Clinical Features and Changes in Insulin Requirements in People with Type 2 Diabetes Requiring Insulin When Hospitalised with SARS-CoV-2 Infection.

Background: Uncontrolled hyperglycaemia before and during hospitalisation is a risk factor for adverse outcomes in people with diabetes and SARS-CoV-2 infection. Insulin often at high doses is frequently required to manage hyperglycaemia associated with SARS-CoV-2 infection during hospitalisation. However, there is limited information on the clinical features and sequelae of people with type 2 diabetes (T2DM) not previously on insulin that require insulin as a new treatment when hospitalised with SARS-CoV-2 infection. Aims: To describe the clinical features and insulin treatment sequelae of 113 people with T2DM that required insulin as a new treatment when hospitalised with SARS-CoV-2 infection. Methods: A single-centre study of 113 people with T2DM who were not on insulin before their admission for SARS-CoV-2 infection. The primary aim of our study was to identify clinical and biochemical features that were associated with the need for insulin as a new treatment in people with known T2DM not on insulin treatment at the time of hospitalisation for SARS-CoV-2 infection. We also describe changes in insulin requirements at time of discharge from hospital and 6 weeks later during the first wave of SARS-CoV-2 infection (April-March 2020) in the UK. Clinical, biochemical, and anthropometric data were collected from electronic health records. Results: We observed that of 113 people with T2DM, 35% (n = 39) needed insulin as a new treatment during their hospitalisation for SARS-CoV-2 infection. People requiring insulin were younger, had a higher preadmission HbA1c, were more frequently on oral medication for diabetes before the admission, and were more likely to be obese (body mass index ≥30 kg/m2), with p ≤ 0.001 for all. In multivariable logistic regression analyses, we observed that younger age and higher HbA1c before admission were independently associated with needing insulin, with one-year increase in age associated with decreased odds of needing insulin initiation (OR 0.91, 95% CI 0.83-0.99), and increasing preadmission HbA1c by 1 mmol/mol associated with an increased odds of insulin initiation (OR 1.05, 95% CI 1.002-1.11) (p < 0.05 for both). Of the 39 people with T2DM who required insulin as a new treatment, 28% remained on insulin at the time of discharge with their insulin dose falling from 1.26 U/kg within the first 7 days of admission to 0.39 U/kg at discharge. At 6 weeks after discharge, 24% of people remained on insulin. Conclusion: More than one-third of people with T2DM not previously treated with insulin required new insulin treatment when hospitalised with SARS-CoV-2 infection, and of this group, 24% remained on insulin at 6 weeks after discharge. This study highlights the important variations of insulin requirements in people with T2DM new to insulin and the importance of a dedicated team for patient education and close follow-up.

Rare case of type B insulin resistance in association with systemic lupus erythematosus: illustrating diagnostic and management challenges.

A 42 year-old Caribbean woman with, known type 2 diabetes, was admitted with worsening fatigue, arthritis and rashes. She was diagnosed with multisystem systemic lupus erythematosus and was initially treated with systemic steroids. During this admission, she had persistently elevated capillary glucose levels with insulin requirements over 8 U/kg/day that still did not control her blood glucose levels. Due to her profound hyperglycaemia, serum samples of fasting insulin, C-peptide, paired with blood glucose were analysed, which confirmed significant hyperinsulinaemia. Further analysis confirmed the presence of insulin receptor antibodies consistent with type B insulin resistance.She was started on intravenous cyclophosphamide (Euro-Lupus regimen) along with continuous glucose monitoring system. After completing her six cycles of cyclophosphamide, she no longer required insulin treatment. The goal of therapy for our patient with confirmed type B insulin resistance was to manage hyperglycaemia with high doses of insulin until autoantibodies were eliminated with immunosuppressive therapy.

Chief registrars: Leading in a time of COVID-19.

The NHS is currently in the midst of a global health crisis that requires rapid action from its staff and systems. The Royal College of Physicians' chief registrars, in their role as middle leaders that bridge the gap between junior doctors and senior leadership in NHS trusts nationwide, are uniquely positioned to respond to the COVID-19 crisis. Our strategies fall into three overlapping categories: our roles as middle leaders, developing effective communication techniques and promoting staff wellbeing. We discuss lessons of good leadership in a time of crisis, from embracing new ways of working and new technologies, to utilising professional networks to drive change, to providing tools to support the wellbeing of the colleagues we both lead and care for. The lessons of our initial response are being shared across our national network. We also hope that the novel approaches we have developed will inform the practice of future middle leaders.

Quality improvement report: setting up a hospital at night service, limitations of bleep filtering and using an electronic task management system.

The 'hospital at night' concept was developed at a joint conference of the London Deanery and Clinical Staff in 2002, as an issue for education and service provision. At the start of the project, our trust had issues with both the structure of the hospital at night handover and the working practices overnight. The vision was to improve team working out of hours, expedite review of sick patients and reorganise care to seek a reduction in bleeps to medical junior doctors overnight in a way that all patients had access to the right person with the right skills for their needs at the right time. The hospital at night project at our hospital was started in 2019 by a multidisciplinary working group. We tried bleep filtering for 4 months and this was later followed on by the development of an electronic out of hour's task list as part of our hospital at night set-up. The bleep analysis data showed an improved distribution of workload but the process was dependent on individuals. The electronic task management system was built in pre-existing online software. The system helped prioritise and review tasks requested by nurses on medical wards. But it was not without its limitations. We worked with the local information technology (IT) team to improve speed and proposed developing an IT solution that is fast and not desktop based to ensure tasks can be assigned and viewed while on the go. The project was overall a success as it demonstrated positive feedback from junior doctors, improved perception of teamwork and ability to take rest breaks. It also demonstrated a drop in ward-based cardiac arrest rates. The hospital at night project at our trust remains a work in progress, but a lot of positive changes have been delivered.

Patient Journey Champions: A project to facilitate delivery of effective board rounds for inpatients, aiding flow through the hospital.

Our quality improvement project was designed to enable delivery of high-quality board rounds across the hospital with a view to improving patient flow. We designed a Patient Journey Champion campaign to enable this. As part of our campaign, we ran sessions with junior doctors. These comprised education on the structure of a board round, giving them an insight into the bigger picture on patient flow and eventually aiming to empower them to lead an effective board round on their respective wards, where they would act as 'Patient Journey Champions'. Following the workshops, we audited the quality of board rounds and compared it with baseline. The quality was measured against the hospital standard operating procedure. We noticed an improvement in the quality of board rounds and also a positive effect on length of stay on the acute admissions ward. We anticipate a continuing trend of improvement as this intervention is rolled out across more doctors and other staff groups, although this relies on the need to involve doctors in board rounds and empowering them with the appropriate skills. Simultaneously, work is now being undertaken by matrons of respective wards to upskill ward nurses and other allied healthcare professionals to aid delivery of improved board rounds.

Quality improvement report: setting up a staff well-being hub through continuous engagement.

The coronavirus pandemic has presented a new set of challenges for the frontline National Health Service staff. It is not only the long working hours but also the uncertainty and increase in patient mortality that has affected mental health and staff well-being. Hospitals all around the country have rightly responded with various well-being initiatives to help their staff such as wobble rooms and developing online resources. Our vision was to set up a safe space for staff away from clinical noise to enable and encourage mindfulness and psychological resilience through a calm and serene environment. We used the continuous quality improvement methodology and administered an initial needs assessment survey to see if our trust staff will be interested in having such a space. Within our team, we managed to secure a place, and used donations to hospital charity and set up a space within a week. Since opening the hub, we have had excellent feedback from various staff groups. Immediate feedback was obtained using emoji stickers asking for feelings before and after visit. A mood board was put up allowing anonymous expression of feelings. Delayed feedback was requested using a repeat survey. We believe that while there is a lot of talk about well-being and an increasing number of resources being offered electronically, the need for a neat and quiet space cannot be overlooked. We collect feedback on a weekly basis and adapt the space to meet the needs of staff. Long-term impact of such spaces will be reassessed at a later stage.