Diabetes

Background

Perioperative management of diabetes is a strong predictor of post-operative outcomes for patients undergoing major elective surgery. The national confidential enquiry into patient outcome and death (NCEPOD) has specific recommendations for diabetes care in the perioperative phase. We aimed to audit current practice in East Sussex Healthcare Trust (ESHT) against these recommendations prior to the introduction of a recognised programme designed to improve the perioperative pathway for patients with diabetes (IP3D).

Methods

A retrospective audit of 30 patients with diabetes who underwent major orthopaedic or colorectal surgery. Data was collected on basic demographics, quality of initial referral, preoperative assessment, intraoperative diabetes management and postoperative recovery.

Results

Mean patient age was 73 (57-91), with the majority having type-2 diabetes (93%, n=28). Initial referral letters mentioned diabetes in 77% (n=23) of cases; 7% (n=2) included the latest HbA1c. 97% (n=29) had a pre-operative HbA1c; mean was 50.9mmol/mol (39-74). 43% (n=13) of patients were scheduled in the first third of the operating list. Blood glucose was measured preoperatively in 93% (n=28), intraoperatively in 40% (n=12) and postoperatively in 77% (n=23). Postoperatively, three patients had hypoglycaemic events and five had hyperglycaemic events. One patient had deficient wound healing due to poorly controlled diabetes.

Conclusions

Perioperative management of patients with diabetes at ESHT does not currently meet the NCEPOD standards. This shortfall will be addressed by the implementation of the IP3D programme and supported by a perioperative diabetes specialist nurse. The programme will focus on educating and supporting patients perioperatively whilst improving diabetes knowledge amongst surgical staff.

Introduction

One in four Care Home (CH) residents have diabetes, making diet crucial for controlling glucose levels (GLs). Continuous blood glucose monitoring (CGM) now offers deeper insights into GL fluctuations. Diabetes in severe frailty is often overtreated, particularly with insulin, posing risks such as hypoglycemia, avoidable hospital admissions, and labour-intensive clinical supervision. While protein and vegetables can slow glucose absorption, dietary advice for CH residents typically emphasizes carbohydrates and may not be tailored to their frailty. This study investigates the impact of modifying protein intake in insulin-using diabetics to improve glycaemic control.

Method

A small pilot study assessed if protein-rich foods (e.g. eggs, peanut butter) given for breakfast stabilise GLs throughout the day. Eight diabetic CH residents using insulin were randomly selected over four months. A diabetic frailty pharmacist monitored GLs with the CGM device (Freestyle Libre) and analysed GLs after a protein-rich breakfast. Descriptive analysis and t-tests were conducted using R before and after the food intervention, and ANOVA was used to analyse significant differences in GLs.

Results

Six out of eight patients showed statistically significant reductions in GL spikes, sustained throughout the day. For the remaining two patients, the food intervention helped maintain target GLs. This led to the discontinuation of insulin in one patient, and in the second, problematic frequent hypoglycemia was mitigated by the food intervention. Clinical decisions on patient safety influenced outcomes for these two patients but were not excluded from analysis.

Conclusion

Six of the eight residents given additional protein at breakfast showed significant GL reductions, leading to decreased insulin dosing and simpler regimes. Carers reported improvements in mood, sleep, and energy levels anecdotally. A holistic dietary approach in managing diabetes in CH residents, emphasizing increased morning protein intake, should be considered to enhance GL control and allow deprescribing. A larger study is planned.

Introduction

16% of adults over the age of 75 years old have a diabetes diagnosis¹ and 1 in 6 hospital beds in the UK is occupied by someone with diabetes². Keeping diabetic patients safe during hospital stays is a priority, and in 2023 the Joint British Diabetes Societies (JBDS-IP) published guidance on managing Diabetes in Frail inpatients³. An audit at our hospital later that year found that 70% of Capillary Blood Glucose (CBG) testing was non-compliant with guidelines resulting in unnecessary patient intervention, use of staff time and consumption of non-recyclable resources. The main aim of our project was to improve compliance with these guidelines and establish potential time and cost saving resulting from this.

Method

Focus on medical education with teaching sessions, information cards for lanyards and prompt posters around the inpatient ward areas. Worked with electronic prescribing team to establish use of an order-set for CBG testing to allow medical team to accurately communicate with nursing colleagues.  In addition, engaged nursing staff via ward bulletins and observed CBG testing on ward.  

Results

There was a reduction in CBG frequency for all diabetic patients of 27.9%. We identified that those patients with diet-controlled diabetes were commonly over tested, and in this sub-group the number of CBG tests performed was reduced by 51.9%. Average time for CBG testing was 147 seconds with anticipated cost savings from staff time and equipment use.

Conclusions

The use of default four times a day CBG testing results in unnecessary intervention in our frail inpatients. Through education and use of electronic systems we can reduce these interventions based on national guidelines, but more work needs to be done. Reducing CBG testing reduces use of healthcare assistant time, costly non-recyclable materials and overall reduces unnecessary patient intervention.

References

1. NHS England (2023) Health Survey for England, 2021 Part 2 < https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-diabetes#:~:text=Prevalence%20of%20doctor%2Ddiagnosed%20diabetes%2C%20by%20age%20and%20sex&text=Prevalence%20increased%20with%20age%2C%20from,adults%20aged%2075%20and%20over.> Accessed 8/11/24
2. Watts.E, Rayman. G (2018) Diabetes UK: Making Hospitals safe for people with diabetes. Available at < https://www.diabetes.org.uk/resources-s3/2018-12/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL%20%28002%29.pd> Accessed 24/07/2024
3. JPDS-IP 2023: Inpatient care of the Frail Older Adult with Diabetes. Available at <JBDS_15_Inpatient_Care_of_the Frail_Older_Adult_with_Diabetes_with_QR_code_February_2023.pdf (abcd.care)>

Background:

Type 2 Diabetes mellitus (T2DM) is the most common long-term metabolic condition in older people. In the UK, half of all diabetic patients are over 65 and prevalence reaches 10% in over 75s. Lifestyle interventions reduce diabetic complications and can achieve remission, however, there are concerns over the generalisability of these findings to the diabetic population, particularly elderly, complex patients, and those from ethnic minorities. This systematic review quantifies the disparity between diabetes clinical trial cohorts and the UK diabetic population.

Method:

This is a systematic review of UK-based randomised control trials (RCTs) of non-pharmaceutical interventions in adults with T2DM. Data was collected on characteristics of participants included in these studies, including age, sex, ethnicity, socioeconomic status and education of participants.

Results:

Our search strategy identified 5437 results, of which 161 met the criteria for full-text screening. After full-text screening and de-duplication, 80 RCTs were included in our analysis. Of 80 studies, 60% (48/80) reported a mean participant age under 60. Only 40 (50%) reported participant age range; of these the maximum participant age was under 65 in 20% and under 75 in 60%. Where the mean age of participants was over 60, 56% (18/32) restricted participation by comorbidities. Almost all of these precluded anyone with pre-existing CVD (17/18), one third precluded any comorbidities, and 5/18 precluded hypertensive patients. Only 26% of studies reported the ethnicity of participants. These cohorts were not representative of the UK diabetic population, with underrepresentation of Asian ethnic groups in 90% of trials.

Conclusions:

Representation of elderly patients with comorbidities and those belonging to ethnic minority groups is severely limited in UK based T2DM RCTs of lifestyle interventions. Failure to include a representative population in clinical trial cohorts risks guidance that is not generalisable to the UK diabetic population, potentially exacerbating existing health inequities.

Introduction

Upper limb recovery after stroke depends on participating in an individualised task-specific exercise programme. However, older adults with stroke find it challenging to maintain an optimal level of physical activity due to personal and environmental factors. The aim of this study was to explore the perceptions of patients and stroke therapists on home-based resistance exercises for upper limbs.

Methods

A qualitative study of semi-structured virtual and in-person interviews was conducted between January and March 2023 in England. Participants were 11 older adults (>65 years) with chronic stroke (>1 year after a stroke and moderate to severe disabilities) and rehabilitation therapists (n=20). The group were asked about perceived personal and environmental barriers and facilitators as well as expectations around resistance exercises in relation to their neurorehabilitation programmes. Interview sessions were audio recorded for transcription and thematic data analysis. The study was approved by the ethics committee at Sheffield Hallam University.

Results

Both groups mentioned that the main barrier to doing upper-limbs exercises is weaknesses in the paretic arm affecting their grip that consequently impacts on their adherence to a home exercise programme and motivation. Patients also reported safety concerns such as dropping equipment and being dependent on a carer to undertake regular exercise. Stroke suvivors preferred a program that activates the paretic arm and is relevant to their daily functional activities. They asked for simple exercise instructions and demonstrations through visual aids and video materials. Patients added that they need regular feedback for adjusting their exercise dose, monitoring progress over time, and ongoing encouragement.

Conclusions

Our study showed that designing home-based resistance exercises for upper limb for older adults stroke survivors should be individualised, functionally orientated, and motivational.

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:

1. Type of diabetes, medication regime and frequency of CBG testing.

2. Staff survey of CBG monitoring knowledge. 

Analysis:

1. Compliance with the Joint British Diabetes Societies for Inpatient Care guidelines for frail older adults with diabetes (February 2023).

2. 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. 

Astaff 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.

Introduction

Older adults with diabetes are at increased risk of hypoglycaemia during inpatient hospital stays. It was noted that a large proportion of diabetic patients on the care of the elderly wards at North Middlesex University Hospital were experiencing hypoglycaemia so a quality improvement project was devised to address this issue and improve patient safety.

Method

Baseline data was collected in October 2021 by monitoring the glucose levels of 21 diabetic inpatients across three care of the elderly wards over a 72-hour period. The project consisted of 3 interventions introduced on one of these wards. The initial intervention was a poster reminding doctors to check the HbA1c results of diabetic patients. The second was the introduction of a bedtime snack for diabetic patients. The final intervention was the inclusion of a hypoglycaemia report in the nursing handover.

Results

In the baseline data collection 3/21 (14.2%) patients had a recorded episode of hypoglycaemia. Following the introduction of the poster, 0/7 (0%) and 1/9 (11%) patients experienced episodes of hypoglycaemia at 2- and 4-weeks post-intervention respectively. Following the introduction of a bedtime snack, 1/5 (20%) patients experienced an episode of hypoglycaemia at 2-weeks post intervention. Following the introduction of the nursing handover report, 1/8 (12.5%) and 0/5 (0%) patients experienced an episode of hypoglycaemia at 4- and 5-weeks post-intervention respectively.

Conclusions

The high rate of hypoglycaemia in elderly diabetic inpatients is likely to be multifactorial and therefore a multidisciplinary approach is essential. The sample size was too small to draw clear conclusions, but suggests that a simple nursing intervention could be effective at reducing the frequency of hypoglycaemia. The next steps will be to formally introduce the nursing handover intervention to the other care of the elderly wards and monitor its impact.

Introduction Type 2 diabetes mellitus (T2D) is associated with poor health outcomes and tight glycaemic targets are questionable in those aged over 70 years. Methods The Older Persons Assessment Service (OPAS) is a local emergency department service which accepts patients on frailty criteria. The OPAS databank was retrospectively analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS). Results 1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (±15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0±2.2 vs 5.9±2.1, p001 of those people with t2d, 175 (59.5%) and 240 (81.6%) had a hba1c ≤53 mmol />mol [7.0%] and ≤64 mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0 mmol/L on admission to the emergency department. People with T2D treated with insulin and/or gliclazide had a greater mortality (36.6% vs 23.6%, p05 greater frequency of hypoglycaemia (35.4% vs 11.8%, p0.001), and hba1c (65.5±17.2 mmol />mol [8.2] vs 48.9±12.1 mmol/mol [6.6%]) compared to those who used other agents. People with T2D were not more likely to live in deprived areas. Conclusion Falls are a significant burden, and hypoglycaemia-inducing agents may contribute to the greater mortality observed in people with T2D. People with T2D had a similar CFS, were more likely to be male, prescribed more concomitant medicines and have greater deprivation. Clinician awareness can support de-prescribing for frail patients with HbA1c less than 64mmol/mol. There should be increased awareness of the impact of hypoglycaemia, especially in those using insulin or gliclizade.