Joint British Diabetes Societies for Inpatient Care: clinical guidelines and improving inpatient diabetes care

Technology in the management of diabetes in hospitalised adults

Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.

Outcome of Diabetic Keto Acidosis Treatment and Associated Factors Among Adult Patients Admitted to Emergency and Medical Wards at St. Paul's Hospital, Addis Ababa Ethiopia, 2023: A Cross-Sectional Study

Background

Diabetic ketoacidosis is a potentially fatal disease that affects adults. Therefore, rapid detection and treatment are required to decrease mortality rates. Most of the earlier research on diabetic ketoacidosis in Ethiopia concentrated on its prevalence and associated factors. This study aimed to assess the treatment outcomes of diabetic ketoacidosis and its associated factors in adult patients admitted to St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, in 2023.

Methods

This institution-based retrospective cross-sectional study was conducted with a sample size of 357. The data were entered in Epidata version 4.6 and exported to the Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Adjusted Odds Ratio (AOR) with a 95% confidence interval was estimated to determine its association with outcome of treatment.

Results

Three hundred fifty-seven diabetic ketoacidosis patients' charts were reviewed. Fourteen (3.9%) diabetic ketoacidosis (DKA) patients had died. Those Patients with diabetic ketoacidosis who had acute comorbidity (presence of sepsis) (AOR = 3.24, 95% CI: 1.20-10.2), international unit (IU) insulin administration in the 1st 24 hours (AOR = 8.046, 95% CI: 3.881-25.32), fluid replacement in the 1st 24 hours (AOR = 5.84, 95% CI: 1.53-10.07), and potassium replacement (AOR = 3.08, 95% CI: 1.835-5.817) were independently associated with treatment outcome of diabetic ketoacidosis. Insulin administration for the first 24 hours more than >60 IU insulin showed improvement in treatment outcome by 8.04 times more likely than less <60 IU insulin administration for the first 24 hours. More >6 liters fluid replacement in the first 24 hours had improvement in treatment outcome by 5.84 times more likely than <6 liters fluid replacement.

Conclusion

A considerable proportion of the patients with diabetic ketoacidosis died at St. Paul's hospital millennium medical college. Stakeholders must emphasize the treatment of patients with diabetes (diabetic ketoacidosis), according to the recommendations of local and international guidelines.

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 (3.0-8.0 mOsm/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 ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Point of care blood glucose devices in the hospital setting

Dysglycemia is common among hospitalized patients. Accurate point-of-care (POC) glucose monitoring is necessary for the safe administration of insulin. Unfortunately, POC glucose meters are not all created equal. Interfering factors such as abnormal hematocrit, abnormal oxygen tension, and oxidizing/reducing substances can lead to inaccurate glucose measurements and result in inappropriate insulin dosing. The introduction of autocorrecting glucose meters has changed the POC testing landscape. Autocorrecting glucose meters provide more accurate measurements and have been associated with improved glycemic control in hospitalized patients. Continuous glucose monitoring has also created interest in using these platforms in at-risk inpatient populations. Future glucose monitoring technologies such as artificial intelligence/machine learning, wearable smart devices, and closed-loop insulin management systems are poised to transform glycemic management. The goal of this review is to provide an overview of glucose monitoring technology, summarize the clinical impact of glucose monitoring accuracy, and highlight emerging and future POC glucose monitoring technologies.

Safety and Efficacy of Inpatient Diabetes Management with Non-insulin Agents: an Overview of International Practices

PURPOSE OF REVIEW

The field of inpatient diabetes has advanced significantly over the last 20 years, leading to the development of personalized treatment approaches. However, outdated guidelines still recommend the use of basal-bolus insulin therapy as the preferred treatment approach, and against the use of non-insulin anti-hyperglycemic agents.

RECENT FINDINGS

Several observational and prospective randomized controlled studies have demonstrated that oral anti-hyperglycemic agents are widely used in the hospital, including studies of DPP-4 agents and GLP-1 agonists. With advances in the field of inpatient diabetes management, a paradigm shift has occurred, from an approach of recommending "basal-bolus regimens" for all patients to a more precision medicine option for hospitalized non-critically ill patients with type 2 diabetes.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background

The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.

Methods

This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.

Results

The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.

Conclusions

VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07883-w.

Safe care for people with diabetes in hospital

Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm - however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.

Detailed analysis of 'work as imagined' in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis

OBJECTIVE

Variable rate intravenous insulin infusions (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Healthcare, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIII is perceived to be used by healthcare practitioners, focusing on one aspect of Resilient Healthcare: understanding how work is assumed to be done, using a method called hierarchical task analysis (HTA).

DESIGN

A qualitative study using document analysis and focus groups.

SETTING

A vascular surgery unit in an acute National Health Service teaching hospital in the UK.

PARTICIPANTS

Stakeholders/users in different professional roles involved in the process of using VRIII.

RESULTS

The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations, for example, proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care.

CONCLUSION

Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIII is used and to understand how adaptations are made in relation to the use of VRIII.

Perioperative hyperglycaemia in elective arthroplasties. Should we do better?

BACKGROUND

Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty.

METHODS

Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed.

RESULTS

A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (>10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%) >10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c < 42 mmol/mol and random plasma glucose < 7.8 mmol/l. Of the 84 hyperglycaemic episodes > 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed.

CONCLUSIONS

Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists.

CLINICAL TRIAL REGISTRATION

Clinical trials, gov. NCT03306810.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.