Management of Diabetes
History
Diabetes management and Annual Review influenced by 1989 St. Vincent Declaration, 1993 Diabetes Control & Complications Trial (DCT) and 1995 St. Vincent Joint Task Force for Diabetes (Dept of Health & BDA) (MacKinnon 1995)
1. Practice diabetic patients seen either at PRH diabetic clinic or practice GP led mini-clinic for annual review. Majority attend Practice, seen jointly by GP and Practice Nurse
2. Annual invitation and information leaflet sent to attend for Annual Review
3. Follow-up appointments and referrals made as appropriate
4. Newly diagnosed diabetics referred to Diabetes Nurse Specialist (DNS) or Practice Nurse with specialist training as appropriate for health education and management plan
5. Mini-clinic run jointly by DNS and Practice Nurse for management of poorly controlled diabetics seen within the Practice.
Current Practice
85 diabetic patients, 1.4% of practice population compared with national average 2% of population
100% of all diabetic patients have been offered Annual Review
66 seen at practice Diabetic Clinic
19 seen at Princess Royal Hospital Diabetic Clinic
Patients not seen within last year sent invitation to see Practice Nurse for blood taking and to discuss management
Recommendations
Write Practice Protocol for newly diagnosed diabetic patients
2nd Practice Nurse and Community Nurse to undertake specialist training in diabetes
Review Annual Review Protocol every 12 months
Identify patients diagnosed as glucose intolerant and invite for annual blood test
Reference:
MacKinnon, M (1995) Providing Diabetes Care in General Practice 2nd ed. London: Class Publishing
Protocol for Diabetic Annual Review
Diabetic Mini-Clinic
Aims
1. To improve the quality of life for the diabetic client
2. Early detection and referral for complications of diabetes
3. Increase client knowledge and self management to improve control
Target Group
All known diabetics registered with the practice who are not reviewed annually at the Hospital Diabetic Clinic
Clinical Responsibilities
Practice Nurse Role
The Nurse participating in the Diabetic Clinic must have relevant training and be competent in diabetes management, communication and basic counselling skills, and health promotion.
Administrative:
1. Maintain practice diabetes register and call/recall system
2. Invite clients annually to dedicated clinic for 30 minute appointment
3. Identify and follow-up non-attenders
4. Maintain equipment and supply of relevant literature
Screening:
1. Weight and height to determine BMI
2. Urinalysis for proteinuria and glycosuria. Arrange MSU if protein present
3. Blood pressure
4. Distant visual acuity using 3 metre Snellen chart and glasses if worn - use pinhole if acuity reduced
5. Dilate pupils with Tropicamide 1% one drop per eye
6. Venous blood sample for HbAlc, creatinine, lipids
7. Capillary blood sample for glucose Record all results on co-operation card, highlight problems and discuss implications with client
Health Promotion and Education:
1. General discussion about lifestyle including diet, exercise, smoking and alcohol if appropriate. Support with written information
2. Assess knowledge of diabetes and self management skills
3. Record current treatment and home monitoring. Observe records and technique
4. Observe injection sites and technique if IDDM
5. Discuss foot care, employment, driving, insurance issues
6. Ensure knowledge of recall system and telephone contact
GP role
The GP participating in the Diabetic Clinic will have a special interest in diabetes.
Screening:
1. Fundoscopy or referral to appropriate specialist
2. Peripheral circulation. Condition of lower limb and foot - discoloration, calluses, ulceration and doppler assessment of pulses
3. Peripheral sensory nervous system. Vibration and pin-prick sensation in feet and legs. Knee and ankle reflexes
4. Refer to specialist for identified problem as per protocol for diabetic referral
Record results on computerised record and discuss implications with client
Discuss:
1. Physical symptoms - vision, claudication, numbness, chest pain, foot problems, impotence
2. Review results of practice nurse screening, management targets and current treatment
3. Contraception and pre-conceptual advice if appropriate
4. Review individual management plan with client
Follow-up appointments
1. Made by practice nurse
2. Minimum 2 week appointment with GP to review results of blood tests and management
3. 20 minute appointment with nurse if required, at same time as GP appointment for client's convenience, to discuss problems, anxieties and give information
Evaluation
1. Review protocol annually to ensure evidence based practice
2. Review training needs annually
3. Annual audit using UK Database for Diabetes to assess effectiveness in prevention of long term complications
Dated
Signed