Diabetes service development

Update on Diabetes Services

41st Annual General Practitioner Study Day

28th January 2012Dr. Eoin O’Sullivan

Consultant EndocrinologistBon Secours Cork

Diabetes service development

• What’s done (or almost done!)– Laboratory developments– Type 1 diabetes– Pre-diabetes policy– Podiatry– Exercise classes for type 2 diabetes– Nurse-led diabetes clinics

• What’s next– Insulin pump clinic restructuring– More work on in-patient hyperglycaemia

Laboratory developments• HbA1c

– Same day turnover in new in-house assay– Better decision making on in-patients with

diabetes/hyperglycaemia– Clearer advice on discharge for patients and

GPs

• Blood ketone testing– Vital for assessment of hyperglycaemic ketosis– Being incorporated into new “Sick day rules”

patient information leaflet

Type 1 Diabetes• Continuous glucose monitor sensors (CGMS)

– To assist in maximising glycaemic control including avoidance of hypoglycaemia

• Restructuring of insulin pump clinics– Unified approach between diabetes nurse

specialist, dietician and clinician• Blood ketone monitoring

– Home care as well as during admissions

Pre-diabetes• “Impaired Glucose Regulation” (IGR) or “Non-

Diabetic Hyperglycaemia” (NDH)• Risk factors similar to T2DM• 1 in 7 adults, with annual progression to

diabetes of 5-12%• Approx 50% will develop T2DM in 5 years• IGT especially is associated with increased

cardiovascular risk• Management

– Diet and exercise (±Metformin)– Cardiovascular risk factor reduction

Diagnostic criteria for diabetes

Normal Pre-diabetes

Diabetes*

F glucose (mmol/l) <6.1 6.1-6.9 ≥7.0

R glucose (or 2 hr on OGTT)

<7.8 7.8-11.0 ≥11.1

HbA1c (%) <5.7 5.7-6.4 ≥6.5

*Single abnormal value sufficient if hyperglycaemic symptoms; otherwise repeat the same test on subsequent day unless have 2 different but concordant tests

Pre-diabetes patient information leaflet

• What is pre-diabetes?• What is the significance of pre-diabetes?• How do Imanage my pre-diabetes

– Dietary and exercise advice• How should my pre-diabetes be followed

up?• Useful contact information

How should my pre-diabetes be followed up?

Your GP will need to follow up your blood sugar levels (as well as your blood pressure and cholesterol). This can be done in a number of ways e.g. a fasting blood test, a non-fasting blood test, and/or an oral glucose tolerance test. This involves a fasting blood test, followed by a prescribed sugary drink and another blood test 2 hours later.

Podiatry

• Foot ulcers in diabetes are a significant cost of care

• Podiatry access will be provided for patients with diabetes who are found to have foot ulcers

Exercise classes for type 2 diabetes

• Minimum of 6-8 patients with diabetes/pre-diabetes

• Pre assessment/ screening• 8 exercise classes once a week (1 hour)• Exclusion criteria include insulin use/high

risk of hypoglycaemia, poorly controlled diabetes, unstable cardiovascular disease

Nurse-led diabetes clinics• Restructuring of types of clinics offered

to maximise patient needs• Increasing communication between

diabetes nurse clinic and review in Cork Clinic

• More referrals from Rooms to nurse-led clinic to try to maximise home control and where possible avoid admission

Diabetes clinics

What next?

Inzucchi SE et al. NEJM 2006

In-patient hyperglycaemia (10-25%)

• Increased in-hospital mortality

• Increased risk of infection

• Increased length of stay

In-patient hyperglycaemia

• New ward-based insulin prescription chart

• Structured approach to in-patient hyperglycaemia

• Protocols for management of hyperglycaemia

Endocrine developments

• Synacthen tests in OPD

• Thyroid nodule MDT

Thank you

Dr Eoin O’SullivanSuite 6, Cork Clinic, Western Road

Tel: 021-4341955Fax: 021-4346148

E-mail: ccendocrinology@gmail.com