This NHS guidance for general practice covers the key points of delivering diabetes care during the challenging times of the COVID-19 pandemic. With routine care of diabetes significantly disrupted during this time, this summary intends to support and guide general practices with a flowchart of the suggested review process and give practical, pragmatic advice with supporting examples.
This summary has been abridged for print. View the full summary at guidelines.co.uk/455659.article
- The COVID-19 pandemic has required healthcare services to adapt their approaches to care delivery, with remote consultations becoming the default where applicable. It has brought a number of challenges regarding clinical capacity and the management of ongoing care needs alongside the risks associated with face-to-face contact
- Reviews should follow a two-stage process: the first part is focused on any necessary elements requiring face-to-face contact (such as venous blood testing and complete foot checks) and may be omitted on a case-by-case basis after discussion of risks and benefits. The second part is essential for all reviews and is a consultation, performed remotely unless face-to-face contact is specifically required, covering information gathering, issues, concerns, results, actions and next steps. Aim to optimally match workforce skill mix to the identified clinical needs and complexity of reviews
- People with evidence of hypoglycaemia or extreme hyperglycaemia, active foot disease, new pregnancy or new insulin initiation have urgent clinical needs and should be reviewed without delay
- Prioritisation for routine reviews may be necessary with various possible approaches. For any approach, consideration should be given to feasibility, complexity, utility, effect on inequalities, possible unintended consequences and any groups needing additional consideration
- The example approach to risk stratification and prioritisation in this document takes into account significant comorbidities and complications of diabetes, missed reviews and last recorded HbA1c, blood pressure and lipid management status. It is intended a guide only and practices should consider approaches and thresholds based on local needs, data and context (see Table 1).
Table 1: Example approach to risk stratification and prioritisation
|HbA1c (mmol/mol)||BP (mm/Hg)||Lipid management status|
> 86 mmol/mol*
Not on statin despite hx of CVD (excl. haem stroke)
59 – 86 mmol/mol
141/81 – 159/99**
Not on statin despite age ≥ 40 yrs and QRISK ≥ 10%
≤ 58 mmol/mol
On statin (or statin not indicated / declined)
If last results fall into GREEN category but are > 24 months old, person should be stratified as AMBER
People with last results in GREEN category with significant co-morbidities (including CKD stage 3-5, CHD, CBVD, heart failure) or known significant complications of diabetes should be stratified as AMBER
*If risk stratifying and prioritising based on this approach, practices are advised to select a suitable threshold for HbA1c based on local needs, data and context
**Note that the threshold between GREEN and AMBER for blood pressure aligns with the treatment target for diabetes used by the NDA and QOF. An alternative approach would be to adopt the blood pressure target level recommended in NICE NG136 of 140/90 mmHg (for people aged under 80 years).
- National Diabetes Audit data show that over 80% of people achieving glycaemic and blood pressure treatment targets in the previous year are likely to achieve these again in the following year
- A personalised approach to reviews should be taken; in people with moderate or severe frailty, avoid over-intensive glycaemic control with agents prone to causing hypoglycaemia and over-intensive control of blood pressure and lipids. For people at end of life, focus care on symptom management
- The need for face-to-face contact for venous blood testing and foot checks should ideally be assessed on a case-by-case basis. This is particularly important for people who are shielding
- Although likely to be needed by most people, venous blood tests may not be necessary for all. The key question to consider is whether venous blood tests will affect clinical management. If required, phlebotomy should occur at COVID-minimal sites
- Blood pressure readings should be obtained remotely. If this is not possible, face-to-face measurement may be performed if seen for other reasons (such as venous blood testing) or if there are specific concerns. People should be encouraged to purchase a monitor for home use although it is recognised that this may not be feasible for all
- Urinary albumin creatinine ratio may be tested without any face-to-face contact with healthcare professionals
- People should be encouraged and supported to check their own feet daily. Any symptoms suggesting diabetic foot disease should be acted on promptly and referred to specialist care within 24 hours
- Elements of foot checks may be performed remotely by video call, although there may be challenges with video quality and positioning. If a venous blood test is arranged and an in-person foot check is indicated, this should be performed at the same visit, by the same person if possible
- Retinal screening providers are also using risk stratification; people who attended their last invited screen and were assessed as being at low risk of sight loss or retinopathy (R0M0) may have the time between screenings extended to up to 24 months. All recall is managed by the provider
- Self-reported weight measurements are acceptable. People with obesity should be supported to lose weight although care should be taken in older people and those with frailty due to the risk of sarcopenia
- Digital self-management tools have recently launched nationally; ensure people are aware of this free-of-charge support and how it may be accessed:
- Digibete is for children and young adults and is accessed via specialist teams
- MyType1Diabetes is for adults and can be accessed directly at www.myType1diabetes.nhs.uk
- Healthy Living for Type 2 Diabetes is due to be released shortly with a direct to consumer route enabled
- People with diabetes should be made aware of sick day rules and what to do if unwell
- Explore psychological and emotional wellbeing and offer support as applicable
- For people at high risk of type 2 diabetes (but not previously diagnosed with diabetes), the NHS Diabetes Prevention Programme is still accepting referrals and is operating fully remotely.
Algorithm 1: Flowchart of the two-stage review process
The two-stage review process
- Wherever possible and clinically appropriate, consultations should be conducted remotely—online, by telephone, or video call. Careful thought must be given to consultation type if injectable treatment is considered
- Amongst the elements of care which cannot be delivered fully remotely are venous blood testing, retinal screening and complete foot checks. For the majority of people, it will be appropriate to offer venous blood tests and foot checks as part of their review with appropriate infection control precautions. Everyone invited to attend a face-to-face appointment should be informed that they must cancel such appointments if they develop any symptoms suggestive of COVID-19 at any time in the prior 2 weeks
- A diabetes review is therefore likely to occur in two stages:
- the first stage is face-to-face and focused on any required elements which cannot be performed remotely (such as venous blood tests or a complete foot check, if these are indicated). On a case-by-case basis, this stage may be omitted if not completely necessary or may be declined following discussion of the risks and benefits of face-to face contact; if so, consider whether alternative approaches may be viable (such as remotely assessing the feet rather than a complete in-person foot check)
- the second stage is a consultation covering information gathering, issues, concerns, results, actions and next steps. The second stage is required for all reviews and should be performed remotely unless specific circumstances necessitate face-to-face contact.
Urgent clinical needs
- It is essential that urgent clinical needs, both physical and psychological, continue to be managed
- Hypoglycaemia, extreme hyperglycaemia and active foot disease pose risk of major harm in the short-term and require urgent attention
- If insulin has been newly started in response to hyperglycaemia during a hospital admission, it is important that they are assessed promptly following discharge to ascertain safety
- Women with diabetes reporting pregnancy need urgent review and referral.
Venous blood testing
- Venous blood tests should take place at COVID-minimal sites, avoiding acute hospital sites. If possible, all required face-to-face checks should be performed at the same visit
- If one blood test is required, such as renal function, then it is sensible to also request all other clinically indicated blood tests at the same time (such as HbA1c and lipids)
- When evaluating the need for renal function testing, consider:
- time since last test
- values and trend of previous readings
- any intervening acute events (such as hospital admissions)
- any intervening new medications (such as diuretics)
- overall risk of complications (i.e. long duration of suboptimal glycaemic control)
- presence of known diabetes complications (if so, then high risk of nephropathy)
- When evaluating the need for HbA1c testing, consider:
- time since last test
- values and trend of previous readings
- changes in treatment since last measurement
- any evidence suggesting hyperglycaemia or hypoglycaemia (such as symptoms noted in the clinical record, OOH / A&E attendances, ambulance service reports)
- data from capillary blood glucose testing (if applicable)
- If only HbA1c may be needed, consider whether the patient already checks CBG readings and if these could provide enough information to guide treatment (if available and sufficiently detailed)
- There is generally little value in arranging a blood test solely to check lipids—use the last recorded values if assessing QRISK
- If it is deemed that a review could reasonably take place without venous blood tests, but the person with diabetes requests that blood tests are arranged, these should not be denied as long as such tests would have been conducted under ordinary circumstances and the additional risks and measures applicable during the COVID-19 pandemic are explained
- It is also reasonable for someone to decline blood tests due to concerns about face to face contact. This is their decision and should be respected, though it is important to explain the rationale for recommending blood testing, the risks posed by contact, and relevant infection control precautions
- If indicated, arrange for the person with diabetes to bring an early morning urine sample to their blood test appointment and for this to be sent for ACR testing by the health professional taking blood.
- Management of blood pressure is a key aspect of diabetes care and has major influence on the development of the complications of diabetes
- It is expected that anyone with a most recent blood pressure greater than 180/120 mmHg should already have had appropriate management initiated and follow-up arranged, in line with NICE guidance. As a precaution, it is suggested that all practices run a search of any people (not limited to those with diabetes) with last blood pressure reading greater than 180/120 mmHg to ensure that such action has been taken and follow-up is in place; if there is any doubt then urgent review should be arranged.
Urinary albumin creatinine ratio testing
- Of the care processes for diabetes, analysis of urinary albumin creatinine ratio (ACR) has the lowest completion rate according to the NDA. Even if venous blood tests and an in-person foot check are not taking place, make sure that consideration is given to urinary ACR testing.
- Diabetic foot problems should be referred to a specialist team within 24 hours, if not requiring immediate acute referral. Delayed referral to a multi-disciplinary footcare team is associated with poorer rates of ulcer healing (National Diabetes Foot Audit)
- It is recommended that everyone with diabetes should be supported to check their feet daily (see www.diabetes.org.uk/guide-to-diabetes/complications/feet/taking-care-of-your-feet), in addition to having a scheduled yearly foot check.
- Although general practice is not directly involved in the scheduling or recall for retinal screening, questions and concerns regarding screening may arise during reviews. As part of the restoration of diabetic eye screening, a risk stratification approach to invitations for screening has been agreed nationally
- People with diabetes most at risk of sight loss and progression of retinopathy will continue to be invited for screening as usual, while people who attended their last invited screen and were assessed as being at low risk of sight loss or retinopathy (R0M0) may have the time between screening extended to up to 24 months.
Weight checks and lifestyle support
- Weight may be measured at the same time as attendance for blood tests or foot checks. If not having other procedures or checks in-person, it is reasonable to accept self-reported weight. In most cases, if there is no other reason for face-to-face contact, the need for an updated weight measurement is unlikely to justify a face-to-face attendance unless there is a specific concern.
Support for self-management
- It is essential to encourage and empower self-management. Historically, diabetes structured education has usually been provided in group, face-face settings; this mode of delivery ceased during the COVID-19 pandemic. Digital diabetes structured education tools have been commissioned nationally; once available, ensure that people with diabetes are aware of such support and how this may be accessed.
- The links between diabetes and psychological ill health are well established. In many people, the COVID-19 pandemic and resultant lockdown have resulted in social isolation and additional anxiety. The diabetes review should not solely focus on blood glucose control, blood pressure and lipids; it is important to enquire about psychological and emotional wellbeing and holistically support the person with diabetes.
Bakhai, C. Delivering diabetes care during the COVID-19 pandemic – the ‘new normal’. Available at: www.diabetes.org.uk/resources-s3/public/2020-06/Delivering%20Diabetes%20Care%20during%20the%20COVID-19%20Pandemic%20220620.pdf
Published date: 22 June 2020.