HYPOGLYCEMIA

Inpatient Diabetes in Scotland conference April 25th 2012- a summary

I attended the Inpatient Diabetes in Scotland conference yesterday in Stirling. Nowadays I find small focused one day meetings actually more useful than vast annual jamborees! It was good to hear and share best practice and also in a way heartened to note that we are all in the same boat. Some of the important points (from all the excellent presentations) that I took home were

1. between 2003 and 2010 there was a 33% increase in incidence of Diabetic Ketoacidosis (DKA) in UK. Unclear why.

2.Thankfully mortality rates are unchanged in most reports and in USA and Taiwan a probable decrease in mortality. Mortality is significantly higher in over 70s

3. Scotland wide DKA protocol has been implemented and audit standards have been set. Public awareness is key- the Parma experience is a model.

4. Hypoglycemia is common in inpatients and management should be improved. Use of Hypobox has improved management but much more needs to be done. The direct cost associated with management of Severe Hypoglycemia is around £900 (Hammer etal J Med Econ 2009)

5. The English National Diabetes Inpatient Audit (NaDIA) has led to improvement in different areas of inpatient care. The Scots were advised to carry out their own McNaDIA! We are doing it our hospital next month.

6. The updated version of SCI-DC– the diabetes database in Scotland will have an inpatient module- excellent for identifying inpatients with diabetes. This hopefully can lead to a proactive management of diabetes in-hospital by teams as opposed to reactive management currently.

7. Think Glucose toolkit pilot has driven change in Dumfries and Galloway and may be rolled out in Scotland. Results from other pilots are awaited. Its crucial that local teams look at their service and adapt the campaign to suit their needs.

8. Jason Leitch gave an entertaining talk about the Scottish Patient Safety Program and its successes ( I had tweeted them earlier). Teams were good at implementing SPSP methodology for technical aspects of care but need to also apply it to patient centred care. NHS funding is “protected” in Scotland and only programs that improve both quality and efficiency will be looked at favorably.

9. Cost of inpatient diabetes care in Scotland is £301 million ie 12% of Scottish inpatient expenditure annually. http://eprints.gla.ac.uk/53646/

A video recording of this meeting will be available soon for all the enjoy. Lots to mull over but a very informative day. Nearly 150 delegates were present and glad to see patients and Diabetes UK were there to engage with the diabetes health care professionals (and a few anesthetists!)

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Guidelines on use of RT-CGM (real time continuous glucose monitoring)

Endocrine Society has published updated guidelines on use of Real time continuous glucose monitoring in patients with diabetes.

A summary of guidelines include (Joslin news)

  • Currently approved RT-CGM devices be considered for use by children (over 8-years old), adolescents, and adults with type 1 diabetes whose A1C levels are below 7 percent to help maintain target levels while reducing the risk of hypoglycemia.
  • Recommend the use of these devices to assist with intensification of diabetes control in children (over 8-years old), adolescents, and adults with Type 1 Diabetes whose A1C levels are at 7 percent or higher, provided they have a history of responsible self-care, and will keep up proper use of the device
  • Occasional use of short-term CGM monitors could be helpful in keeping track of blood glucose levels when reviewing conditions such as nocturnal hypoglycemia, dawn phenomenon, and post-prandial hyperglycemia; hypoglycemic unawareness; and in patients who have recently made major changes in their care, such as the use of new insulin or the switch to insulin pumps. This suggestion was made for children (over 8-years old), adolescents, and adults.
  • Recommend against the use of RT-CGM on its own during treatment in an intensive care unit or in an operating room until more studies are done to asses the technology’s accuracy and safety under those conditions.