Over the past decade, the incidence of all types of diabetes has been increasing rapidly around the globe. Although the incidence of type 1 diabetes peaks in puberty and early adulthood, it affects all age groups, with a global prevalence of 5.9 per 10 000 population (Mobasseri et al, 2020). Within the UK, the NHS National Diabetes Audit or ‘NADIA’ (NHS Digital, 2020) estimated the figures for type 1 diabetes to be approximately 400 000, including around 29 000 children (NHS Digital, 2021a). Around half of newly diagnosed cases of type 1 diabetes are those of people over the age of 18 years (NHS Digital, 2021b). The incidence of new diagnoses of type 1 diabetes is increasing by about 4% each year.
The latest NADIA data for type 1 diabetes in the UK (NHS Digital, 2021b) highlighted that people with confirmed type 1 diabetes at an adult specialist service was low (78 585, which is 35.9% of the total number of people with type 1 diabetes (218 670). This means that a proportion of these patients are seen within primary care or in the community setting. Specialist care for those with type 1 diabetes is accessed locally when specific specialist care input is needed, such as in cases of frequent hypoglycaemia or impaired awareness of hypoglycaemia, complex long-term complications, insulin pump therapy, recurrent secondary care admissions, pre-conceptional care and pregnancy.
Type 1 diabetes is caused by autoimmune damage of the insulin-producing β-cells found in the islet cells within the exocrine pancreas (Mobasseri et al, 2020). This will usually lead to severe endogenous insulin deficiency. Multiple clinical characteristics can help diagnose or confirm type 1 diabetes, but they should not be used alone, as the misclassification of type 1 diabetes in adults is common, with over 40% of those developing type 1 diabetes after the age of 30 years being initially diagnosed with type 2 diabetes (Thomas et al, 2019). The most commonly occurring features are younger age at diagnosis (<35 years), a lower BMI (<25 kg/m2), unintentional weight loss, ketoacidosis and blood glucose >20 mmol/L (Holt et al, 2021). Other symptoms that can be used to clinically correlate a diagnosis include osmotic symptoms, family history or a history of autoimmune conditions (Rabbone et al, 2020).
Long-term complex conditions such as type 1 diabetes come with an exceptional psychological burden of management on the individual (Gold et al, 1994; Hessler et al, 2017). In addition to complex medication regimens, other behavioural changes are needed to navigate hyper- and hypoglycaemia, as well as psychological issues. Therefore, self-management, education, support and psychosocial care are key to multidisciplinary team (MDT) care of those with diabetes from the outset.
COVID-19 and diabetes
During the year of 2020, the world faced the SARS-CoV-2 pandemic. The World Health Organization (WHO) cited the worldwide death rate from the pandemic to be 4.1 million (WHO, 2021).
It is well known in the NHS that primary care is the first line of defence for healthcare, particularly within diabetes care. Evidence from NHS England published in 2020 showed that those with diabetes were at high risk of poor outcomes from COVID-19 (Barron et al, 2020). Primary and community-based care reinforces public health communications and help patients manage their conditions effectively at home (Krist et al, 2020). It became important to be able to review people with type 1 diabetes and for health professionals to have the skills to confidently assess hypoglycaemia via remote consultations.
Glycaemic variability and real-time continuous glucose monitoring
Although glycosylated haemoglobin (HbA1c) is an indicator of mean glucose levels, it does not reflect glycaemic variability and hypoglycaemia. It is often these characteristics of diabetes that cause the significant worsening of quality of life for those living with it. With the recent advent of real-time continuous glucose monitoring (rt-CGM) and flash glucose monitoring systems in the NHS and wider healthcare organisations, ti is no longer acceptable to use HbA1c as the only tool for glucose evaluation in type 1 diabetes (Beck et al, 2017a). Beck et al (2017a) confirmed that, even with frequent capillary blood glucose testing, many with type 1 diabetes will have undetected and often high frequency of glycaemic variability. It is important to note that the frequency of blood glucose testing required can correlate with high levels of diabetes distress and burnout as well (Hessler et al, 2017).
Diabetes-specific emotional stress is thought to affect 20–40% of people with type 1 diabetes (Hessler et al, 2017). The feelings of grief, powerlessness, as well as fear of hypoglycaemia are among the most common reasons associated. Continued diabetes distress is linked with low mood, increased admissions for diabetic ketoacidosis and elevated HbA1c levels (Hessler et al, 2017).
There are two types of rt-CGM devices that provide a continuous value of glucose and trends to a receiver: while one requires a physical scan of a sensor worn upon the body to read glucose levels, others rely on Bluetooth technology to transmit the data from the sensor to reader or a phone app highlighting a person's blood glucose levels continuously. All sensors can be connected via compatible phone apps, readers, smartwatches and some closed-system insulin infusion pumps (CSII). The ability to review glucose data remotely during the pandemic was particularly useful, and telemedicine was vital. Based on randomised controlled trial data (Beck et al, 2017b), rt-CGM has been shown to be successful for adults with type 1 diabetes in improving their HbA1c, reducing hypoglycaemia for those using CSII and reducing multiple daily injections (MDI). It has also been found to be beneficial in reducing worry of hypoglycaemia (Heinemann et al, 2018) and hypoglycaemic events in those with impaired awareness of hypoglycaemia.
Hypoglycaemia
Hypoglycaemia is biggest challenge for strict glycaemic management of type 1 diabetes. Hypoglycaemia can be defined as three noticeable levels (Table 1). Problematic hypoglycaemia is defined as two or more episodes per year of severe hypoglycaemia or as one episode associated with impaired awareness of hypoglycaemia, extreme glycaemic lability or where major fear is a challenge for the patient (Choudhary et al, 2015).
Table 1. Definition of hypoglycaemia levels
| Alert value | 3–3.9 mmol/L has been defined as a hypo alert value | Often seen in people without diabetes, if asymptomatic or not wakingThis is perhaps a normal physiological process |
| Serious hypoglycaemia | <3 mmol/L with typical symptoms of hypoglycaemia | Accompanied by slowing of brain function; people can experience confusion or altered mental stateNon-severe symptomatic—symptomatic, without cognitive impairment; person can self-treat |
| Severe hypoglycaemia | <3 mmol/L without any symptoms of hypoglycaemia | Severe non-symptomatic—cognitive impairment where someone has needed to assist themLoss of awareness of hypoglycaemia (no or limited symptoms most of the time when glucose <3 mmol/L) |
| Prolonged hypoglycaemia | Over 2 hours <3 mmol/L |
Level 1 hypoglycaemia is common, with most people with type 1 diabetes experiencing several episodes per week. It is thought that up to 10% of readings below 3.9 mmol/L are seen in those with HbA1c around 7% (53 mmol/L) and does not lead to harm (International Hypoglycaemia Study Group, 2021). Serious hypoglycaemia is a blood glucose level of >3 mmol/L (International Hypoglycaemia Study Group, 2021). This may or may not be accompanied by symptoms. Repeated episodes at this level increase the risk of severe hypoglycaemia. Severe hypoglycaemia occurs more often and is picked up more frequently now due to rt-CGM data (Heinemann et al, 2018). The rate of hypoglycaemia seen on rt-CGM is similar between those with normal awareness and those with impaired awareness of hypoglycaemia by clinical scores, indicating that, while rt-CGM is useful to identify those with hypoglycaemia, it cannot be used to define hypoglycaemia unawareness (Choudhary et al, 2015). While newer basal analogue insulins reduce hypoglycaemia compared with first-generation basal analogues, Heinemann et al (2018) showed that rates of hypoglycaemia have not reduced, despite their frequent use. Spending >10% of time at levels below 3.9 mmol/L is usually considered to be a high amount of hypoglycaemia.
Impaired awareness of hypoglycaemia (IAH) is also a serious concern in people with type 1 diabetes. High mortality from severe hypoglycaemia is not rare, with a trial showing that more than 8% of deaths are attributed to this. The Gold questionnaire (Figure 1; Gold et al, 1994) can be used efficiently by health professionals to demonstrate people's level of hypo awareness by a score. Guidance from the National Institute for Health and Care Excellence (NICE) (NG17; NICE, 2020) recommends that hypoglycaemia be assessed in patients, including awareness, at every consultation (NICE, 2020).
Risk factors for hypoglycaemia
There are several risk factors for hypoglycaemia in people living with type 1 diabetes, which health professionals should be aware of (Table 2). Defective glucose counter regulation and failure to generate an adequate glucagon response to hypoglycaemia play a key role in the susceptibility to severe hypoglycaemia (Heinemann et al, 2018). Working through these with people can highlight key areas where nursing intervention can help improve quality of life and prevent hospital admission.
Table 2. Risk factors for hypoglycaemia
| Injection technique | Lipohypertrophy can cause variable insulin absorption. Needle length increase the potential for hypoglycaemia. Needle size is important as 4-mm needles are usually sufficient to reach the subcutaneous layer. However, a longer needle will result in intramuscular injection, potentially causing glycaemic variability and hypoglycaemia Spoiled and expired insulin is a safety risk and may cause increased glycaemic variability and hypoglycaemia |
| Frailty | Frailty is frequently associated with weight loss, which may increase insulin sensitivity and improve glucose tolerance. There is also an increased risk of cognitive impairment and risk of polypharmacy |
| Alcohol | Consuming alcohol can mask some of the important warning signs of a hypoglycaemia, which can raise the risk of a severe hypoglycaemia occurring. Alcohol stops the liver being able to break down glycogen stores to raise low blood sugar levels |
| Activity/exercise | Unplanned activity and aerobic exercise can increase the risk of hypoglycaemia. This needs to be relative to the activity undertaken and depends on many things, recent glucose data, timing of activity, type of activity and duration of activity |
| Chronic kidney disease | Chronic kidney disease imposes restrictions on therapeutic options for those with diabetes. Additional factors are altered drug metabolism, drug interactions, albuminuria, autonomic neuropathy, malnutrition, infection, problems linked to dialysis and associated cardiac and hepatic disease |
| Impaired awareness of hypoglycaemia (IAH) | Longer duration of type 1 diabetes and patient age are consistently related to IAH identified with the Gold questionnaire in those people who are not using rt-CGM. This can be related to ‘too strict glycaemic management’. |
Case study
This case study will aim to look at diabetes specialist nursing interventions within the community. The Nursing and Midwifery Council's (NMC) code of conduct (NMC, 2018) was adhered to, and all information is used under a pseudonym. Neil was referred to the author from the ambulance service, with a level 3 or ‘severe hypo’ event. He was unable to treat this effectively himself. His wife had to call an ambulance, and the paramedics treated him at the scene with IV dextrose.
Neil is a 54-year-old man who has had type 1 diabetes for 37 years (diagnosed at age 17 years). He has a previous diagnosis of non-proliferative retinopathy in the right eye and moderate proliferative retinopathy moderate in the left eye. He had not had a routine annual retinal screen since 2018.
A detailed history was taken from Neil to assess the nursing interventions needed. Neil reported that his view of the current problem was as follows:
‘I am going up really high and then plummets with rapid insulin. I am managing diabetes with rapid insulin. I take my long acting maybe once a week if going to bed with an arrow up.’
Neil had been using the Freestyle Libre device for a year when he spoke with the author. With consent, Neil was asked for permission view his data, which he verbally agreed to (NMC, 2018). Neil was scanning on average 14 times a day, with 91% of the data from the sensor captured and a 3-month history of glucose data (Figure 2). The glucose variability was 46%, showing a considerable variability of glycaemic levels; international consensus standards recommend this to be no higher than 36% (Battelino et al, 2019). Neil's current level of hypoglycaemia was alarming and clinically relevant.
Neil also explained that he had had two severe hypoglycaemic events in the past month, which occurred while he was on holiday in Spain. He had been admitted to hospital on one occasion, requiring IV dextrose.
Neil's latest HbA1c level was 84 mmol/L was historic, dated December 2020. Neil explained that he had had type 1 diabetes for 17 years, and he ‘never took his diabetes seriously and didn't really understand it.’ Time was spent educating Neil about type 1 diabetes and the profile of the insulin he was using. Neil was currently prescribed Tresiba u100 15 units once daily, although he was not using this, relying solely on larger doses of NovoRapid to manage his glucose levels. In response to stopping the Tresiba, Neil had increased his NovoRapid dose to 12–14 units three times daily with meals. Neil was not currently carbohydrate counting and had no understanding of his insulin-to-carbohydrate ratios.
When asking Neil about his hypoglycaemia awareness, he rated his GOLD (Gold et al, 1994) score to be around 6, indicating IAH, although he did report that he gets symptoms of a numb tongue around 3–4 mmol/L. He treated his hypoglycaemia appropriately with quick-acting carbohydrates if he was aware of it. However, he often failed to follow this up with longer-acting carbohydrate.
Prioritising nursing interventions
Several educational subjects educational subjects that needed addressing were identified, along with positive nursing interventions that could make a real difference:
- Hypoglycaemia assessment: injection technique, driving, exercise, alcohol intake (Table 3)
- FreeStyle Libre/rt-CGM: access to alarms
- Insulin: restarting basal insulin with readjustment of the bolus insulin
- Education support with diabetes and carbohydrate counting.
Table 3. Hypoglycaemia assessment tool
| Type of diabetes | T1/T2/T3c/GDM/MODY |
| Duration (years) | |
| FSL/Dexcom data reviewed | Dates covered:Glucose variability (%):Average glucose:GMI:Target ranges set (4–10 mmol/L):Time above range:Time in target:Time below range (abnormal=3.9 mmol/L for >10% of the time or <3 mmol/L for 5% of the time):Hypoglycaemic events/2 weeks:Event pattern (early nocturnal (bedtime to midnight), late nocturnal (midnight to 7 am), post-prandial, post-exercise, variable):Scans per day:Data % usage: |
| Patient is reporting increased hypoglycaemia affecting QoL | Duration:Severe hypoglycaemia (requiring third-party assistance):Severe hypoglycaemia requiring hospital admission in the past year:Prolonged hypoglycaemia (<3 mmol/L for 2 hours or results in anxiety/reduced QoL):GOLD score:IAH:Symptoms at mmol/L:Symptoms include:Quick-acting carbohydrate treatment:Longer-acting carbohydrate treatment: |
| Frailty | Is this an issue for the patient?Consider frailty assessmentDo they need HCP involvement for insulin/BG monitoring—community nursing?Consider outside HCPs (OT/sensory services/physio)Would rt-CGM/FSL help? |
| FSL/rt-CGM alarms | Low alarm:Low soon alarm:Urgent low alarm:Using FSL 1/2: |
| Alcohol | Discussed alcohol consumption and explained the action of alcohol on the liver and BG levelsPatient is consuming units/day:Drinking on how many days of the week: |
| Holidays/heat | Discuss effect of heat/holidays |
| Exercise | Exercises regularlyAnaerobic/aerobic:Explain process of how exercise affects the body, discuss use of carbohydrate therapy and using arrows on CGMExplain that exercise should be avoided if patient has experienced hypoglycaemia in the past 24 hoursAdvise that hypoglycaemia in the morning is less likely if the patient is exercising, due to insulin resistance |
| Pregnancy | Any chance the patient is pregnant (hypoglycaemia is more likely in the first trimester) |
| Injection technique | Size of needle usedDiscuss lipohypertrophy and how to check for this at homeInjection sites assessedIf lipohypertrophy is found, advise patient to avoid using this area, mark with a penAdvise to reduce insulin doses by 20–30% when moving to a fresh site and re-titrate dosesAdvise to avoid using lipohypertrophy sites for 6 months and to use healthy sitesDiscuss using 4-mm needles and brand-new ones each time to maintain good injection sites |
| Insulin | Basal insulin:ICR:ISF:Carbohydrate counting:Ratio of basal-to-bolus:Has insulin been spoiled/is it expired?: |
| Driving | Explain DVLA regulations and need for patient to access theseDiscuss safety when driving, how to treat a hypoglycaemic event if driving (to pull over, get into passenger seat and remove keys from ignition. Wait 45 min once above 5 mmol/L before setting off again) |
T1=type 1; T2=type 2; T3c=type 3c; GDM=gestational diabetes mellitus; MODY=maturity onset diabetes of the young; GMI=glucose management indicator; QoL=quality of life; IAH=impaired awareness of hypoglycaemia; BG=blood glucose; HCP=health professional; OT=occupational therapy; rt-CGM=real-time continuous glucose monitoring; FSL=Freestyle Libre BG=blood glucose; rt-CGM= real-time continuous glucose monitoring; ICR=insulin-to-carbohydrate ratio; ISF=insulin sensitivity factor
It would have been overwhelming to discuss all of these in a single session, so prioritising interventions to ensure immediate safety was paramount. The pressing concerns were Neil's hypoglycaemia episodes and safety, as well as avoiding further admission to acute services. A move to rt-CGM was considered, but Neil had not yet tried the FreeStyle Libre2, so this was enabled immediately, allowing him to use a monitoring device which would alarm him to hypoglycaemia. The low alarm was set at 5 mmol/L, giving Neil a chance to treat a hypoglycaemic episode at the alert level before it happened. Effective treatment of an episode using the trend arrows on the device was discussed. Safety and driving were explored, and Neil was informed that, with the amount of severe hypoglycaemia he was experiencing, he should no longer drive, and he was advised of the importance of informing the DVLA.
Injection technique
Neil had been using his abdomen to inject for the past 16 years or more. He felt that, when he was in Spain, he had started using his legs more often, as he was wearing shorts, so he had better access to his thighs. Injection sites were assessed for lipohypertrophy, and a large area on the right-hand side of his abdomen was discovered, which Neil had been using repetitively to inject. The variability in absorption at these sites was explained and was discussed with Neil. The fact that he had been using his abdomen for his injection sites, with significant lipohypertrophy, and then had moved to healthy injection sites free from lipohypertrophy, could explain the new onset frequency of hypoglycaemia. Storing insulin correctly and not leaving it out in the heat, which can lead it becoming damaged (Forum for Injection Technique UK, 2020), was discussed.
Alcohol
Neil's alcohol intake was explored. He reported that he consumed alcohol on at least 6 days of the week, around 14 units per day. Neil was advised this was an excessive intake. Neil felt this had increased likely due to his holiday. He was not aware that it was associated with hypoglycaemia, and this, again, was a likely risk factor for his recent severe hypoglycaemia. Neil was made of the aware of the pathogenesis of drinking alcohol with type 1 diabetes. He was advised about the safety measures he could put in place, namely, having a carbohydrate snack before going to bed and while drinking alcohol. He was also offered some patient literature about consuming alcohol with diabetes (TREND, 2020), and how alcohol affects blood sugar was discussed. Neil was advised about slowly reducing his alcohol intake, either by reducing units consumed or the number of days a week that he drank. Further health promotion was put into place, and Neil completed the audit-C score. This highlighted that Neil was at high risk; therefore, he was offered the support of the specialist alcohol service.
Education
Later, attendance at some structured type 1 diabetes education was discussed with Neil to include carbohydrate counting, which would allow greater flexibility with his rapid dosing. He was keen to attend this and get some further support. He was also directed to online resources and the impact that these could have on his quality of life.
At this session, the holiday that Neil had taken was discussed, including the effects of warmer weather increasing the likelihood of hypoglycaemia and the importance of remaining hydration and checking glucose levels more frequently to keep safe. Neil was given some patient information literature and signposted to other resources and peer support to enable him to live safely with type 1 diabetes.
Optimisation of insulin
It was imperative that Neil resume basal insulin and titrate his bolus requirements to keep him safe. Neil was asked to start with brand-new insulin pens from his supply, in order to be sure that the insulin was not spoiled in the heat (Forum for Injection Technique UK, 2020). Neil's current insulin supply was all expired. Therefore, this was discarded, and new pens were ordered. Neil was instructed to restart basal insulin using healthy injection sites at 6 units once daily, reducing the NovoRapid down to 3 units three times a day with meals, which was a considerably lower dose than the one he was taking. However, this approach was assumed so that Neil could re-gain his confidence in insulin and keep safe from further hypoglycaemia events.
Discussion
This article aimed to demonstrate how some simple prioritised nursing interventions from a diabetes specialist nurse can have a positive impact on safety and quality of life in those with type 1 diabetes, as well as providing cost savings to the NHS. Neil's time in range improved immensely after some brief time with the specialist. Neil is now meeting the international consensus safety standards (Battelino et al, 2019). He went from 18% of the time below 4 mmol/L to 1%. Neil is once again taking his basal insulin and is using this safely to great affect, with 94% of time falling into his personalised glycaemic target range. Neil is using the Freestyle Libre2 device with alarm functions and has found it particularly helpful. He is at low risk for further long-term complications both from hyper- and hypoglycaemia.
Although this case study was over a short timeframe, spanning just 5 months, the interventions were all undertaken in the community setting; they were easy to assess, plan and evaluate. They required consolidated knowledge in diabetes, as well as looking at wider issues related to diabetes and the person's life to aid understanding. Hypoglycaemia is often seen as something as the fault of the person living with diabetes. Neil's is a good example of how many things people are dealing with in their lives alongside their type 1 diabetes. All of these had an impact, culminating in the severe hypoglycaemia he experienced. The article also highlights how important it is to preform a regular, thorough nursing assessment of both symptomatic and potential asymptomatic hypoglycaemia in individuals living with type 1 diabetes.
It is clear that the interventions had to be prioritised, which is an important part of nursing care, ensuring safety for the patient. A list of interventions was slowly approached so Neil felt supported to make changes to his diabetes, and to ensure he felt confident in what he was doing with the diabetes specialist nurse. With each intervention, Neil could see the changes to his own glucose data, using the Freestyle Libre2, which encouraged a trusting relationship. Having access to glucose data in real time supported both the health professional and Neil in terms of remote access and consultation. Neil has not had any further admission to hospital or severe hypoglycaemia episodes since this was undertaken.
In order to provide the best, evidence-based care, a ‘hypoglycaemia template’ was inputted into the clinical IT system. When people present with either hypoglycaemia symptoms or IAH is suspected, each team member can access the template to systematically work through all of the factors discussed. This ensures that all team members are meeting the same, evidence-based standard of care for patients with type 1 diabetes in the community setting.
Conclusion
A proportion of patients with type 1 diabetes are seen in primary care or in the community setting. This condition comes with serious lifestyle burden and psychological distress, and navigating hyper- and hypoglycaemia can cause multifactorial problems. Self-management, education, nursing interventions and support and psychosocial care remain fundamental for this cohort of people.
Through frequent modern use of rt-CGM and the FreeStyle Libre device, the flaws in using HbA1c as the only indicator of glucose levels have come to the fore. These levels do not reflect glycaemic variability and, importantly, hypoglycaemia, which are the two characteristics of diabetes that patients report greatly affect their quality of life. This highlights the need for appropriate nursing intervention around the safe use and interpretation of rt-CGM and its data, as well as understanding hypoglycaemia in more detail.
There are many factors which can put people at higher risk of hypoglycaemia, including injection technique, chronic kidney disease, frailty, alcohol and exercise. In Neil's example, several of these issues confounded his case, contributing to dangerous levels of hypoglycaemia. The need to take a very detailed history when exploring hypoglycaemia with people was highlighted, along with the need to undertake several external assessments. All these nursing interventions were easily achieved in a community setting with Neil, reducing the need for secondary care intervention.
KEY POINTS
- Over the past decade, the incidence of all types of diabetes is increasing rapidly around the globe
- Long-term complex conditions such as type 1 diabetes come with an exceptional psychological burden on the individual
- In addition to complex medication regimens, other behavioural changes are needed to navigate hyper- and hypoglycaemia
- There are often multiple nursing interventions which can be performed in the community by nursing teams to improve quality of life for the person living with diabetes, as well as for keeping them safe at home.
CPD REFLECTIVE QUESTIONS
- Why are glycosylated haemoglobin levels inadequate for determining the risk of hypoglycaemia?
- How does hypoglycaemia affect quality of life for people living with type 1 diabetes?
- When seeing people living with diabetes in your practice, how much emphasis or time do you assign to hypoglycaemia assessment and discussion?
- Thinking about the advice you give on hypoglycaemia, what considerations have you changed because of this article?