#3584 COMPLIANCE OF DIABETIC MONITORING IN PATIENTS WITH END-STAGE RENAL DISEASE ON MAINTENANCE HAEMODIALYSIS
Authors: Choo Alwyn Yung Zhuang , Aung Thatoe , Yiu Vivian 
Published: June 2023

Abstract

Background and Aims
Diabetic nephropathy is a major cause of end-stage kidney disease (ESKD) in the UK, accounting for nearly 30% of patients requiring dialysis and in some units over 40% of the people on dialysis have diabetes. The national reviewing and benchmarking committee (GIRFT NHS) had highlighted the disjointed and variable care received by these patients, with increasing risk of complications including blindness, foot ulcers and amputations from suboptimal care. Increased monitoring is shown to be cost-effective and co-ordination of a multi-disciplinary team focus can reduce complications especially lower limb amputation rates. Hence, we aimed to review the quality of care on our setting and compare it to national recommendations.

Method
We performed a cross-sectional review on patients with diabetes on haemodialysis in the satellite unit at a district general hospital to assess compliance with the Joint British Diabetes Societies (JBDS) and the UK Kidney Association (UKKA) recommendations on management of adults with diabetes. Subsequently we introduced monitoring protocols for the relevant key areas of diabetes monitoring (pre and post-dialysis glucose checks, HbA1c checks, check boxes for once weekly feet inspections, criteria for inpatient podiatry review), highlighted potential complications including hypoglycaemia, re-emphasised the importance of adequate documentation to allied healthcare teams, and updated the haemodialysis monitoring sheets. We worked with the unit manager to highlight the rationale for monitoring and provided brief education on complications to the team, and over repeated visits, gained the confidence and support of staff for the changes suggested despite an increased workload.

Results
We reviewed data from January to April 2021 followed by re-evaluation 12 months later after implementation of changes. Data for 25 patients were reviewed and re-assessed after a year. 7 patients passed away during this period. Initial review recognised the lack of awareness of good practice management of diabetic patients in the haemodialysis unit. Most patients have type 2 diabetes which carries a higher risk of ESKD. After a year of change in protocols there were significant improvements in monitoring parameters, with greatest improvements seen in glucose monitoring and routine feet inspections.

Conclusion
The review was based on care standards that included diabetes parameters as part of the recommended national care processes, and individualised treatment approach. The aims included were performing annual reviews, adequate glucose monitoring and rational glycaemic targets, and earlier targeted involvement of the diabetes specialist team. There was improvement in most of the monitoring parameters and clearer documentations from allied healthcare teams. Implementation of recommendations was initially challenging due to the COVID-19 pandemic and staff workload on the unit however with persistence we were able to obtain co-operation from the team. As expected, patients on insulin/sulphonylureas (SUs) had proper blood glucose monitoring methods. Most were on insulin, and the remaining were on SU and DPP-IV inhibitor, and those with HbA1c &lt;58 mmol/mol declined. One-third of these patients used flash glucose monitoring and with increasing recognition and recommendation by the NHS hopefully more patients will benefit from this. This audit showed that simple interventions such as staff engagement and education can improve care and monitoring of patients in this population. With recovery of service provisions, more interventions can be put in place. Following this, we can reaudit amputation rates and gather patient feedback, plan interventions with the community team, and encourage involvement from general practitioners and their trainees to deliver better care to these patients. Hence, we emphasise the importance of clear protocols for the management and monitoring of each patient with diabetes mellitus in haemodialysis units to ensure care standards are met.