The Rowan Hillson Inpatient Safety Award 2022 The best interventions: redesigning, rebuilding and maintaining safe inpatient diabetes care during COVID

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

Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD).

Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.

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

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 !earnings for diabetes communities, and the information can be used to improve and galvanise delivery of integrated diabetes care in the UK.

Can HbA1c levels be used as an independent marker of mortality and morbidity risk in patients with COVID-19 positive swabs?

Background: Diabetes mellitus has been considered a significant risk factor for morbidity and mortality for COVID-19.1 HbA1c levels are often used as a marker of poor glycaemic control and are one way of diagnosing pre-diabetes as well as diabetes.2,3 We tried to explore whether HbA1c levels could be an independent risk factor for mortality and morbidity in patients with positive coronavirus (SARS-COv-2) swabs. Methods: This was a retrospective multicentre study of coronavirus swab positive patients who had a recent HbA1c test. Their demographic data, medical history, COVID-19 swab and laboratory results, and final outcomes were analysed. Patients were divided into three groups;HbA1c in normal (group 1), pre-diabetic (group 2) and diabetic (group 3) ranges. Data were analysed using JASP and statistical computation using a χ2 test. Results: A total of 1,226 patients had SARS-CoV-2 RNA identification swabs between 10 February 2020 and 1 May 2020. A cohort of 120 of these patients had positive swab results and recent HbA1c results. Mortality rates for group 1 (normal HbA1c) and 3 (diabetic HbA1c) were relatively higher than group 2 (pre-diabetic HbA1c). Among group 2, female patients had greater mortality, perhaps because of fewer male patients, although overall co-morbidity was less (4/120 (3.33%) in group 2 compared with 18/120 (15%) in group 1 and 14/120 (11.66%) in group 3. Overall, 36/120 (30%) patients died and 84/120 (70%) survived. Survival curves after analysis of data showed that increasing HbA1c levels were associated with poorer outcomes across all groups. Analysis was significant with p=0.003. Conclusions: HbA1c levels in this study were an independent marker of increased risk of mortality in COVID-19 swab positive patients. The findings are statistically significant (p=0.003). Increased co-morbidities at normal HbA1c seem to have a contributing role in enhanced mortality.