Diabetes Specialist Team Research Articles

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: (i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults; (ii) http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance; (iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf. This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter. (ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response. (iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers. (iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only. Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved. (ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued. (iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus(®), Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir(®), Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses. Delivery of care (i) The diabetes specialist team should be involved as soon as possible. (ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.

Shared practice: integrating diabetes care

Shared practice: integrating diabetes care

Suboptimal glycaemic control in primary care: is the need for intensification of therapy recognised?

AbstractThe United Kingdom Prospective Diabetes Study demonstrated the importance of good glycaemic control in patients with type 2 diabetes. Despite this knowledge, half of the population with diabetes have an HbA1c above 8%.Five general practices in Torbay identified all patients with type 2 diabetes and suboptimal glycaemic control (HbA1c >7.5%) who were not on insulin. A retrospective review of the general practice records of patients was performed. Patients were categorised into: need to consider insulin; need to increase oral agents; treatment has recently been appropriately increased; patient plans to commence insulin; insulin considered inappropriate or patient declined insulin; patient under a secondary care diabetes team; patient diagnosed with diabetes within the last year.In all, 376 patients with an HbA1c >7.5% were identified. Of these, 118 patients (31.4%) had appropriately increased their oral medication. Only 21 had discussed insulin initiation but an additional 74 were classified as needing to consider insulin therapy. Twenty‐three percent required an increase in their oral hypoglycaemic medication. Insulin was declined by the patient or thought inappropriate in 49 cases. There were 17 new diagnoses and only eight under secondary care.In conclusion, 43% of patients with type 2 diabetes and HbA1c >7.5% required an increase in oral medication or consideration for insulin. This need had not been recognised in the majority of cases. We believe that closer liaison between primary care and specialist diabetes teams is required. Copyright © 2008 John Wiley & Sons.

A national survey of in‐patient diabetes services in the United Kingdom

To examine in-patient diabetes services in all UK acute hospitals. We asked the diabetes specialist team in all UK acute hospitals to complete a structured questionnaire on in-patient diabetes management guidelines, in-patient referral patterns, diabetes in-patient specialist nurse (DISN) services and diabetes bed occupancy in their hospital. Of the 262 UK acute hospitals, 239 (91.2%) provided data (2005-2006). UK teams reported high levels of clinical risk associated with in-patient diabetes care. One-third did not have diabetes management guidelines for day surgery, endoscopy, barium studies or immediate management of the diabetic foot. Patients admitted with diabetic ketoacidosis were not immediately referred to the specialist team in one-third of hospitals. About half had no routine access to podiatry or dietetic care for in-patients with diabetes. The majority of UK hospitals either never adopted Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI)-1 protocols or had recently changed practice, and half do not endorse the use of in-patient subcutaneous insulin 'sliding-scales'. One in five UK hospitals survey in-patient diabetes treatment satisfaction. DISN numbers have increased rapidly-126 hospitals (51.4%) had a DISN, most (69.1%) appointed since 2002. Most (80.2%) hospitals without a DISN used the out-patient specialist nurse team to provide in-patient care. This survey has identified substantial gaps in in-patient diabetes care in the UK. The rapid increase in DISN numbers indicates increasing attention to in-patient diabetes care in UK hospitals.

Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the ambulance service to a diabetes specialist nurse team

Objectives: To evaluate the effectiveness of ambulance crew referral of patients treated for acute hypoglycaemia, to a diabetes specialist nurse (DSN) team. Patients were assessed by the ambulance service and...

Predisposing factors in diabetic emergencies

Diabetes mellitus is a lifelong condition which requires acceptance, understanding and some degree of lifestyle discipline in order to maintain glycaemic equilibrium. The situation is complicated by the fact that poor glycaemic control is not necessarily symptomatic. Routines recommended by health professionals may not always be acceptable to the recipients or may be difficult to translate into the individual's framework of daily living. Dramatic emergencies may arise from a complex interrelated multiplicity of actions or omissions, or for reasons outside the control of the patient. Most emergencies are technically preventable. An attempt should be made by Accident and Emergency (A & E) staff to determine the cause. Referral to the diabetes specialist team is usually indicated.

Influence of an Interdisciplinary Diabetes Specialist Team on Short-Term Outcomes of Diabetes at a Community Health Center

To assess the effect on short-term diabetes outcomes of intervention with an interdisciplinary diabetes specialist team at a primary-care community health center in East Harlem, New York City. An interdisciplinary diabetes specialist team, consisting of a diabetologist, a bicultural certified diabetes nurse-educator, and a nutritionist, attended weekly clinics at a primary-care community health center in East Harlem. Emphasis was placed on communicating in the patient's primary language and providing nutritional counseling, diabetes education, and diabetes management. After 1 year, a retrospective review of medical records for patients seen by the diabetes team was performed to assess the influence of this intervention on performance of home glucose monitoring (HGM), frequency of hypoglycemia, and changes in diabetes treatment regimens. Of 70 patients referred to the diabetes team by their primary-care providers, 50 underwent follow-up for at least 6 months and were included in the statistical analysis. Of the 50 study patients, 94% had type 2 diabetes, with a mean duration of 11.2 years. Eighty-two percent were Hispanic, and 18% were Afro-American. The mean age was 54.6 years. Microvascular complications were present in 44%, and macrovascular complications were present in 22%. HGM was done by 13 patients (26%) before and 33 patients (66%) after diabetes team intervention (P<0.001). Before intervention by the diabetes team, 14 patients (28%) were having episodes of unrecognized hypoglycemia. Unrecognized hypoglycemia resolved after intervention in all but two patients with type 1 diabetes (P<0.001). Before intervention, diabetes treatment was dietary in 6 patients, a sulfonylurea in 19, and insulin in 25; after intervention, 5 patients had dietary management of their diabetes, 14 were taking a sulfonylurea, and 31 were receiving insulin (P<0.05). Providing access to an interdisciplinary diabetes specialist team at the site of primary care had a beneficial effect on short-term diabetes outcomes in inner-city Hispanic and Afro-American patients with diabetes. Providing specialty care in the primary-care setting may be one model for improving the quality and long-term outcomes of diabetes care, particularly in high-risk populations.

Management of non-insulin-dependent diabetes mellitus. The United Kingdom experience.

Care of persons with non-insulin-dependent diabetes mellitus (NIDDM) in the United Kingdom resembles that in the United States. However, health care practice in Europe is being influenced by the Saint Vincent Declaration, the joint European World Health Organization-International Diabetes Federation initiative, which emphasizes prevention of diabetic complications. In recent years, the responsibility for care for NIDDM has shifted in the United Kingdom to general practice teams. The effect of this shift on the quality of care and the coordinating and educational role of local diabetes specialist teams is discussed, as is the importance of an individualized "menu" of care for each patient. This menu aims for optimum blood glucose level control as well as detection and correction of risk factors for diabetic complications. The pervasive and dangerous notion of NIDDM as a "mild" disease must be corrected. The importance of systematic auditing of process and outcomes in diabetes care is emphasized, as is the need for regular data acquisition, aggregation, and analysis to achieve continuous improvement in the quality of care. Although patient-health professional encounters are the core of good diabetes care, the need for larger-scale appraisal on a local, regional, and national basis is now apparent.