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Hypoglycaemia in the Elderly Patient

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Harry Harry

on 3 July 2013

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Transcript of Hypoglycaemia in the Elderly Patient

Dan Staines
Care of Older People in the Out-of-hospital Urgent Care Environment
Monday 15 April 2013
Case study of a patients encounter in which the referral pathways available played a key role in influencing the outcome
Aims of Presentation
Case Study
Critical Analysis of the evidence/research relating to hypoglycaemia in the elderly
Model of regional good practice in the UK
Future Advances
Conclusion
Questions/Discussion

Hypoglycaemia in the Elderly Patient
Case Study
78
"diabetic problems
?hypoglycaemia"
"Patient is concious and breathing"
A - Clear, open, self maintaining
B - Rate 24 - R/L bilateral a/e - 97% O/A
C - Radial 90bpm - diaphoretic
D - V on AVPU; BM
1.2mmol/l
Patient found on chair in living room of sheltered accommodation
Imp:
Tx: 1mg glucagon IM,
simple carbohydrates,
complex carbohydrate, BM = 5.4 mmol/l
Primary Survey:
Care Plan
You are sent on your next emergency call...
but wait...
let's review that last case?

How safe will this patient be at home?
How much risk is a recurrent hypoglycaemic episode?
How effective are the safety netting you have implemented and what about the follow up?
What are the other considerations specific to elderly patients with diabetes with hypoglycaemia?
Clear on scene
Epidemiology
Ask patient to self Refer to their GP
Identify cause where possible
Any repeat of signs/symptoms = 999
Sign PRF ("cover our backs")
Left in care of wife on scene
2.9 million patients diagnosed with diabetes in the UK
(Diabetes UK, 2012)
Percentage
Age
(Diabetes UK, 2012)
th
Older people make up almost half of the people diagnosed with diabetes in the UK and approximately 1 in 5 older people have diabetes
(Institute of Diabetes for Older People, 2013)
"An estimated 40% are transferred to Emergency Departments; where approximately 10% are admitted"
(Diabetes UK, 2008)
Diabetes accounts for around 10% of the NHS budget;
£10 billion per annum
NHS Hospital admission for severe hypoglycaemia is estimated to be approximately £1000 per patient


In 2007-2008 there were over 10,000 admissions with hypoglycaemia in the UK with the majority over 75yrs, resulting in a total of 50,000 bed days
100,000 emergency 999 calls are recieved in the UK for diabetes, most often for hypoglycaemia
Emergency Care
Cost of Hospital Admissions
(Primary Care Diabetes Society, 2011)
(National Health Service Information Centre, 2008)
Cost of Diabetes
What should the referral process look like?
"The rest are treated and left on scene once the patient has been treated and that the person is safe".
Evidence For Referral Pathways for Hypoglycaemia in the Elderly
Conclusion
Future Advances
Case Study
Case Study 2
Assessment & Treatment
Paramedic Critical Decision Making
Yorkshire & Humber Region
Pioneering referral pathway to improve service for patients with hypoglycaemia in the pre-hospital environment.

Three month pilot trial
(December 2002-March 2003)
National Service Framework for Diabetes
"The aim of management of diabetic emergencies is to on people with diabetes of the acute complications of diabetes"
Standard 7
"The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained healthcare professionals"
"These protocols will include the management of acute complications and procedures to minimise risk of reoccurance"
minimise the impact
2001
2013
Taking Healthcare to the Patient
2005
Taking Healthcare to the Patient 2
2011
More attention for 90% without life threatening conditions
Better assessment and better care and only taken to ED when necessary & resolving needs of patient who do not need ED
Resolving needs of patients who do not need ED and complex decision making - especially elderly patents - assisting primary teams to keep the patient in their own home where possible
(National Institute for Health & Care Excellence, 2011)
(Joint Royal Colleges Ambulance Liaison Committee, 2013)
Call
999
Ambulance crew treated
If left at home or refused ED
Information leaflet
Optional & Consent
Referral to Diabetic specialised nurse (DSN)
Patients contacted within 7 days
Results
Methods
38 patients reffered to DSN
Age ranged from 25-92 years

38/38 spoke to DSN
30/38 attended for review
1/38 had episode of severe hypoglycaemia prior to review
20/38 required a change in their medications
26/38 returned the questionnaire
23/26 AGREED or STRONGLY agreed that it had improved their understanding of the hypoglycaemic episode
Critical Analysis
1. Clearly low subjects within evaluation
2. No subjects refused referral and referral was made direct to DSN
3. All patients recieved education regarding managing their diabetes
4. Patient needed to be randomised to either control or intervention & over longer period of time
5. No forms - easy for crews to refer
Presently there is little research available on attempts to follow up patients treated by Paramedics and left at home in the UK
50% of subjects were over 60 years
Following the pilot, this referral process has been introduced across all of Yorkshire & Humber region
Lives alone, reduced mobility; frail
Dizziness and confusion injury but in vulnerable older person it may be particularly dangerous if it leads to falls and confusion.
Our Health, Our Care, Our Say
2006
2011
2011
ED
(Diabetes UK, 2008)
?
"Treat & Discharge"
"Transport to Hospital"
Hypoglycaemia Diabetes Emergency
"I don't want to go to the hospital"
"Illness in frail older people typically presents atypically"
(Forsyth, 2013)
Affect of chronic co-mobidities/pathophysioloy
Hypoglycaemic Associated Autonomic Failure (HAAF)
Dunning (2005)
Clinical Assessment
Recurrent Hypoglycaemia Episodes
Fitzpatrick & Duncan (2009)
Systematic review
Improving patients safety following hypoglycaemic episodes in pre-hospital setting
Specifically type II diabetics on oral hypoglycaemic agents (OHA)
Post hypoglycaemic patients treated in pre-hospital setting are at a risk of experiencing recurrent hypoglycaemia episode within 48 hours
Recommends potential of recurrent hypoglycaemia with patients on OHA - High risk Transport to hospital
2-7%
Sulfonylurea Drugs
Significant Prolonged half life
Second generation: Gliclazide
"Transport to hospital"
"Easier said than done"
There is no standard recurrent hypoglycaemia episode time period
Referral Pathways Ineffective
Risk of Falls
(Brackenridge, Wallbank, Lawrenson, 2006; Roberts & Smith, 2003)
Education is Key...
Diabetes is a highly prevalent medical condition in the elderly which challenges healthcare systems to meet specific needs and deliver high quality care.
Limited development in development of referral pathways in recent years has lead to sub-standard, non specific patient care.
It remains a challenge to identify elderly patients who require "Transport to ED" or "Treat & Refer".
is key from healthcare professions in supporting patients with diabetes with an increased risk of hypoglycaemia
Treat & Refer
Treat & Transport
Referral made to primary care; local diabetic specialist nurse team
Pre-Hospital Assessment & Clinical Decision Process
The referral pathway need to be structured and supportive with improved pre-hospital clinical decision making as well as recognition of complex health needs improving patient safety
Education
Patient was reffered to their regional DSN through a phone call to EOC from Paramedic crew.
A day later the DSN met with patient
Highly specific
Education
Holistic assessment in community
Medication review and modification
GP review
Patient was pleased of high standard of specific care recieved within the community setting and service delivery.
Case Study
(Alternative Referral Pathway)
Any Questions...
Thank You
Breaking down barriers and improved communication in delivering multi-disciplinary care
Increased knowledge, education and application of pre-hospital practitioners within complex patient groups such as the elderly
"Not protocol driven
Wide variation in referral pathways for elderly within UK
IT Issues
European Diabetes Working Party for Older People, 2011)
Self referral = ineffectve
Roberts & Smith (2005)
Issue: Some patients do not want to be referred
Follow up?
Most patients can be treated safely at home
40% hypoglycaemic unaware
1 in 6 required change in medical management
Identified outcomes for patients treated for hypoglycaemia in the pre-hospital setting & included set of reccomendations for safe follow up of patients
Concluded it is safe for around 90% of patients
Safety netting included referral letter to GP
Every patient should be woken up every two hours
Elderly patients considered "high risk"
Results
Short term patient centred investigation to see if education would improve patients living in residential homes in Coventry & Warwickshire area
Cluster randomised controlled trial
Intervention (57 residents from 25 homes)
Control (45 residents from 26 homes)
Intervention included medical review and educational programme whereas the control group received normal care.
Measures included glycaemic control, quality of life, functional ability, mood, cognition and diabetes knowledge for 6 months.
Results
After 6 months the intervention group had a better quality of life, mood and diabetes knowledge and
reports of hypoglycaemia were less at the end of the study in both groups.
Analysis
The reduction in hypoglycaemia attacks in both groups could suggest the impact of increasing understanding and education of care staff across both arms of the study
Case Study
Critical Analysis
Hypoglycaemia
(Hex, Bartlett, Wright, Taylor and Varley, 2012)
(Kropff, Selwood, McCarthy, Farmer and Owens, 2011)
Roberts & Smith, 2003; Brackenridge et al., 2006; Sinclair et al., 2012; JRCALC, 2013)
(Sinclair, Paolisso, Gastro, Bourdel-Marchasson, Gadsby & Manas, 2011)
(Walker, James, Bannister & Jobes, 2006)
(Primary Care Diabetes Society, 2011)
Patients attendance for follow up care in primary care is low & when patients do make an appointment the time delay between referrals = relapse (Walker et al., 2006)
(Sinclair, Girling, Gadsby, Bourdel-Marchasson & Bayer, 2012).
(Joint Royal Colleges Ambulance Liaison Committee, 2006)
In the survey by Daniels (et al,10 only 37% of respondents had consulted their diabetes carer despite advice to do so
(Association of Ambulance Chief Executives, 2011)
(Department of Health, 2005)
(Department of Health, 2001)
(Department of Health, 2006)
Full transcript