The Department of Health and Social Care directed NHS Digital (now NHS England) to carry out this work in response to concern over the increase in prevalence of diabetes in the population and the associated long-term health implications.
The audit records the details of any adult who has one of four avoidable diabetic complications whilst being an inpatient.
Linking with other health datasets allows the identification of high-risk demographics which enables the development of proactive processes to reduce the occurrence.
The audit collects data on four harms which can occur to inpatients with diabetes:
‘Did the patient require injectable rescue treatment for an episode of hypoglycaemia starting more than 6 hours after admission?’
For the purpose of this audit an episode should be recorded only if subcutaneous and/or intravenous injected rescue treatment (glucagon, glucose) for severe hypoglycaemia was used.
For consistency and compatibility this harm is defined not by the measured blood glucose level but by the need to urgently counteract severe hypoglycaemic symptoms such as loss of consciousness, acute confusion or seizures with injected treatment.
Rescue treatment would usually be intravenous glucose or subcutaneous/intramuscular/intravenous glucagon.
For example, these treatments may be required if pre-meal insulin had been given but the meal had not been delivered resulting in severe hypoglycaemic (loss of consciousness, acute confusion, seizures etc due to a low blood glucose) requiring rescue treatment.
Low blood glucose arising in patients receiving intravenous insulin infusions as well as intravenous glucose has led to some misunderstanding of ‘rescue treatment’. Intravenous glucose infusions should always run alongside continuous intravenous insulin and their use in this situation should not be considered ‘rescue treatment’ even when the CBG falls below 4.0 mmol/L provided that the patient has no severe hypoglycaemic symptoms. If, however, the person develops severe hypoglycaemic symptoms such as loss of consciousness, acute confusion or seizures during the infusion and require additional glucose or glucagon this would be considered ‘rescue treatment’.
Diabetic Keto Acidosis (DKA)
‘Was the patient diagnosed with new onset DKA more than 24 hours after admission?’
DKA requires three key features for diagnosis:
- known diabetes or blood glucose over 11.0 mmol/l
- Ketonaemia (blood ketones 3.0 mmol/l or more) or urine ketones 2+ or more
- Acidosis with venous pH less than 7.3 or bicarbonate less than 15 mmol/l.
For more on the definition of DKA please refer to the JBDS guidelines on the ABCD web site.
Hyperglycaemic Hyperosmolar State (HHS)
‘Was the patient diagnosed with new onset HHS more than 24 hours after admission?’
HHS has characteristic features used in its diagnosis:
- marked hyperglycaemia (blood glucose 30 mmol/l or more) without significant ketonaemia (blood ketones less than 3 mmol/l) or acidosis (venous pH 7.3 or more/bicarbonate 15 mmol/l or more)
- Osmolality usually 320 mosmol/kg or more.
For more on the definition of HHS please refer to the JBDS guidelines on the ABCD web site.
Diabetic foot ulcer
‘Was the patient diagnosed with a new onset foot ulcer more than 72 hours after admissions?’
The audit is not intended to collect reports of foot ulcers that are present on admission, or which develop within 3 days of admission. Grade 2+ Pressure sores on the foot that develop more than 72 hours after admission should be included. Deep tissue injury which has not progressed to skin ulceration is not included. Traumatic skin foot lesions and foot infections which arise during the admission are included.