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Introduction .
Summary •
Pathways •
Team & contacts •
New patient •
Continuing care •
Guidelines •
Developments •
Audits / targets •
References •
Glossary •
Appendices •
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GUIDELINES
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| * For clinical purposes, the diagnosis of diabetes should always be confirmed by repeating the test on another day, unless there is unequivocal hyperglycaemia with acute metabolic decompensation or obvious symptoms. Return to top of page |
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| 2. NEW PATIENT REFERRAL | |||||||||||||||
- Register on practice database Unwell, e.g. suspicion of ketoacidosis, emergency under on-call medical team Other, contact specialist team, outpatient assessment within 24hrs or admission, guided by circumstances - Type 2 B. For all other Type 2 patients: - Refer all patients to Patient Education Programme - Referral to consultant led clinic - Use Referral Guidelines below to determine patients who are likely to benefit from referral to specialist Team:
3. REFERRAL LETTER - If patients are referred to the consultant led clinic, attendance on the Patient Education Programme will automatically be arranged. - The use of electronically produced referral letters with full clinical information included is encouraged. - All referral letters can be addressed to the ‘Diabetes Team’. - All referral letters can be faxed to 01242 274477 - Suggested minimum referral information; Diagnostic Criterion 4. DATABASE - All practices need to maintain a register of diabetic patients, to be used for call/recall system and audit purposes (for relevant Read Codes refer to Countywide Read Code Formulary) 1. Date of diagnosis - In addition to practice database’s we propose the development of a PCT database through development of the existing Gloucestershire Diabetes Eye Screening Database. This electronic database will be available to primary and secondary care, for accessing & updating information in real-time. The current GDESS uses an electronic database stored at Gloucestershire Hospitals NHST. - Practices will be expected to maintain this database to assist in the systematic care of their patients. - greatly improve communication between primary & secondary care 5. NURSE ASSESSMENT -This will be a newly diagnosed patient’s first opportunity to discuss their diabetes in depth with a health professional; 6. ANNUAL REVIEW / RISK ASSESSMENT A comprehensive review and risk assessment is undertaken within 4 weeks of diagnosis, and annually thereafter.(Appendix 2) Risk assessment in diabetes can be looked as the management and assessment in 4 priority areas: This pathway is not intended to be a clinical guideline, however, below is offered advice on minimum assessment at annual reviews to allow risk assessment & management decisions to be completed. (Appendix 1) - History - Using this information, each patient can be assigned a risk level; management targets and follow-up can then be adjusted to the new level of risk. - We encourage the use of electronic template for recording care of diabetic patients. 7. INTERVAL REVIEW - This constitutes an ‘interval assessment’. (Appendix 2) 8. APPROPRIATE CARE - We encourage the concept of the DIABETES CARE TEAM, meaning all concerned with the care of diabetic patients in primary and specialist care. The care pathway determines the most appropriate clinic for a patient to be attending, dependent on several factors. The free movement of patients between primary and specialist care through rapid referral mechanisms and full information sharing is critical to our aims. Several factors influence the appropriate clinic for follow-up: - type of diabetes We therefore suggest, as a guide: - Type 1 diabetics – specialist clinic When to refer to specialist clinic? - Unsatisfactory glycaemic control despite maximum OHA (HbA1c >8%) where tighter glycaemic control desirable. 9. INVESTIGATION RESULTS - We encourage sharing of all relevant investigation results between primary and secondary care, e.g., HbA1c. Tests ordered by specialist team will be copied to primary care. *(From January 2004) 10. PATIENT HELD RECORD - A patient held record is a very important tool to empower patients to become informed and involved in their own care. 11. DIGITAL RETINAL PHOTOGRAPHY - Gloucestershire Diabetic Eye Screening Service - All diabetic patients will be offered the opportunity to undergo retinopathy screening by annual* retinal photography. 12. SPECIAL GROUPS - Immobile/housebound. Practices will need to pay particular attention to this group through involvement of community nursing teams in continuing care. Additional Dietetic and Diabetes Specialist Nurse resources will be able to assist in the management of this vulnerable group. 13. CALL – RECALL -Essential element of systematic care. Using practice diabetes register / database all patients need to be recalled for routine care. It is important patients in special groups are included in re-call. 14. GESTATIONAL DIABETES & DIABETES IN PREGNANCY All antenatal patients are screened for gestational diabetes through random glucose measurement at booking and 28 weeks. 15. PATIENT EDUCATION PROGRAMME This programme is run by members of the specialist team and is intended for the education of all newly diagnosed patients along with their partner’s and / or carers. The sessions are group sessions run on an interactive basis with written information to take away in the form of an Education Folder which forms the basis of the patient’s hand held records for the future. Proposals for the future include expanding the number of education sessions to allow at least 2 follow up sessions at 3 months and 12 months. Also, to open the education programme to existing patients, partners and / or carers. 16. PODIATRY For most practices available through community clinics. Routine examination / risk assessment undertaken by appropriately trained nurse within practice diabetic clinic. Risk category 2 and above (appendix 3) refer to podiatry service for regular review. 17. CONTINUING EDUCATION FOR PROFESSIONAL’S Part of the additional funding given to practices is to resource practice nurses to attend continuing education sessions in the care of diabetic patients. Contact Diabetes Specialist Nurse with Primary Care Responsibilities The format for continuing support / education for primary care Doctors will take place through the regular Diabetes Team Forums. We also hope to involve Diabetes within the regular PGMC education programme. 18. CARE MANUAL An expert reference manual for professionals to aid them in decision-making regarding the care of diabetic patients. Prepared by the specialist team at GHNHST, this will provide local guidelines for the management of patients using evidence-based practice. The manual will be published on the GHNHST intranet and be updated on a regular basis. 19. DATA QUALITY For the purposes of consistent recording and to improve audit, data recording should be via electronic templates using the agreed countywide Read Codes. These codes are available on the PRIMIS website. Practices needing support in updating their electronic templates should contact their PRIMIS facilitator. 20. REVIEW PROCESS FOR ICP - The ICP will be monitored and reviewed by the C&T Diabetes Review Group. This will comprise of Specialist Team Members, PCT representatives, users and any other person or persons it is felt should be appropriately represented. The meeting will be chaired by the PCT Professional Executive lead for diabetes. The meeting will normally take place annually in June. - A ‘Diabetes Team Forum’ will be held on a regular basis, with invitations going out to the wider team membership and users. The forum will be used to debate service development and delivery issues and for education and support. |
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