The COVID-19 pandemic has had a tremendous impact on both inpatient and outpatient diabetes secondary care in the UK, with many diabetes specialist services being suspended and teams re-deployed to work on the frontline, while others are shielding at home. Although this has been unsettling and challenging, it has presented diabetes teams with opportunities to re-set and innovate some of their ways of working. The pandemic occurred against a backdrop of the most recent National Diabetes Inpatient Audit data (NHS Digital, 2020), which showed a prevalence of inpatient diabetes of 18% (an increase from 14% in 2010), increases in patient harms including diabetic ketoacidosis, and insulin errors and 18% of hospitals lacking inpatient diabetes specialist nurse cover (NHS Digital, 2020). In addition, teams were working towards guidance from Diabetes UK (2018) regarding ‘Making hospitals safe for people with diabetes’ with recommendations of having sufficient diabetes inpatient specialist nurses to run a daily and weekend service.
The disruption to inpatient and outpatient diabetes care has seen a reduction of specialist nurses and consultants providing routine patient care, which has placed a strain on service provision, alongside the redeployment of clinicians without diabetes expertise now providing diabetes care. Although redeployed diabetes practitioners do their best to exert their influence by providing advice and support on the wards, it does not make up for the usual pre-COVID structured diabetes specialist service within secondary care.
Referrals
One side-effect of the COVID-19 pandemic has been the rise in diabetes-related referrals to diabetes specialist care teams by non-specialists, unfamiliar with inpatient diabetes management, which is a reflection of the complexity of inpatient diabetes management (Pasquel et al, 2021). However, this has not always occurred and errors are often picked-up retrospectively during patient reviews. There has always been a recognition by diabetes teams that the existence of guidelines does not guarantee adherence and this was made apparent during the COVID-19 pandemic. The availability of electronic health records in many inpatient settings meant that diabetes specialist teams were able to review referrals, monitor results of point-of-care tests and adjust therapy remotely as appropriate (Pasquel et al, 2021). One of the factors that brought inpatient diabetes to the forefront was the link between diabetes, obesity and COVID-19 (Abdi et al, 2020; Feldman et al, 2020) and the development of the ‘COVID and diabetes’ guidelines for managing hyperglycaemia with or without diabetes (Diabetes UK et al, 2020). This tool, and subsequent updates, have helped inpatient diabetes teams to support non-specialist colleagues in managing very sick patients. Additionally, some diabetes specialist services have developed more robust front-door presence to help avoid unnecessary admission and readmission of people with uncomplicated diabetes into hospital as well as introducing 7-day working (Diabetes UK, 2018; Burr et al, 2020).
Education
The safe care of patients with diabetes relies on the ongoing provision of education and training to inpatient staff by educators and specialist practitioners. Training on the safe use of insulin and the main diabetes harms and how they can be prevented should be mandatory for all health professionals caring for people with diabetes (Diabetes UK, 2018; Rayman and Kar, 2020). Most diabetes teams have traditionally delivered staff education in classrooms or on the wards reactively in response trends in incidents and proactively before symptoms manifest (Setty et al, 2017; Stewart, 2017). The infection control risks associated with face-to-face education meant a move to online learning as an emergency response to the pandemic (Bakhai, 2020). Some teams revised and updated pre-existing local online learning content during the initial wave as a stop-gap, and over the past year, diabetes teams have made their foray into online and virtual learning platforms with the aim of developing meaningful online educational diabetes resources (Ives, 2020).
Outpatients
For secondary care teams providing outpatient services, these too have been adapted in response to the pandemic, with remote consultations becoming the default where applicable (Bakhai, 2020). Specialist services have evolved in terms of adoption of remote virtual telemedicine clinics, which have had both favourable and unfavourable outcomes for patients and staff (Quinn et al, 2020). Although networked glucose monitoring and insulin pump online download technology has always lent itself to remote review (Diabetes UK, 2020), its use was maximised during the pandemic. In addition to reviews, diabetes teams initiated pump and Freestyle Libre starts remotely, using video calling platforms and making use of the online resources (Vigersky et al, 2020; Mumford et al, 2021). Additionally, DAFNE (dose adjustment for normal eating) courses, which are normally held face-to-face, were cancelled from March 2020 due to COVID-19 and various diabetes centres trialled a new online ‘Remote DAFNE’ (DAFNE, 2020).
Staff education
The need for staff education has become more urgent than ever, due to anecdotally reported diabetes-related errors as well as CPD requirements of pre-existing and newly qualified staff (Lange and Pearce, 2017; Diabetes UK 2018). In addition to development of intranet online learning platforms, inpatient diabetes teams have used events such as Hypo Awareness week (5–11 October 2020), Insulin Safety week (6–12 July 2020) and World Diabetes Day (14 November) to educate staff. However, with social distancing measures in place, the capacity to interact face-to-face with staff is greatly reduced and the uptake of online activities remains a challenge due to the ongoing staff shortages, redeployment, illness and general fatigue from work pressures. Further resources have been provided by Diabetes UK and NHS England to supplement existing educational resources, but diabetes teams have had to acknowledge that staff may not have the capacity, head-space or access to learn from home.
Conclusion
In many ways, diabetes inpatient teams have faced similar challenges to other specialities during the COVID-19 pandemic and lessons were learned and shared among disciplines. This knowledge sharing and camaraderie has been a hallmark of inpatient care. Specialist diabetes services continue to run the best way they can, in spite of the current difficulties. With the introduction of the COVID-19 vaccine, there is hope for a return to service of updated and rejuvenated diabetes in-patient and outpatient specialist services.