All Hands on Deck: UK Advice for Diabetes Care During COVID-19

Becky McCall

March 23, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

Diabetes physicians in the UK must not only try to deliver essential diabetes care during the coronavirus pandemic, but may also have to work outside their specialty, according to a new clinical guide by the National Health Service (NHS).

Throughout the guide, there is an emphasis on the use of virtual clinics and remote consultations, with as many contacts as possible performed via telephone, email, and video conferencing.

"Regarding services, we are pushing for all face-to-face appointments to go virtual," remarked Partha Kar, MD, lead author of the guide, who is also National Specialty Advisor, Diabetes for NHS England, in an interview with Medscape Medical News.

"The only services we would like to continue, as long as pragmatic and possible, comprise diabetes patients who are pregnant and those with diabetic foot problems."

Diabetes Not in Front Line but Endocrinologists Have a Key Role

"Diabetes may not seem to be in the frontline with coronavirus but we do have a key role to play and this must be planned," says the new guide.

"We should seek the best local solutions to continue the proper management of people with diabetes while protecting resources for the response to coronavirus," it notes, in acknowledgment of the pressures on the NHS in the current environment.

The guide advises on obligatory admissions and secondary care — emphasizing that outpatient visits should be minimized — as well as diabetes care delivered via primary care.

With regard to pregnant women, Kar told Medscape Medical News: "There are major health outcomes — related to mother and baby — linked to diabetes control in [pregnant] patients. The Royal College of Obstetricians and Gynaecologists (RCOG) says the same in a message to these patients: 'If you're pregnant with diabetes please keep your appointment'," he stressed.

With respect to diabetic foot disease, he added, "If these patents are ignored or miss appointments they might end up with amputations or infections and this places further pressure on the funder."

"These are the two key clinic scenarios that we want to see maintained with whatever staff you have. Everything else goes virtual," emphasized Kar, who is a consultant in Diabetes & Endocrinology at Portsmouth Hospitals NHS Trust, UK.

And for patients with diabetes in general, Kar reinforced the messages for the wider public, saying any adult with diabetes should practice social distancing, such as avoiding crowds and maintaining a safe physical distance from others when out, which is distinct from self-isolation.

Dealing With the Rise of Diabetes Inpatient Care

The NHS clinical guide notes that 18% of hospital beds in England are currently occupied by someone with diabetes and, as such, inpatient diabetes services need to continue.

"People with diabetes are more likely to have more severe manifestations of coronavirus infection, so this percentage is likely to increase over the next few weeks or months," Kar said.

Kar went on to explain that the main role of diabetes staff will relate to inpatient management.

"All the COVID-19 case data suggest that if you have diabetes then you have a higher risk, so we need the inpatient teams of nurses and doctors to ensure intensive care units, anesthetics, and other services have all the support they need," he said.

"We've also asked all the community diabetes teams to shut services in the community and move these clinicians into hospitals during this stage to help the acute team," explained Kar.  

The guide also emphasizes the need to provide support that facilitates early discharge, maximizing inpatient bed capacity, and providing remote support if necessary for those discharged to prevent readmission.

In terms of who should be seen remotely or in person, they advise: "Prior triaging of clinic lists, with evaluation of individual risk factors and clinical needs, will be required to assess which patients may still require face-to-face contact."

In the secondary care setting, there should also be a designated "lead consultant", an essential role during crisis management, which is not the job of the consultant "on-call", they write.

The lead consultant "must be free of clinical duties and the role involves coordination of the whole service from the emergency department; this duty can be for 1 day, a few days, or even 5 days in small units."

The NHS clinical guide for the management of people with diabetes during the coronavirus pandemic was published March 19, 2020.

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