Hyperglycaemia in acute
coronary syndromes
Clinical audit tool
Implementing NICE guidance
2011
NICE clinical guideline 130
Audit support: Hyperglycaemia in acute coronary syndromes (2011)
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This clinical audit tool accompanies the clinical guideline: ‘Hyperglycaemia in acute
coronary syndromes: management of hyperglycaemia in people with acute
coronary syndromes’ (available online at www.nice.org.uk/guidance/CG130).
Issue date: 2011
This is a support tool for clinical audit based on the NICE guidance.
It is not NICE guidance.
Implementation of this guidance is the responsibility of local commissioners and/or
providers. Commissioners and providers are reminded that it is their responsibility
to implement the guidance, in their local context, in light of their duties to avoid
unlawful discrimination and to have regard to promoting equality of opportunity.
Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.
National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn, London WC1V 6NA; www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2011. All rights reserved. This
material may be freely reproduced for educational and not-for-profit purposes. No
reproduction by or for commercial organisations, or for commercial purposes, is allowed
without the express written permission of NICE.
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Using this clinical audit tool
The clinical audit tool can be used to measure current practice in managing
hyperglycaemia within the first 48 hours in people admitted to hospital for acute
coronary syndrome against the recommendations in the NICE guideline. Use it for a
local audit project either by using the whole tool or by amending it to suit the
project.
The clinical audit tool contains criteria and a data collection tool. The data collection
tool can be used or adapted for the data collection part of the clinical audit cycle by
the trust, service or practice.
A baseline assessment tool is also available
www.guidance.nice.org.uk/CG130/BaselineAssessment/xls/English. This can help
ascertain your Trust’s baseline against the guideline’s recommendations and
enable you to prioritise implementation activity including clinical audit.
The sample for this audit should include people admitted to hospital with acute
coronary syndromes with hyperglycaemia (defined as blood glucose above 11
mmol/litre). It could be identified using data from the Myocardial Ischemia National
Audit Programme (MINAP) as follows:
 people with acute coronary syndromes (data item 2.0: ‘Initial diagnosis’)
 with hyperglycaemia (data item 2.28: ‘Serum glucose’)
 admitted to hospital within 48 hours of cardiac symptom onset (data item 3.06:
‘Date/time of arrival at hospital’ and 3.01: ‘Date/time of symptom onset’)
Select an appropriate sample size in line with your project aims or local clinical
audit strategy.
Organisations may also like to audit whether blood glucose was checked and
recorded for patients admitted to hospital with acute coronary syndromes.
Whether or not the audit results meet the standard, re-auditing is a key part of the
audit cycle. If your first data collection shows room for improvement, re-run it once
changes to the service have had time to make an impact. Continue with this
process until the results of the audit meet the standards.
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Links with other clinical audit priorities
The audit based on this guideline should be considered in conjunction with other
clinical audit priorities such as:
 Myocardial Ischemia National Audit Programme (MINAP)
www.ucl.ac.uk/nicor/audits/minap
The following MINAP data items may be of use when conducting an audit based
on this clinical audit tool.
2.01
Initial diagnosis
2.17
Diabetes
2.28
Serum glucose
3.01
Date/time of symptom onset
3.06
Date/time of arrival in hospital
3.41
Inpatient management of hyperglycaemia/diabetes
4.01
Date of discharge
5.1
Smoking cessation advice given
5.2
Dietary advice given during this admission.
 NICE Unstable angina and NSTEMI: audit support
www.guidance.nice.org.uk/CG94/AuditSupport/doc/English
 NICE Chest pain of recent onset: audit support
www.guidance.nice.org.uk/CG95/AuditSupport/doc/English
 NICE Type 1 diabetes in children, young people and adults: NICE guideline
containing audit criteria
www.guidance.nice.org.uk/CG15/NICEGuidance/pdf/English
 NICE Type 2 diabetes: audit support
www.guidance.nice.org.uk/CG66/AuditSupport
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Criteria for ‘Hyperglycaemia in acute coronary
syndromes’
MANAGING HYPERGLYCAEMIA IN INPATIENTS WITHIN 48 HOURS OF ACUTE CORONARY
SYNDROME
Criterion 1a
When it occurs, hyperglycaemia should be managed in patients admitted
to hospital with an acute coronary syndrome.
In the first instance, a dose-adjusted insulin infusion with regular
monitoring of blood glucose levels should be considered.
Exceptions
None
Guideline reference
1.1.1
Definitions
For the purposes of this guideline, hyperglycaemia is defined as a blood
glucose level above 11 mmol/litre.
NICE recommends that hyperglycaemia is managed in patients admitted to
hospital for an acute coronary syndrome by keeping blood glucose levels
below 11.0 mmol/litre while avoiding hypoglycaemia. It states that, in the first
instance, a dose-adjusted insulin infusion with regular monitoring of blood
glucose levels should be considered.
Additional information
Information about whether patients received treatment is contained within
MINAP data (dataset item 3.41: Inpatient management of
hyperglycaemia/diabetes).
Criterion 1b
Intensive insulin therapy should not be routinely prescribed to manage
hyperglycaemia in patients admitted to hospital for an acute coronary
syndrome.
Exceptions
None
Guideline reference
1.1.2
Definitions
Intensive insulin therapy is defined as an intravenous infusion of insulin and
glucose with or without potassium.
NICE recommends that organisations should not routinely offer intensive
insulin therapy to manage hyperglycaemia in patients admitted to hospital for
an acute coronary syndrome unless clinically indicated.
Additional information
If intensive insulin therapy has been prescribed, the auditor could look at why
this occurred. The audit data could be used to look at prescribing patterns
within an organisation.
IDENTIFYING PATIENTS WITH HYPERGLYCAEMIA AFTER ACUTE CORONARY SYNDROME WHO
ARE AT HIGH RISK OF DEVELOPING DIABETES
Patients with hyperglycaemia after an acute coronary syndrome and
without known diabetes should have tests for:
Criterion 2

HbA1c levels before discharge and

fasting blood glucose levels no earlier than 4 days after the onset of
acute coronary syndrome.
These tests should not delay discharge.
Exceptions
None
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Guideline reference
1.1.3
Definitions
NICE recommends that oral glucose tolerance tests should not be routinely
offered to patients with hyperglycaemia after an acute coronary syndrome and
without known diabetes if HbA1c and fasting blood glucose levels are within the
normal range.
Additional information
Information about whether patients had an existing diagnosis of diabetes is
contained within MINAP data (dataset item 2.17: Diabetes).
NICE recognises that formal testing and diagnosis of diabetes will normally
take place following referral to primary care after the acute episode. An audit
across secondary and primary care could determine whether this took place.
See the Healthcare Quality Improvement Partnership’s ‘Guide to facilitating
clinical audit across different care settings’ (2010) www.hqip.org.uk/clinicalaudit-resources-3
ADVICE AND ONGOING MONITORING FOR PATIENTS WITH HYPERGLYCAEMIA AFTER ACUTE
CORONARY SYNDROME AND WITHOUT KNOWN DIABETES
Patients with hyperglycaemia after an acute coronary syndrome and
without known diabetes should be offered lifestyle advice on the
following:
Criterion 3

healthy eating

physical exercise

weight management

smoking cessation

alcohol consumption.
Exceptions
None
Guideline reference
1.1.5
Definitions
None
Additional information
Information about whether smoking cessation and healthy eating advice was
given is contained within MINAP data (dataset items 5.1: Smoking cessation
advice given and 5.2: Dietary advice given during this admission).
Criterion 4
When a patient has had hyperglycaemia after an acute coronary
syndrome and is without known diabetes, their GP should be informed
that they should offer at least annual monitoring of HbA1c and fasting
blood glucose levels.
Exceptions
None
Guideline reference
1.1.7
Definitions
None
Additional information
The auditor could check discharge letters to determine whether they contain
this information.
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Data collection tool for ‘Hyperglycaemia in acute
coronary syndromes’
Complete one form for each patient.
Patient identifier:
Sex:
Age:
Organisation/service:
Ethnicity:
White
British
Irish
Any other White
background
Date of cardiac
symptom onset*:
No.
Data
item
no.
Mixed
White and
Black Caribbean
White and
Black African
Asian or Asian British
Indian
Black or Black British
Caribbean
Other
Chinese
Pakistani
African
Any other
ethnic group
White and
Asian
Bangladeshi
Any other Black
background
Not stated
Any other mixed
background
Any other Asian
background
Date of admission*:
MINAP initial
diagnosis*:
Admission blood
glucose*:
Criteria
Yes
Date of discharge*:
No
NA/
Exceptions
Managing hyperglycaemia in inpatients within 48 hours of acute coronary syndrome
1
1.1
Was hyperglycaemia managed?*
If ‘yes’, was it managed using:

a dose-adjusted insulin infusion with regular monitoring of blood
glucose levels?
1.3

intensive insulin therapy?
1.4

other? (please specify)
1.5
If intensive insulin therapy was used, why?
1.2
Identifying patients with hyperglycaemia after acute coronary syndrome who are at high risk of developing
diabetes
2
2.1
Was the patient known to have diabetes?*
If ‘yes’, end audit here. If ‘no’, go to question 2.2.
2.2
Were HbA1c levels tested before discharge?
2.3
Were fasting blood glucose levels tested no earlier than 4 days after
the onset of acute coronary syndrome?
2.4
If these tests were not done, was this because the patient was
discharged?
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Advice and ongoing monitoring for patients with hyperglycaemia after acute coronary syndrome and
without known diabetes
3
4
3.1
Was advice given on:
3.2

healthy eating?*
3.3

physical exercise?
3.4

weight management?
3.5

smoking cessation?*
3.6

alcohol consumption?
4.1
Was the patient’s GP informed that they should offer at least annual
monitoring of HbA1c and fasting blood glucose levels?
* Information available from MINAP data.
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Further information
For further information about clinical audit refer to a local clinical audit
professional within your own organisation or the Healthcare Quality
Improvement Partnership (HQIP) website www.hqip.org.uk. HQIP was
established in April 2008 to promote quality in healthcare, and in particular to
increase the impact that clinical audit has on healthcare quality in England
and Wales.
Supporting implementation
NICE has developed tools to help organisations implement the clinical
guideline on Hyperglycaemia in acute coronary syndromes (listed below).
These are available on our website (www.nice.org.uk/guidance/CG130).
 A costing statement which details why it is considered that implementing
the recommendations will not have a significant national resource. The
statement also highlights possible areas that might have resource
implications at a local level as a result of variation in clinical practice across
the country.
 Slides highlighting key messages for local discussion.
 Baseline assessment tool for identifying current practice and prioritising
implementation of the guideline.
 Clinical audit tool for local clinical audit (this document) and an electronic
audit tool.
A series of practical guides to implementation are also available on our
website (www.nice.org.uk/usingguidance/implementationtools).
The guidance
You can download the guidance documents from
www.nice.org.uk/guidance/CG130. For printed copies of ‘Understanding NICE
guidance’, phone NICE publications on 0845 003 7783 or email
[email protected] and quote N2676.
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