Introduction

This section gives guidance on managing patients with elevated capillary blood glucose (CBG) levels and/or diabetes within the Emergency department (ED) and admission areas.  Guidance covers patients who are not known to have diabetes as well as those known to have diabetes.  There is also guidance on the management of hypoglycaemia in ED.

Hyperglycaemia

Patients with diabetes may present with an emergency directly related to their diabetes (eg, hyperglycaemia, diabetic ketoacidosis (DKA), Hyperosmolar hyperglycaemic state (HHS), hypoglycaemia, foot emergency, continuous subcutaneous insulin infusion (CSII) pump failure) or may be admitted for many other emergencies where diabetes is a secondary diagnosis (eg, pneumonia, stroke, trauma, appendicitis, etc).  Patients may also present as an emergency, with elevated CBG and no previous diagnosis of diabetes.  A proportion of these patients will have newly diagnosed diabetes and some will have stress hyperglycaemia.

This section aims to give pragmatic guidance on managing hyperglycaemia and diabetes safely in the first few hours within either ED or the admissions areas.  It also covers how to safely manage a patient who is treated with insulin but is unable to tell you which insulin they take when admitted to hospital.  Management of the diabetes emergencies is covered in each relevant section.

Key Safety messages:

• Never omit or stop insulin in patients with type 1 diabetes – risk of DKA
  (see Safety NewsFlash from Royal College of Emergency Medicine )

• If patients are acutely unwell and have an elevated capillary blood glucose (CBG) consider if variable rate intravenous insulin is required (exclude DKA and HHS first)

• Prescribe diabetes medication as soon as patient has been assessed.  Ensure it is appropriate and given at the correct times.  Establish appropriate CBG monitoring from admission.

• Rarely patients with type 2 diabetes on the SGLT2 inhibitor class of tablets can develop DKA – check pH, bicarbonate and ketones if a patient is admitted acutely unwell on these tablets

• Involve the specialist diabetes team at the earliest opportunity

UHL decision support tool for the management of hyperglycaemia - capillary blood glucose (CBG) >12 mmol/L “at the front door

ITS ANIMATION: SAFE USE OF FRIII

Hypoglycaemia

Many patients who attend ED or admissions areas with hypoglycaemia do not require admission.  For elderly patients admitted with hypoglycaemia consider medications review and rationalisation of diabetes medication where possible.  Be especially aware of elderly patients with diabetes who have an HbA1c of less that 7% (53 mmol/mol) and are treated with insulin or sulphonylureas. These patients are at risk of hypoglycaemia and are likely to require reduction or discontinuation of their medication.  Ensure any discharge letter details treatment given, changes to medication and follow-up plan.

The following pathway aims to support assessment and safe treatment for this group of patients.

• Link to JBDS ABCD page for National guidance.

• Management of Hyperglycaemia “at the front door” - Emergency department (ED) and adult assessment area UHL Guidelines