Diabetes - a Contemporary Approach

Diabetes – A contemporary approach.

Diabetes is defined as a chronic illness by the World Health Organisation (WHO) in which there is inefficient use of insulin or insufficient amounts of insulin produced. This in turn leads to a state of high blood glucose known as hyperglycaemia (WHO 2014). The WHO categorises diabetes as type I or type II and mentions gestational diabetes as hyperglycaemia first recognized during pregnancy (WHO 2014).

With 347 million people affected individuals worldwide diabetes has a strong economic impact (WHO 2014). 245 billion dollars are spent yearly for diabetes care and its complications in the US alone (McCage et al 2013). Diabetic individuals have much higher admission rates (including Emergency admissions) than people without the condition and have longer stays with increased mortality rate when admitted (Allan 2014). Apart from this global economic burden diabetes affects the social, psychological and physical aspect of every diagnosed individual (Delamater et al 2001). Nash (2013) recognises Diabetes as a very challenging and demanding chronic illness.

In the following write up a case study approach is taken to evaluate a patient with poor self managed diabetes. This poor management is identified during an emergency admission following minor trauma. The assignment will evaluate the work of the Diabetes specialist nurse (DSN) together with the multidisciplinary team. The common goal discussed here is to achieve good patient self-management through support and education and reducing diabetes complications as much as possible. The name of the patient has been changed to protect privacy. During the assignment the patient shall be referred to as Jane.

The need for Diabetes care funding is predicted to rise substantially, yet it cannot be assured that allocated funds will always match the demand. One-way to tackle this is to plan new strategies with the current resources and maximise the use of a collaborative multidisciplinary effort in both primary and secondary care (Williams 2011). Research shows better quality of care, reduction in hospital admissions and mortality rates with effective teamwork. A broader skill mix and professional group yields even better patient care (Tapp et al 2012, Williams 2011). Birdsall et al (2013) also mention the importance of a clinical lead role with managerial skills to assist all specialist staff achieve standards of quality care and safety. The staff should work together and attend scheduled meetings from members of every discipline to assess progress and project for improvement (Tapp et al 2012). Sumpio et al (2010) agree that an interdisciplinary approach provides optimal care, improved outcomes and a reduction in complications but also recognises the fact that there are many barriers to how broad a team can be.

A main aspect of the work of the DSN is to co-ordinate this team approach, and offer expertise to the primary care team (Birdsall et al 2013). Proper teamwork is a complementary effort towards a common goal rather than a group of individuals working together. Every member of a good working team is accountable for their part towards achieving this goal (Williams 2011). Birdsall et al (2013) also adds that the DSN has a pivotal role in reducing diabetes related admissions, preventing costly complications and offering patient support.

Jane was admitted for 48 hours to monitor vital observations, pain relief and to settle the blood glucose level. Once transferred from the minor trauma emergency to the ward the patient was seen twice by the inpatients DSN. Upon first encounter the DSN established the basis for a professional relationship, obtained a history and inquired about adherence to treatment and exercise regimes. Adherence should be used as a term by professionals instead of compliance as it does not imply any intentional treatment omission or lack of interest in self-care. The term rather states a number of facts upon which the individual can discuss and work upon (Nash 2013). The DSN also checked that all the necessary investigations were available, treatment was being given according to protocol, reassured the patient, gave some initial diet advise, cleared queries and set another meeting for the following day prior discharge. Bode et al (2004) mention the importance to use hospitalised time as efficiently as possible. During the admission the patient should have a treatment re-assessment and obtain good glycaemic control. An individualised approach to a multidisciplinary referral should be used to continue follow up. Jane was visited by the inpatients DSN once again prior discharge. Glycaemic control was satisfactory and referrals were setup. The specialist nurse assessed the patient on glucose monitoring, medication administration, recognition of hypo and hyperglycaemia symptoms and basic meal planning. Assessment was not done solely to evaluate technique but also to gather the patient’s general attitude towards self-care.

The patient was not visited by any other member of the team while hospitalised. This could have resulted from the fact that a consult to DSN was done and it is generally taken for granted that further care related to diabetes can be taken care of or referred to other specialists by the DSN (Healy et al 2013). Still the patient might have benefited from early psychosocial support while an inpatient.

Pledger (2005) demonstrates the need for an inpatient specialist care as this compensates for deficiencies in general nursing settings. Some of these aspects include lack of diabetes knowledge and confusion about medication and proper administration. An audit commission carried out in 2000 also reported that most nurses did not encourage patients to start self-managing while admitted and took over diabetes care entirely. Patients felt the wish to self-administer, make adjustments and have their wishes heard. Inpatient diabetes specialist nurses were found effective in reducing length of stay (LOS) especially in patients whose admissions were not directly associated with diabetes (Pledger 2005). Chinnasamy et al (2011) found that general nurses knowledge about diabetes to be insufficient. A survey they conducted about hypoglycaemia management resulted in only 28% of nurses recognising all the symptoms. These figures can be easily attributed to other aspects of diabetes knowledge highlighting the need for more up to date training. The inpatients DSN work proved extremely valuable for Jane. The appropriate referrals uncovered other problems like retinopathy and mild depression. There is no protocol to refer all hyperglycaemic patients to the DSN at the A&E where Jane was treated, yet appropriate referral was done as she was deemed to have lack of family support and a laid back attitude towards diabetes management.