Can a virtual ED reduce diabetes hospitalisations?

Victorians living with diabetes now have improved access to specialised care via a new telehealth service, which is also expected to ease pressure on hospital emergency departments (EDs).
 
While virtual EDs are expanding across all Australian states and territories with varying degrees of public access, the new extension of the Victorian Virtual Emergency Department (VVED) is the first of its kind tailored for people living with diabetes with urgent, non-life-threatening complications.
 
Launched on 21 July, VVED Diabetes is the result of a two-year collaboration across the diabetes sector, including the Australian Centre for Accelerating Diabetes Innovations, Ambulance Victoria, Diabetes Victoria, Northern Health, the Royal Flying Doctor Service, as well as people with lived experience.
 
Dr Ben Nash is a Northern Health endocrinologist who is overseeing the new service, alongside a team of specialist diabetes nurse practitioners, GPs and emergency physicians.
 
He told newsGP the goal is to work towards ‘a common ground’ around best care for people with impending or non-life-threatening diabetes emergencies, through identifying those who can be safely managed at home.
 
‘A silver lining of COVID has been the establishment of telehealth, which has been such a success story,’ Dr Nash said.
 
‘With the VVED, if it’s a non-life-threatening emergency secondary to the diabetes, then we’ve got specialists available to help them troubleshoot it and keep them home, and it’s essentially more effective triage in trying to take the pressure off the hospitals and healthcare system.
 
The model caters for two broad referral pathways: initiated by the person with diabetes or their carer, and a referral from the healthcare provider.
 
‘If a paramedic is with someone with hyperglycaemia or severe hypoglycaemia, they can call in and get advice,’ Dr Nash said.
 
‘If a GP is with someone in their clinic and they’ve got a new diagnosis and are not sure what to do, they can certainly call in as well.’
 
Since its establishment in 2020, the VVED claims to have supported more than 300,000 patients and helped prevent unnecessary hospital presentations. The extended diabetes-specific service is designed to reduce long ED waitlists and facilitate timely access to urgent care.
 
Dr Gary Deed is a GP and Chair of RACGP Specific Interests Diabetes. While welcoming the initiative to ease hospital loads, he raises questions that it may lead to fragmented care.
 
‘It certainly may assist some patients improve access to emergency care when their GP is unavailable, however it does pose the risk of not assisting continuity of care,’ Dr Deed told newsGP.
 
‘How does that person then continue to support their health needs the next day, the next week, etc? Does the GP get notified of the attendance so adequate community follow up is supported?
 
‘The dilemma is that preventing hospitalisation is just one metric of adequate patient care – we need prevention of further re-admissions and support in the community primary care setting to further the ongoing care needs.’
 
Dr Deed cites a 2021 Polish study assessing predictors of re-hospitalisation and mortality in diabetes-related hospital admissions, finding 7.3% of hospitalisations resulted in death within 90 days following discharge.
 
Although just one measure, he says this supports the need for appropriate shared care models to prevent adverse outcomes.
 
‘There are multiple factors to be considered and followed up in primary care that drive the need for better integration back into general practice services to prevent further [ED] attendances, let alone hospitalisation,’ he said.
 
‘GPs need to assess all the listed comorbidities to assist this, plus make sure the person is supported by an appropriate skilled healthcare team and allied health.’
 
The VVED Diabetes team also hope the initiative will be adapted by other services to build on emerging telehealth models of care, saying it is ‘another example of how collaboration between service providers and research institutions can inform new models of care for people living with chronic conditions.’
 
Dr Deed said while he would support this initiative, the same caveats relating to continuity of care apply, and patients’ usual GP should be advised of the episode of care to ensure best outcomes.
 
‘This may allow the GP to consider being involved in a shared-consult framework,’ he said.
 
The second step of the VVED Diabetes rollout is expected later this year and includes collaboration with Ambulance Victoria paramedics and the virtual clinic to test ketone levels for people with diabetes to determine whether they can be safely managed at home.
 
According to Dr Nash, hypoglycaemia makes up 1% of all cases that present to Ambulance Victoria, while for hyperglycaemia, he says nine out of 10 people who are seen by a paramedic get taken to hospital.
 
‘They don’t necessarily get admitted – most of them don’t – but there’s a lot of capacity for helping keep people at home and treat them in their home where they want to be,’ he said.
 
Dr Nash said the work to reduce preventable hospitalisations that can accompany the ‘huge condition affecting the community’ is also aiming to take some of the burden of the acute management issues for GPs.
 
‘We know people with diabetes are doing well in the community and looking after themselves and troubleshooting a lot of their stuff on a day-to-day basis, and may only have a very small slither of their time with the condition with a healthcare professional,’ he said.
 
‘But sometimes they just need a bit of reassurance and assistance, and not necessarily need the whole emergency workup.’
 
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