This short guideline is for healthcare professionals working in acute emergency departments and emergency decision units. It aims to give a quick guide to triage when adults with known or unknown diabetes attend these departments. These guidelines follow the GIRFT best practice pathways which have been adapted locally for our Trust.

Specific guidelines relating to DKA, HHS and Diabetic foot ulcers can be found on the FHFT Clinical Guidelines Platform

According to The National Diabetes Inpatient Audit (NaDIA, 2017), 83-90% of people with diabetes are admitted as an emergency. However, the majority are not admitted for their diabetes per se. In 2017 diabetes specific emergencies only accounted for 8% of the total number of admissions (16,010) audited on a single day in England and Wales.

The most common reasons for diabetes specific admissions are foot ulceration,

hypoglycaemia, hyperglycaemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycaemic state (HHS).

Other reasons for admissions to hospital in the diabetes population include but are not limited to:

newly diagnosed diabetes, cardiovascular disease, stroke, and end of life care.

Each section relates to the commonest diabetes specific emergencies and algorithms can be printed off to enable ease of access and use.

This tool is to support discharge for patients with new diabetes diagnosis.

Review by senior ED (Spr/Consultant) to confirm discharge plan

Review by senior ED (Spr/Consultant) to confirm discharge plan

Hypoglycaemia – in the Emergency Department

Admit, observe or discharge? – follow steps 1 to 4 below:

Step 1: Confirm hypoglycaemia treatment is completed, there is return to cognitive baseline and glucometer reading has remained above 4 mmol/l, with no downward trend, for 2 hours after treatment

Step 2: Consider whether there needs to an education review/discussion between the patient and the specialist diabetes team (Table 4) either whilst the patients is still in ED or whether this can be urgent next day/next working day review

Table 3. People where a discussion with the diabetes team is recommended before discharge

Step 3: Use the hypoglycaemia decision support tool below, together with the criteria for safe discharge (Table 4) to decide whether to admit, observe or discharge.

Step 4: Review medication.

Sulfonylurea

In the event of patients experiencing hypoglycaemia on sulfonylurea, dose reductions should be followed according to guidance within the BNF. Advice from a registered prescriber should be sought if further advice needed.

Insulin

In the event of patients experiencing hypoglycaemia, blood glucose readings below the agreed target range or other contributing factors which may result in hypoglycaemia, the insulin dose should be based on a guidance reduction of a 10-30% of the current total daily dose. If it is felt that the reduction should be larger, for example in the event of acute renal impairment, advice from a registered prescriber should be sought, and a new reduced dose agreed.

After full recovery, use the above to determine the risk of further hypoglycaemia and therefore need for admission or prolonged observation.

Please note that people with background of: Dementia, cognitive impairment, poor oral intake, Learning Disability, NH or RH residents, or those relying on 3rd party carer, low BMI, age >80 y, inability to self-manage, eating disorders, insulin or sulphonylurea OD, will need admission.

Acronym for remembering the 5 essential checks

SNACK and TICKLE (T hink I nsulin, C heck K etones, L ook at feet, E xamine for loss of protective sensation)

Please refer to the above pathways to help with management of hyperglycaemia in the emergency department.

Anybody presenting to emergency department acutely unwell should have a glucose check (either VBG or capillary glucose) please ensure glucose is reviewed.

 If initial glucose concentration of ≥7.8mmol/L at presentation, or if they have any risk factor for developing hyperglycaemia venous blood gases should be taken to exclude metabolic acidosis. If these are abnormal, then ketone concentrations should be checked to exclude diabetic ketoacidosis (DKA).

NOTE: If acidotic but glucose ≤11 mmol/l, check ketones to exclude ‘euglycaemic’

ketoacidosis. Be aware that DKA can occur with a normal glucose concentration, in

particular with SGLT-2 inhibitor use (Empagliflozin, Dapagliflozin, Canagliflozin).

Diagnosis criteria for DKA:

• PH< 7.3, HCO3 < 15,

• Glucose >11 mmol/L,

• ketones > 3 mmol/L

Diagnostic criteria for HHS:

• Marked Hypovolaemia

• Marked hyperglycaemia (glucose ≥ 30 mmol/L)

• No significant hyperketonaemia (ketones ≤3.0 mmol/L)

• The serum osmolality of 320mOsmol/kg (2 x serum sodium + serum glucose + serum urea, all in mmol/L).

• No significant acidosis (pH ≥7.3 and blood or serum bicarbonate ≥15.0 mmol/L)

Refer to the guidelines (links below) if DKA or HHS present

DKA in Adults

Management of hyperosmolar hyperglycaemic state (HHS) in adults with diabetes

The individual is not known to have diabetes

If all capillary blood glucose readings are ≤7.8mmol/L within the first 24 hours, testing can be stopped unless circumstances change. The discharge summary should include the fact the admission glucose was raised but subsequent readings were normal. This is consistent with ‘stress hyperglycaemia’. In this patient group, it is recommended that the individual should have a yearly fasting blood glucose or HbA1c because they are at an increased risk of developing Type 2 diabetes over time.

If they have a capillary blood glucose ≥7.8mmol/L within the first 24 hours, an HbA1c should be requested. If the HbA1c is ≥48mmol/mmol, the person probably has Type 2 Diabetes and should be informed of this. This diagnosis should be clearly documented within the notes and in the discharge summary.

If an individual is not known to have diabetes and random glucose is ≤7.8mmol/L with no additional risk factors for the development of hyperglycaemia, further glucose/capillary glucose testing is not necessary, unless the clinical team feel appropriate (e.g. concurrent high dose glucocorticoid).

Risk factors for developing hyperglycaemia

• Aged >40 years old (>30 years in people of South Asian origin)

• Family history of diabetes

• Personal history of gestational diabetes

• Personal history of hypertension

• Personal history of dyslipidaemia

• Personal history of pre-diabetes

• Personal history of long term/ high dose of glucocorticoid/immunotherapy

Criteria for diagnosing Diabetes:

• Diabetes symptoms plus a random venous plasma glucose ≥11.1 mmol/L or a venous plasma glucose ≥ 7.0 mmol/L

• If no symptoms, a minimum of 2 confirmatory blood tests required taken on separate days

• HbA1C ≥48 mmol/mol and symptoms present.

If HbA1C > 48 mmol/mol and no symptoms, patient at risk of diabetes and needs follow up by GP.

Hypoglycaemia is common in people with diabetes and mainly affects people taking insulin and / or sulphonylurea agents (SUs) such as gliclazide, glipizide and glimepiride or prandial regulators such as Nateglinide and Repaglinide.

Hypoglycaemia is lower than normal blood glucose. It is defined as “mild” if the episode is self-treated and “severe” if assistance by a third party is required.

For the purposes of people with diabetes who are hospital inpatients, any glucose less than 4.0mmol/L should be treated. The majority attending emergency units will have experienced a “severe” hypoglycaemic event.

Hypoglycaemia can cause coma, hemiparesis and seizures. If the hypoglycaemia is prolonged neurological deficits may become permanent. Severe hypoglycaemia is associated with increased mortality.

Table 1. Risk factors for hypoglycaemia

Assessment:

• Review the cause of the hypoglycaemic event

• Follow-up on the available HbA1c results. Consider requesting an HbA1c if > 3 months since the last available result. These results can take some time to be reported, so please ensure follow up and review is arranged and documented.

• Ask about recent or recurrent hypoglycaemic events. If these are recurrent, then the specialist diabetes team should be asked to review the person either in the emergency department or acute assessment unit where admission may or may not be necessary, or urgently as an outpatient.

• Assess the patient for hypoglycaemia unawareness: Are patients aware of symptoms of hypoglycaemia on or before their glucose falls below 4 mmol/L?

Sulphonylureas:

• BEWARE of the low eGFR <30 mml/min and low HbA1c (below 53 mmol/mol)

• Ensure that sulphonylureas are used with caution in frail or older people

• Sulphonylurea must be given with food and hence are not recommended in those who have compliance aids. This is because the patients and /or their carers will be unable to detect and omit which tablet is the sulphonylurea if they are unable or unwilling to eat. Sulphonylureas must be given with food.

• Consult the BNF if in doubt on whether sulphonylureas or other oral hypoglycaemic agents should be continued or the dose adjusted due to hypoglycaemia. The smallest tablet size of gliclazide for example is 40mg so dose reductions need to be in 40mg decrements.

People with diabetes on SUs and/or insulin who have had an episode of hypoglycaemia, in particular the frail, older person, those with other exacerbation of co-morbidities, those who live alone or people who have sustained an injury e.g. fracture, should be admitted to hospital as they are at high risk of further hypoglycaemic episode in the next 48 hours as sulphonylureas, even when discontinued, are slow to be excreted. Everyone admitted with hypoglycaemia and/or their carers should receive education and a leaflet on prevention and treatment of hypoglycaemia. Link to diabetes patient leaflets

Staff should ensure that people are ready for discharge once the acute phase of care is complete (see Table 2 and 3)

NOTE: Any patients admitted to an assessment ward or for a period of observation should be referred for specialist diabetes team review via Epic.

For patient initiated or requiring insulin initiation appropriate referral must be made to the Diabetes Specialist Team for follow up as per Standard Operating Procedures for patients with diabetes in Medical SDEC,add link. The patient must be informed of the location, date and timing of the follow up prior to discharge.

The Diabetes Specialist Nurse Team will provide patients with all necessary equipment and education relating to their diabetes care to manage at home.

Changes made to diabetes care should be communicated to the relevant care provider in the community setting, to ensure continuity.

As far as possible, patients and carers should be made aware of the expected treatment pathway post discharge, the diabetes care provider and contact details.

Self-managing Patients: Those with type 1 or insulin-treated type 2 diabetes who self-manage can usually be discharged with insulin dose advice.

Nurse-administered Insulin: Patients needing insulin administered by District Nurses require a referral and a community authorisation form (community drug chart- add link) with new doses to avoid a failed discharge.

Table 2 Discharge Criteria for patients admitted with hyperglycaemia

Table 3 Discharge Criteria for patients admitted with hypoglycaemia

People with type 1 and those with insulin-treated type 2 diabetes who are usually well, and can self-manage their condition and medication can usually be discharged following insulin dose advice and possible reduction.

They and/or their carers should receive education and a leaflet on prevention and treatment of hypoglycaemia.

Those who are discharged from the emergency department should be strongly encouraged to inform their diabetes team at the earliest opportunity that they have had an episode of severe hypoglycaemia. If in doubt whether the insulin dose should be adjusted, ask the specialist diabetes team for advice.

Ensure the discharge letter states the treatment given, the drugs changed and the follow up plan

and where appropriate, that an HbA1c was taken should also be recorded, and were

necessary, followed up by the primary care team. If the person drives, they must be informed of

the appropriate DVLA regulations regarding severe hypoglycaemia. This advice can be found at https://www.gov.uk/diabetes-driving, if in doubt, call the specialist diabetes team.

If insulin brand and doses known, every effort should be made to obtain the correct insulin from pharmacy, other wards or the emergency cupboard. The site manager keeps a stock list of medications kept throughout the trust. Contact them in the first instance to find out where an insulin is kept. The on-call pharmacist can be called if further advice is required or similarly if that type of insulin is not available. Insulin is an emergency medication and should NOT be omitted.

If insulin brand and doses are known but insulin not available, refer to the “Emergency insulin substitution chart”. When the usual insulin regimen is available, this can be resumed when appropriate.

If insulin brands regimen and doses are NOT KNOWN, manage patient according to “Initial management of Hyperglycaemia in adults in emergency department”, then follow “Decision Support Tool for New Diagnosis” - clinical picture of type 1 diabetes. This will ensure patients with type 1 diabetes who present without any insulin history do not develop DKA in the emergency department.

Emergency Insulin Substitution Chart

• Within working hours contact the diabetes team for advice.

• See the list of insulin below for use when patients’ regular insulin is unavailable.

Unless instructed by the Diabetes Team please switch to usual insulin regimen as soon as the patient’s insulin is available.

• Most insulin stocked on wards or in the emergency cupboard are vials.

University Hospitals of Leicester NHS Trust (2019) Management of hyperglycaemia "at the front door". Emergency Department (ED) and adult assessment areas. Version 1. Available at: https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Hyperglycaemia%20%E2%80%9CAt%20the%20Front%20Door%E2%80%9D%20-%20Emergency%20Department%20and%20Adult%20Assessment%20Areas%20UHL%20Guideline.pdf (Accessed: 21 February 2025).

Getting It Right First Time [GRIFT] (no date) Essential safety checks to prevent diabetes related harms arising in ED and acute admission units. Available at: https://girft-interactivepathways.org.uk/diabetes-essential-safety-checks/ (Accessed: 21 February 2025).

Getting It Right First Time [GRIFT] (no date) Diabetes workstream - Getting It Right First Time. Available at: https://gettingitrightfirsttime.co.uk/medical_specialties/diabetes-workstream/ (Accessed: 21 February 2025).

Joint British Diabetes Societies for Inpatient Care [JBDS-IP] (2023) Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group. Available at: https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_16_Diabetes_at_the_Front_Door_Guideline_with_QR_code_May_2023.pdf (Accessed: 21 February 2025).

Inpatient Diabetes Training and Support (2019) Diabetes "at the front door". Available at: https://www.inpatientdiabetes.org.uk/diabetes-at-the-front-door (Accessed: 21 February 2025).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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