VOL: 98, ISSUE: 23, PAGE NO: 36
Dawn Brookes, BA, RGN, RM, is district nursing sister, Milman Road Health Centre, ReadingDiabetes mellitus officially affects 3% of people in England and Wales (Audit Commission, 2000). However, its prevalence is thought to be higher than current rates of diagnosis suggest and an estimated two million people in the UK have the disease (Health Service Guidelines, 1997).
Diabetes mellitus officially affects 3% of people in England and Wales (Audit Commission, 2000). However, its prevalence is thought to be higher than current rates of diagnosis suggest and an estimated two million people in the UK have the disease (Health Service Guidelines, 1997).
Type 2 (non-insulin dependent) diabetes is most often found in adults over the age of 40, with most aged over 60.
The complications of diabetes are well documented and can be life-threatening. They include ischaemic heart disease, peripheral vascular disease, amputations, retinopathy, blindness, nephropathy, cerebral vascular accident and peripheral neuropathy (Mackinnon, 1993; Forbes and Morris, 1999). The cost of these complications has been estimated at 5% of the NHS budget (Health Service Guidelines, 1997).
However, the UK Prospective Diabetes Study (UKPDS Group, 1998) has shown that appropriate treatment and interventions aimed at reducing patients' risk can greatly reduce the rate of complications. This has serious implications for primary care, where most of the responsibility for interventions lies.
The primary sector has addressed the management of diabetes over the past five years by introducing diabetes clinics in GP surgeries, most of which are run by practice nurses working closely with GPs. These offer screening, health assessments and education to help patients manage their condition (Box 1).
For most patients, clinics held at GP surgeries are a convenient way to get help in managing their diabetes. However, those who are housebound usually have difficulties getting to clinics so they may not be offered a regular service.
This article reports on an audit carried out at a GP surgery in Reading which revealed a need to include housebound patients in routine diabetes screening, and discusses whether district nurses can fill the gap in services.
Practice nurses in the surgery had developed a system whereby patients with diabetes were routinely invited to attend the surgery for an annual review, which was carried out by the practice nurses. Those who did not attend were sent reminders.
However, an audit of the system revealed that it did not cater for housebound patients with diabetes, who therefore missed out on diabetes education and monitoring. This finding was backed up by other research (Hendra and Sinclair, 1997; Forbes and Morris, 1999).
The practice population consists of 10,466 generally white and middle-class patients, although the area has pockets of social deprivation. Increasing numbers of patients are of Asian origin, a group known to be at increased risk of developing type 2 diabetes. Employment levels in the practice population are generally high, although there are pockets of high unemployment, particularly on local authority housing estates.
Trials have shown that effective control of blood pressure reduces the risk of complications and lowers mortality rates (UKPDS Group, 1998). A medical student attached to the surgery carried out an audit of blood-pressure monitoring and the treatment of type 2 diabetes, obtaining the data from the practice's computer records. Table 1 shows the target standards and the results of the audit.
The audit highlighted a number of issues surrounding the treatment of patients with type 2 diabetes that needed to be addressed by the practice. However, patients with type 2 diabetes whose condition was not entered on the computer would not have been part of the audit, and would be even less likely to have their blood pressure monitored. This suggests that an even greater number of patients were receiving inadequate treatment than the recorded 34%.
Of 19 patients who had not had their blood pressure checked over the past year, 12 were housebound (including two who were in residential care). Although the audit focused on blood-pressure monitoring, it also revealed that 12 of these patients had not had annual reviews of their diabetes for two to five years.
As the health care professionals with the most regular contact with housebound patients, members of the district nursing team were keen to fill the gap in services for those with diabetes. The team met with the GPs and the practice nurse involved to discuss the possibility of annual reviews for such patients. It was agreed that after the district nurses had carried out a patient's annual check, the GP would visit to review medication, blood results and other tests as appropriate.
The district nurses devised an assessment form for use in the annual reviews, which included a risk assessment tool to highlight potential diabetic foot problems. The information gathered was entered on both community trust paperwork and the practice's computerised records.
The district nurses' annual review includes checks on the following:
- Type of diabetes;
- Alcohol intake;
- Smoking history;
- Blood pressure and pulse;
- Height, weight and body mass index;
- Capillary blood sample;
- Foot examination, including a sensitivity test and reflexes, presence of callus, redness, discoloration, dryness or maceration.
Bloods would also be taken for a glycosylated haemoglobin test (HbA1c - a laboratory test that reveals average blood-glucose levels over two to three months by measuring the number of glucose molecules attached to haemoglobin), urea and electrolytes, plasma glucose, cholesterol (where indicated) and liver function. Urine would be tested for protein, glucose and ketones.
The district nurses required further training to develop their understanding of diabetes and its complications, ensuring that they could highlight problems to the GPs and give patients sound educational advice. The training was organised by the district nursing sister and the practice nurse. It included the following:
- Up-to-date information on diabetes and treatments;
- Knowledge of the complications of diabetes;
- Foot examination, including tests for reflexes and sensory dysfunction, and risk categorisation (Dorgan et al, 1995);
- The treatment and classification of diabetic foot ulcers (Wagner, 1979).
The team was also invited to attend a practice meeting to discuss practice protocol on diabetes care.
Of the 12 patients visited for annual review, 10 had poor glycaemic control, mainly because of their diet. HbA1c in this group was 10-15%. These patients were given dietary advice and the GPs reviewed their medication, changing oral hypoglycaemic drugs where appropriate. Two patients were started on insulin after referral to the diabetes specialist nurse.
The blood pressure of four of the patients measured over 140/180mmHg so they were prescribed angiotensin-converting enzyme (ACE) inhibitors by the GP, in line with recommendations from the UKPDS Group (1998). Three patients needed foot care and were referred to the local podiatry service for home visits. In all cases, the district nurse discussed foot care and explained foot examination to the patients and their relatives.
Two patients showed signs of peripheral vascular disease, with some intermittent claudication and an ankle brachial pressure index of less than 0.7 on Doppler assessment. They were referred to a vascular surgeon.
All 12 patients showed little understanding of the role of diet and exercise in relation to glycaemic control and were advised to exert greater control over what they were eating. Three were receiving meals on wheels, none of whom were on diabetic diets, and each had a pudding every day. Social services were contacted and the meals-on-wheels service was asked to deliver meals suitable for people with diabetes.
Although these patients were unable to do rigorous exercises, they were given advice tailored to their individual conditions, including armchair exercises. One patient who was living in a residential home was able to attend the home's day centre, where armchair aerobics was organised once a week. Ten of the 12 patients expressed satisfaction with the interest shown in their health and were pleased to incorporate some changes in their daily routine.
The outstanding problem for housebound patients with diabetes is eye testing. This should occur annually and should include visual acuity and fundus examination through a dilated pupil (Kritzinger, 1994). This service is currently lacking, although there are plans for a mobile eye unit to visit the area once or twice a year and staff are being recruited for this purpose.
Further developments in the review service are being introduced by the district nursing team. These include opportunistic screening of patients aged over 75, which will include capillary blood sampling followed by venous sampling if random glucose is above 7mmol as 10% of this group are at risk of developing type 2 diabetes (Mackinnon, 1993). Another method of opportunistic screening for diabetes is to carry out capillary blood sampling on patients who present with possible complications of diabetes, such as foot ulcers and infected leg ulcers that are slow to heal. The practice is also considering carrying out tests for microalbuminuria and how best to test for this to detect early signs of diabetic nephropathy.
Discussions on diabetes care with other district nurses in east Berkshire have made it apparent that housebound patients with diabetes are not being screened regularly. This puts them at risk of developing complications, which are usually preventable (Sinclair and Barnett, 1993; UKPDS Group, 1998).
It also highlights a gap in services for patients who are unable to get to clinics, a problem that needs to be addressed by primary health care services to improve their quality of life and meet the standards of the National Service Framework for Diabetes (Department of Health, 2001). It is also a clinical governance issue, the aim of which is to provide a framework for the local delivery of quality health care (DoH, 1999).
The problems that housebound people with diabetes face should concern all health professionals, including those who work in residential care. Some nursing homes may not be providing annual screening checks or adequate education for residents with diabetes.
At the beginning of this project, nurses from local nursing homes were invited to a meeting to discuss annual reviews. Four nursing homes were invited, but only two sent one nurse each. These nurses, however, were enthusiastic about developing annual reviews in the homes they worked for. Training issues were raised, along with phlebotomy skills (which one home did not have). These were addressed, and a plan for training and support is to be provided by the district nursing sister and the practice nurse.
As a result of the project, all known housebound patients with type 2 diabetes served by the practice have annual screening, thereby ensuring early detection and treatment of complications. The GPs and practice nurses refer newly diagnosed housebound diabetic patients to the district nursing team and the team is taking a proactive approach to screening for diabetes.