Adult insulin initiation safety bundle and setting up virtual diabetes review on discharge: A trust-wide quality and safety initiative

Background and Aims: Both corticosteroids and covid- 19 infection can impair glucose metabolism resulting in significant hyperglycaemia. A trust-wide guidance was issued following alert from the National Inpatient Diabetes covid-19 Response Group, highlighting the need to use insulin instead of oral glucose-lowering agents. Owing to this, a higher number of patients were being initiated and discharged on insulin. Methods: All adult patients who were new to insulin were given a pre-packed 'Insulin initiation bundle' by the diabetes educators. This was a new initiative. It included consumables to last for two weeks and standardised patient information leaflets. All the patients discharged home on insulin were booked follow-up in a diabetes educator-led telephone clinic. A protocol was developed outlining the process above and each staff member's role. This was communicated widely. Results: The standardisation of insulin initiation safety bundles removed the need for the diabetes educators to write additional letters to the GP and improved efficacy of the discharge process. The virtual follow up on discharge ensured safe titration or withdrawal of insulin treatment until they completed their course of steroids and insulin. Conclusions: We believe this was an innovative practice. It universalised the approach to safe discharge from the hospital for patients who were newly started on insulin. This also ensured that patients had enough supplies to last them for two weeks post-discharge. We also found that the structured protocol for booking patients onto a virtual clinic list facilitated safe and early discharges at a time of increased pressure on hospital beds and ensured safe follow up.

Managing hyperglycaemia and reducing glycaemic variability in critically ill COVID-19 patients

Background: There are limited data on interventions to improve glycaemic control in critically ill COVID-19 patients, who often have high intravenous insulin requirements and challenging hyperglycaemia. Aims: To evaluate if a safe reduction in carbohydrate content received from enteral feeding improved time in range (TIR) in critically ill patients with COVID-19. Methods: We studied 21 critically ill patients (14 male, median age 57 years) with blood glucose levels >10 mmol/L despite high intravenous insulin requirements of >5 units/hour for >24 hours. All patients were on continuous enteral feeding and on >6 mg/day dexamethasone. Our intervention was a 30% reduction in the amount of carbohydrate delivered hourly via individualised enteral feed rate adjustments while still keeping within the recommended 20-30 kcal/kg ideal body weight/day. TIR was defined as the percentage of time blood glucose values were 6-10 mmol/L. TIR, time above range, mean blood glucose levels (using hourly venous blood glucose readings) and intravenous insulin requirements were evaluated 48 hours before and after the intervention. Results: TIR more than doubled post intervention from median (interquartile range) 20.0% (7.64-40.4%) to 47.1% (24.3-56.3%), p=0.001. Significant reductions in time above range, mean blood glucose levels and intravenous insulin requirements (median (interquartile range) 8.96 (6.97-10.4) units/hour to 5.22 (4.25-7.59) units/hour) were also observed (p<0.05 for all). Conclusions: In a cohort of critically ill COVID-19 patients, a safe reduction in the carbohydrate content from enteral feeding reduced glycaemic variability, more than doubling TIR, with concomitant reductions in intravenous insulin requirements.

Hyperglycaemia to the extremes and the complex challenges

A 28-year- old Afro-Caribbean gentlemen with a body mass index of 28.5 kg/m2 presented with a 2-week history of osmotic symptoms and was found to have a glucose of > 122 mmol/L. His medical history includes a SARS-CoV- 2 infection 6 months prior. On presentation, plasma ketones were >7 mmol/L, sodium 126 mmol/L, potassium 4.3 mmol/L, pH 7.09 with an osmolality of 450 mOsmol. In the emergency department, he was treated initially with intravenous sodium chloride and intravenous insulin following diabetic ketoacidosis protocol. Insulin dosing was reduced to a requirement of 1-2 units per hour alongside a dextrose infusion to maintain a glucose level around 40 mmol/L. This was done for the first forty eight hours to avoid the over-rapid correction of glucose and subsequent over rapid correction of osmolality. Ketones were deescalated to <1 mmol/L within eight hours. Following initial treatment, severe hypokalaemia occurred requiring significant potassium replacement up to 400 mmols over seven hours. Treatment dose low molecular weight heparin was used to prevent thrombotic complications. The clinical course was complicated by rhabdomyolysis (creatine kinase 81,573 IU/L), hypocalcaemia (1.94 mmol/L) which was cautiously replaced, pancreatitis (amylase 776 IU/L), acute kidney injury requiring haemoflitration for seven days and stress-induced duodenal ulceration causing malaena. This case was particularly challenging due to the extremely high blood glucose levels coexisting with very high ketones, resulting in acid base and electrolyte abnormalities;the normal potassium in the context of significant acidosis can disguise the true potassium levels. The patient made a full recovery.

The impact of the coronavirus disease 2019 (covid-19) pandemic on young people with diabetes and preferences for future care: A patient survey

Aims: Covid-19 restrictions have impacted social interaction, work, education and care provision for young people with diabetes. Furthermore, people with diabetes have increased morbidity and mortality from covid-19. We aimed to explore the impact of the pandemic on young people's diabetes care and management;their psychosocial well-being;and identify preferences for future diabetes care. Methods: A survey was emailed to all patients aged 16-23 with diabetes attending two London (UK) hospital-based diabetes clinics. Descriptive and content analyses were conducted. Results: Response rate was 33% (n = 74/222). Respondents reflected clinic population in age, ethnicity and area-level deprivation, although males were underrepresented (34%, n = 25). Since the pandemic 55% (n = 41) felt well supported by their diabetes team;35% (n = 26) felt more confident and 40% (n = 29) more motivated to manage their diabetes. Conversely 22% (n = 16) felt less confident or motivated, which they attributed to decreased physical activity, disrupted diabetes routines and a lack of support. Mental well-being was reportedly negatively impacted in 57% (n = 42) of patients, with no differences by area-level deprivation or ethnicity. 31% (n = 23) and 41% (n = 30) of respondents felt more negatively about their diabetes and future health, respectively. Face-to- face care in the future remained the most popular option (69%, n = 51), despite increased virtual appointments during the pandemic. Conclusion: Negative impacts on mental well-being, feelings about diabetes and future health need to be considered when providing care for young people with diabetes. Variable experiences and views on care provision indicate the need for a flexible approach to future care delivery models.