Best practice library – diabetes

Key overarching resources

The resources below are relevant across most or all of the areas and metrics listed on this page.

Sentinel top decile metrics

Metric / recommendationGIRFT standard
Hyperglycaemia – Diabetic Ketoacidosis (DKA) : Total admissions (36 month rolling metric)n/a
Hypoglycemia : Total admissions (36 month rolling metric)n/a
Hyperglycaemia – Diabetic Ketoacidosis (DKA) : Mean length of stay (days) (36 month rolling metric)                      5.3
Hypoglycemia : Mean length of stay (days) (36 month rolling metric)                      9.8
Hyperglycaemia – Diabetic Ketoacidosis (DKA) : Emergency Readmissions within 30 days of discharge (%) (36 month rolling metric)14.3%
Hypoglycemia : Emergency Readmissions within 30 days of discharge (%) (36 month rolling metric)13.2%
Diabetes: Major amputations : Total admissions (36 month rolling metric)n/a
Diabetes: minor amputations : Total admissionsn/a
Major amputations – patients with diabetes: mean length of stay                    10.9
Diabetes: minor amputations : Daycase rate (%)50.0%
Major amputations – patients with diabetes: Emergency Readmissions within 30 days of discharge (%)4.4%
Minor amputations – patients with diabetes: mean length of stay                      4.9
Minor amputations – patients with diabetes: Emergency Readmissions within 30 days of discharge (%)5.9%
Repair of fracture neck of femur (patients with diabetes): Total admissionsn/a
Repair of fracture neck of femur (patients with diabetes): Mean length of stay (days)14
Repair of fracture neck of femur (patients with diabetes): Emergency Readmissions within 30 days of discharge (%)8.0%
Diabetes: Pneumonia : Total admissionsn/a
Diabetes: Pneumonia : Mean length of stay (days)                    11.6
Diabetes: Pneumonia : Emergency Readmissions within 30 days of discharge (%)14.1%
Patients with diabetes: Emergency Readmissions within 30 days of discharge (%)8.6%
Non-diabetic patients: emergency readmissions within 30 days of discharge6.2%

Pathways and decision tools

These tools and resources have been developed by the GIRFT programme, with input and endorsement from the Association of British Clinical Diabetologists and Diabetes UK.

Hyperglycaemia: Initial management of hyperglycaemia in adults in the emergency department

Hypoglycaemia: Management of patients admitted in hypoglycaemia

Hypoglycaemia: Admit, observe or discharge – decision support tool

Foot problem: Management of patients presenting to the emergency department with a foot problem

Discharge support tool for new diagnosis of diabetes

Discharge support tool for pre-existing diagnosis of diabetes

Leaflets to support pathways

Keeping safe whilst you wait in A&E

Keeping well after attending A&E

Map of tools for managing adults with diabetes in emergency and acute units

Click here to download the information below as a PDF >

Essential care to prevent harm from acute diabetes complications arising in acute units (Click to expand infomation on preventing hypoglycaemia, diabetic ketoacidosis and hospital acquired foot lesions)

Preventing hypoglycaemia in your patient

At risk–

  • Type 1 People with Diabetes (PWD)
  • Type 2 PWD on insulin and/or a sulphonylurea (SU)

Determine

  1. When they had their last dose of short acting insulin* or SU
  2. When they last ate

If insulin/SU was given within the last 6 hours and they had not eaten they are at high risk of hypoglycaemia

Actions

Check capillary blood glucose-

  • •If <6.0 mmol/l give fast acting carbohydrate followed by long acting carbohydrate
  • If 6-10 mmol/l give long acting carbohydrate
  • Recheck capillary glucose at 2 and 4 hours- the patient can do this themselves

*Actrapid/Humulin S/ Novorapid/ Humalog/Aprida) or Pre-mixed (Humulin M3/Humalog Mix 25/Humalog Mix 50

Preventing Diabetic Ketoacidosis in your patient

At risk–

  • Type 1 People with Diabetes (PWD)- High risk
  • All sick patients on an SGLT2 inhibitor- Rare, but possible

Type 1 PWD

  1. Determine when they had their last dose of insulin- If >4-6 hours previously they are at risk 
  2. Determine if they on a subcutaneous insulin pump. Pump or s.c. cannula failure rapid development of DKA*

Actions

Check capillary blood glucose

  • If >12 mmol/l check ketones and follow local hyperglycaemic protocol
  • If <12 mmol/l and not hypoglycaemic ensure insulin is given when next due (PWD will know)

* If on an insulin pump and hyperglycaemic check that the cannula is in situ and the pump is fully functioning- the patient may be able to check this themselves but seek assistance from the diabetes specialist team

All sick patients on an SGLT2 inhibitor-

Check blood ketones irrespective of blood glucose level to exclude euglycaemic diabetic ketoacidosis

Preventing Hospital Acquired Foot Lesions and overlooked foot disease causing illness

  • PWD are at increased risk of heel pressure ulcers
  • PWD admitted for other reasons may have an existing foot lesion contributing to or causing their illness (e.g. sepsis secondary to an infected foot ulcer/osteomyelitis

Actions

  • Inspect the feet of all PWD (except young healthy people) removing dressings where necessary
  • If likely to remain trolley/bed bound for several hours examine for loss of protective sensation (LOPS). The Ipswich Touch the Toes Test is a simple way of doing this- it takes less than 15 seconds (see hyperlink below)
  • Protect the heels of those with LOPS

Recommended Educational Video

CoMICs Episode 64: Diabetic Foot – YouTube

Over 90% of people with diabetes (PWD) in acute units are there for non-diabetes reasons (e.g. a fracture). When managing the presenting complaint, it is easy to overlook their diabetes needs which could result in an otherwise avoidable admission. This ‘check list’ guides you through the needs of PWD to prevent this.

Key message- Empower the patient- listen and learn from the person with diabetes- they care for their diabetes day to day and if well they should be allowed to self monitor their blood glucose and if insulin treated make their own decisions on insulin dosing

Diabetic
ketoacidosis

JBDS Guidance >

See pages 23 – 28 for diagnosis & management in the first 60 minutes

Single page summary >

Recommended educational video >

Hyperglycaemic hyperosmolar state

JBDS Guidance >

See pages 12 – 15 for diagnosis & management in the first 60 minutes

Single page summary >

Hyperglycaemia
(Not for DKA or HHS)

GIRFT pathway >

Acute Diabetic Foot Lesions

GIRFT pathway >

Contributors to pathways and supporting resources

  • Emma Page
  • Ketan Dhatariya
  • Caroline Davies
  • Sophie Harris
  • Kath Higgins
  • Elizabeth Camfield
  • Suma Sugunendran
  • Andrea Lake
  • Rajiv Gandhi
  • Daniel Lasserson
  • Esther Walden
  • Unmesh Dashora
  • Alistair Lumb