Unit 1 – Core aspects of care: Managing diabetes emergencies

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At any one time, up to 15% of people in English and Welsh hospital beds have diabetes, and on the day of the 2013 National Diabetes Inpatient Audit, just under 14200 people in this setting had the condition (Health and Social Care Information Centre [HSCIC], 2014a; 2014b). Nearly 85% of these had been admitted as an emergency, although the majority were not admitted for something directly related to diabetes: 66.3% were admitted for a medical problem and only 8.1% were admitted specifically for management of their diabetes. Where diabetes was the main reason for admission, 47% had been admitted because of active foot disease (HSCIC, 2014b).

Diabetes inpatient care is expensive for the NHS. Between £2.3 billion and £2.5 billion is spent on this annually, and at least £600 million of this is excess spending when compared with those of the same age group admitted to hospital without diabetes (Kerr, 2011). The 2013 National Diabetes Inpatient Audit found that inpatients with diabetes admitted as an emergency case stayed an extra 2 days compared with those who had a planned admission (HSCIC, 2014b). Other research has found that the median overall length of stay for inpatients with diabetes is 3 days longer than those without (8 days versus 5 days), and this disparity does not appear to have changed over time (Davies et al, 2001; Sampson et al, 2007).

Two reports from the 2012–13 National Diabetes Audit have also recently been published. The first, which was based on data from 2058321 people with diabetes in England and Wales, reviewed care processes and treatment targets (HSCIC, 2014a), predominantly focusing on the level of care and surveillance carried out in primary care and on achievement of HbA_1c targets. It found that treatment targets for glucose and blood pressure control were less likely to be achieved in younger people and in those with type 1 diabetes. Younger people (those under 55 years of age) with either type 1 or 2 diabetes were less likely than older age groups to have completed all their annual checks or achieved their treatment targets. This, combined with very low numbers of people being offered structured education at diagnosis to enable self-management (3.9% for type 1 diabetes and 16.7% for type 2 diabetes), raises concerns that poor outcomes and future complications may be particularly likely in this group of individuals.

The second report (HSCIC, 2015) reviewed data on 2460261 individuals and focused on complications and mortality. It investigated the prevalence of:

• Cardiovascular complications, many of which would require hospital admission, such as angina, myocardial infarction, heart failure and stroke.
• Serious kidney disease, as measured by the uptake of renal replacement therapy.
• Foot disease, including minor amputation and major amputation.
• Diabetic ketoacidosis (DKA).
• But not retinopathy, which is reported separately by NHS Diabetes Eye Screening.

Heart failure is now the second most common complication of diabetes among these (see Table 1) and contributes the most to additional mortality (HSCIC, 2015).

Based on data from the audit, it was estimated that, compared with the background rate, diabetes was responsible for 22060 additional deaths in England and 1926 additional deaths in Wales during 2013 (HSCIC, 2015).

These audit reports, along with the Commissioning Outcomes Framework and the Diabetes in adults quality standard (NICE, 2011; 2012), provide the foundation for clinical commissioning groups (CCGs), and challenge healthcare providers and clinicians, to review clinical processes and access to patient-centred and peer-reviewed structured education, in order to reduce variations in care and hospital admissions.

Diabetes emergencies are more often than not preventable. This article focuses on the more common clinical emergencies, including DKA, hyperosmolar hyperglycaemic state (HHS), hypoglycaemia, the diabetic foot and the presentation of newly diagnosed children with diabetes.

DKA and HHS
DKA occurs mainly in people with type 1 diabetes but can occasionally present in those known to have type 2 diabetes. HHS is a condition that affects only people with type 2 diabetes. Both conditions are life threatening. They are caused by a complete or relative lack of insulin and require emergency hospital admission. In a study that analysed data from the US, significant declines in the rates of death due to hyperglycaemic crisis (DKA or HHS) were found between 1985 and 2002 (Wang et al, 2006). But while mortality rates associated DKA in the US have dropped below 5%, for those with HHS the mortality rate is over 10% (Kitabchi et al, 2006). Furthermore, the prognosis in both conditions is substantially worsened at the extremes of age and in the presence of coma and hypotension (Hansen and Møller, 2010).

Data from the National Diabetes Audit revealed that 14240 individuals identified in the 2009–10 audit were admitted for DKA at least once during a 3-year follow up time-span (HSCIC, 2015). Clinical services and commissioners are tasked with investigating new approaches to reducing admissions to hospital. Part of the challenge is that readmission rates for DKA are high, with an average of 31% of people readmitted with DKA within a year of their initial admission (Joint British Diabetes Societies Inpatient Care Group, 2013b).

DKA
Diagnosis of DKA can be difficult and individuals may be defined as having DKA but simply be hyperglycaemic. Precipitating factors for DKA include infection, intercurrent illness, surgery and omission of insulin. People with DKA tend to be younger, and there is evidence that socioeconomic, psychosocial and educational factors contribute to poor compliance to insulin therapies (Randall et al, 2011). Diagnosis is dependent on three components: uncontrolled hyperglycaemia, ketonaemia and acidaemia (Joint British Diabetes Societies Inpatient Care Group, 2013a). Successful treatment has traditionally focused on frequent monitoring, correction of hypovolaemia and hyperglycaemia, correction of electrolyte losses, and investigation for the precipitating cause. However, recent national guidelines recommend that, rather than focusing on hyperglycaemia, a reduction in ketones is a more effective measure of success (Joint British Diabetes Societies Inpatient Care Group, 2013b).

The majority of DKA cases occur in people with a known history of diabetes and should be largely preventable through early detection and with the education of patients and healthcare professionals. The Diabetes in adults quality standard (NICE, 2011) emphasises the important role that structured education plays in enabling people to manage their own diabetes and recommends that people admitted for DKA receive educational and psychological support prior to discharge. In practice, access to psychological support is limited in the UK, and so healthcare professionals need to ensure that patients know how to prevent reoccurrence and readmission following an event. During periods of intercurrent illness, prevention of DKA is a major part of reducing admissions to hospital. Recently, TREND-UK formed an expert working group with representatives from major healthcare professional organisations in the UK, with the purpose of formulating guidance and ensuring consistency in advice given on managing intercurrent illness. (This document, entitled Managing diabetes during intercurrent illness in the community, is available at http://www.trend-uk.org/resources.php [accessed 18.05.15].) With suspected DKA, a “rule of thumb” is that children, pregnant women or any patients who are unable to keep fluids down should always be admitted to hospital as an emergency.

HHS
HHS is often the result of poorly treated type 2 diabetes or delayed diagnosis of type 2 diabetes. Affected individuals are usually frail, severely dehydrated and clinically very unwell, with an altered level of consciousness. Infection or cardiovascular events are the most common predisposing factors. Strict differentiation between HHS and DKA is often difficult as some patients with HHS may present with ketonuria. The onset of symptoms with HHS is very slow whereas symptoms of DKA occur rapidly (Table 2), and the presenting blood glucose readings are often the key sign as values with HHS can be 30–40 mmol/L or more. This, combined with hypovolaemia and a calculated serum osmolality of >320 mOsm/kg, is diagnostic (Hansen and Møller, 2010).

Treatment of HHS is focussed on blood glucose reduction and otherwise usually follows the main treatment objectives shown for DKA: rehydration, correction of hyperosmolality, electrolyte imbalance and hyperglycaemia. These patients are usually more sensitive to insulin (Joint British Diabetes Societies Inpatient Care Group, 2012).

Sick day education, given through structured education programmes at the diagnosis of diabetes and reinforced at annual review, may play a part in reducing occurrences of HHS or DKA.

Hypoglycaemia
Hypoglycaemia is the most common diabetes-related reason for ambulance call-out and is associated with increased morbidity and mortality (Brackenridge et al, 2006). There are approximately 70 000–100 000 emergency call-outs for hypoglycaemia per year (NHS Diabetes, 2012). These events are expensive: it is estimated that ambulance call-outs cost the NHS £13.6 million per year (Farmer et al, 2012). Each admission to hospital due to hypoglycaemia costs the NHS about £1000 (Amiel et al, 2008). People with diabetes may have a fear of hypoglycaemia, which can impact on adherence to medication and agreed glycaemic targets (Wild et al, 2007).

CCGs are tasked with reducing: the number of people with diabetes who require medical attention as a result of a hypoglycaemic episode; and the rate of recurrence of an episode of hypoglycaemia requiring medical attention over 12 months (NICE, 2011). If commissioners are to meet this requirement, patient and healthcare professional education will be important, as will innovative commissioning processes.

National guidance regarding hypoglycaemia is readily available for hospital and community staff and includes algorithms and care pathways (Joint British Diabetes Societies Inpatient Care Group, 2013a; TREND-UK, 2011). Online training on hypoglycaemia for staff and patients also exists (Virtual College, 2012). Innovative ways of reducing admissions are being implemented across the UK; the case example in Box 1 describes a pilot study undertaken in Leicestershire with the aim of reducing repeat episodes of hypoglycaemia and enabling people living with diabetes to prevent and manage hypoglycaemia.

The diabetic foot
Around one in 20 people with diabetes will develop a foot ulcer in a given year, and diabetes is the most common cause of lower-limb amputations. Annually, approximately 6000 people with diabetes have leg, foot or toe amputations, of which, it is estimated, 80% are potentially preventable (Diabetes UK, 2015). Despite this, 28% of people with type 1 diabetes and 13% of people with type 2 diabetes are not receiving an annual foot check (Diabetes UK, 2015). Up to 80% of people will die within 5 years of having an amputation as a result of diabetes (Diabetes UK, 2015).

As mentioned in the introduction, the 2013 National Diabetes Inpatient Audit found that among inpatients admitted for the management of their diabetes or an associated complication, 47% had been admitted for active diabetic foot disease (HSCIC, 2014b). In terms of financial costs, it has been estimated that £1 in every £150 spent by the NHS in England is related to diabetic foot ulcers (McInnes, 2012).

Major predisposing factors to foot ulceration include the following (Boulton, 2013):

• A history of ulceration.
• Neuropathy or nerve damage.
• End-stage renal disease.
• Vascular disease.

National initiatives such as the Putting Feet First campaign and the development of the National Minimum Skills Framework (NHS Diabetes and Diabetes UK, 2011) have helped to inform clinicians and commissioners of the foundation for high-quality foot care in diabetes.

Prevention of foot disease and referral
For the incidence of diabetic foot disease to reduce, there needs to be effective foot screening in place, along with foot protection teams, care pathways and information for healthcare professionals and people with diabetes that is provided routinely and repeatedly. The development of a simple tool to identify if people with diabetes have reduced sensation and are at risk of foot ulceration – the “Touch the toes” test – is availably online for all to access (Diabetes UK, 2012b). The “traffic light” referral system developed by Diabetes UK is easy to use and gives clear guidance on when to refer (Figure 1). Intravenous antibiotics can be given at home. Fast-track referral pathways to specialist diabetes foot services should be in place in each locality.

Children newly diagnosed with diabetes
There are around 35000 people under the age of 19 with diabetes in England. Of these, 96% have type 1 diabetes, 2% have type 2 and 2% are recorded as having maturity-onset diabetes of the young. The peak age of diagnosis is 10–14 years (Diabetes UK, 2014).

DKA is a common problem in children with diabetes. The frequency of DKA at diagnosis of type 1 diabetes varies widely by geographical region. For instance, among the 11 European centres in the EURODIAB study that recorded DKA status, the frequency varied from 26% to 67% (Lévy-Marchal et al, 2001). In the UK, approximately one quarter of children with newly diagnosed type 1 diabetes present with DKA (Diabetes UK, 2012a). The National Diabetes Audit Paediatric Report 2009–2010 estimated that 15.5% of children and young people had one episode of DKA over a period of 5 years, while 10.4% of children had two or more episodes (HSCIC, 2011). Furthermore, there are approximately 10 deaths from DKA a year in the UK in children with diabetes (Ali et al, 2011).

It is vital that clinicians are aware of the signs and symptoms of type 1 diabetes in children (Table 3). Symptoms in those under 2 years of age are more difficult to identify but will include lethargy, polydipsia and polyuria.

A marked elevation of blood glucose level confirms the diagnosis. If ketones are present in blood or urine, treatment is urgent, and the child should be referred the same day to avoid the development of ketoacidosis. Insulin therapy should be instituted in most cases as soon as the diagnosis of diabetes is made, to prevent development of DKA (International Diabetes Federation and International Society for Pediatric and Adolescent Diabetes, 2011).

There should be a specialist team with expertise in diabetes and paediatrics, including the child and family, a paediatrician, a diabetes specialist nurse educator, a dietitian, and a paediatric social worker, psychologist, or psychiatrist. Ongoing care should encompass: structured education; links with nurseries, schools and colleges, and community teams; assessment of growth and development; psychological support; and consideration of traditional markers for glycaemic control, treatment options and prevention of complications.

Conclusion
Diabetes-specific emergencies requiring hospital admission are not common, but they do, in general, require prompt diagnosis and treatment. It is important that healthcare professionals have the correct knowledge, skills and competencies to recognise the different emergency situations, and understand treatment and referral pathways, in order to support people living with diabetes.

Information for healthcare professionals and individuals living with diabetes is freely available and easily accessible and should be offered to patients at diagnosis and at annual review. Structured education programmes can reinforce the message and enable attendees to recognise when they may need urgent assessment and assistance. Clinical management plans should be in place for all urgent and emergency care, ensuring appropriate referral and assessment by the “right” healthcare professional, for the “right” individual at the “right” time.

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