared to those who were under the care of a specialist. Although this is unexpected, it may be explained by the fact that those under a diabetes team have poorer control of their blood sugars, and/or more advanced diabetes to begin with.

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.

Effects of link nurses guided working mode on improving the nursing quality of diabetic care in hospital

Objective To explore the effect of link nurses guided working mode on the improvement of diabetic knowledge and skills in nurses and the nursing quality of clinical diabetic care. Methods The 433 N1 nurses and 67 patients who received training in 2015 were selected as control group; the 433 N1 nurses and 67 patients who were trained in 2016 were enrolled as observation group. The control group was trained with the diabetes specialist team core members guided mode, while the observation group used the mode guided by the diabetes link nurses. The results of the theoretical and skill assessment, the qualified rate of reaching nursing quality, and the qualified rate of patients health education were compared between the two groups. Results In nursing theoretical knowledge, the observation group (qualified rate of 95.2%) was better than the control group (78.5%) , and the difference was statistically significant (P<0.01) . In practice skills, the qualified rates of the use of insulin and blood glucose meter of the observation group were 93.3% and 91.5% respectively, which were higher than those of the control group (61.7% and 67.2%) , the differences were statistically significant (P<0.01) . The qualified rates of nursing quality and patients health knowledge of the observation group were all higher than those of the control group, with statistical significance (P<0.01) . Conclusions The working mode guided by diabetes link nurses can effectively increase the diabetes knowledge and skills and nursing quality in nurses who are not from endocrinology department. Key words: Diabetes mellitus; Link nurses; Nursing quality