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Organising a Diabetic Clinic

Resources

Protocol for routine review

Protocol for annual review

Diabetes clinic record

 

Resources

Staff

  • RGN with appropriate training (eg Warwick cert)

  • GP in support

  • Administrative support for arranging appointments, collecting notes. ordering supplies etc

Diabetes register

  • The Diabetes register should be used to recall patients at specific intervals and for annual review

  • For non-attenders a decision should be made within the team to agree the process for follow-up, e.g. send total of 3 appointment dates, and if still no attendance, document and flag up on repeat prescription

  • For patients who are housebound or in residential care a decision should be made as to who will take responsibility for the care of the annual review of these patients, e.g. practice nurse who runs the Diabetes clinic to withhold one clinic session periodically to perform annual review for these patients, or district nurse

Facilities and equipment

  • Area/ room to hold your clinic
  • Computer
  • Facilities for recall of patients
  • Height measure
  • Weighing scales
  • Blood pressure monitoring equipment
  • Blood sugar monitoring equipment
  • Ketone labstix
  • Tuning fork (Rydell-Seiffer C64 fixed weight)
  • Visual acuity chart and pinhole
  • 10g Monofilament
  • Patient Invite letters (see example following)
  • Dietary Assessment form (see following)
  • Patient information leaflets/ booklets (e.g. Diabetes UK )
  • Information and contact addresses
  • Appointments cards
  • Referral forms
  • Blood test request forms
  • Assessment Sheet (for non computerised practices, this sheet can be incorporated into the patients notes, see "Diabetes Clinic Form" section)

 

Protocol for routine review

  • Ensure that patients with established diabetes
    - are included on the practice diabetes register
    - have provided written consent for retinal photography

    Patients who should be seen in the clinic include:
    •  Patients with established Diabetes
    •  Hospital discharge - newly diagnosed patients with diabetes, patients discharged from hospital clinics
    •  Self-referral
    •  Referral by other health care professional
    •  Annual review

  • A standard invitation letter should be sent to the patient at least two weeks before the clinic accompanied by a blood form, urine sample bottle (for microalbuminuria) and the dietary assessment form (see following)

  • Arrange the following tests:
    - body mass index
    - blood pressure
    - HbA1
    - lipids if previous level above target

  • Discuss the patient's general well-being and progress:
    - patient concerns
    - blood glucose
    - symptoms of hypo's
    - lifestyle issues - smoking, diet, exercise

  • Evaluate knowledge and self management

  • Negotiate targets for education, metabolic control and lifestyle issues and record these in a Care Plan

  • Use a patient hand held record to encourage patient self management and to share information between the multidisciplinary diabetes care staff in primary and secondary care (see section on Self Management)

  • Modify treatment if necessary for:
    - glucose
    - blood pressure
    - lipids

  • Refer the patient as required to the appropriate services for advice on smoking cessation, alcohol problems, nutrition advice and exercise prescription (see Lifestyle sections)

  • Specialist referral via the GP may be required for aspects of metabolic control and diabetic complications (see section on Referral Guidelines)

  • Record all details in patient held record and in practice record

  • Arrange next appointment

 

Protocol for annual review

  • Arrange the following tests:
    - body mass index
    - blood pressure
    - urine microalbumin
    - HbA1
    - U&E
    - lipids
    - LFT's if on a glitazone

  • Enquire about symptoms of complications:
    - angina, SOB, claudication, TIA's
    - neuropathy, erectile dysfunction

  • Examine feet for diabetic complications:
    - dorsalis pedis and posterior tibial in both feet
    - sensation with tuning fork or microfilament
    - callus, amputations, ulcers past or present
    - clawed toes, bony prominence, hallux valgus or varus, hammer toes, Charcot foot

  • Ensure eye screening has occurred

 

Diabetes clinic record

  • It is essential to record clinical information in a structured way to enable audit of the diabetic clinic. A paper based diabetes annual review form (accessed by clicking here) can be used for this purpose if your diabetes service is not yet computerised.

  • Most General Practice Software Packages have a dedicated "diabetes clinic" screen. This can be used instead of a paper record, so long as it contains the minimum data set as detailed below:

Name
Date of Birth
NHS number
Date
Type of Diabetes Type1, Type2, IGT, IFG, GDM
Date of diagnosis
Treatment Diet, oral (1drug, 2 drugs, 3 drugs), insulin, anti-platelet, lipid lowering, weight reducing, ACEI, A2, other CV drugs, erectile dysfunction drugs, neuropathic pain modulators
Complications (with date of onset) Angina, MI, stroke, TIA, peripheral vascular disease, retinopathy, neuropathy, foot ulcer, amputation, microalbuminuria, nephropathy
Procedures (with dates) Laser photocoagulation, coronary angioplasty, CABG, lower limb arterial bypass or angioplasty, amputation (above knee, below knee, below ankle, toe), renal dialysis, renal transplant
Height m
Weight kg
BMI
BP mmHg
HbA1c %
Lipids
Serum creatinine mmol/l
Urine microalbumin mg/l
Peripheral pulses R/L Present/absent
Sensation R/L Normal/abnormal
Visual acuity R/L
Retinal photo grade R/L (with date)
Smoking Never smoked, ex-smoker (with date), current smoker (with number of cigs/day)
Seen by podiatrist, dietitian, DSN, optometrist, other health professional
Care plan
Education Diet, exercise, smoking, alcohol
DNA
Patient dissent
Next appointment