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Setting up a fast-track insulin start clinic for type 2 diabetes

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Caroline Byard, RGN, is diabetes specialist nurse, Leicester General Hospital, University Hospitals of Leicester NHS Trust;Robert Gregory, MD, FRCP, is consultant diabetologist, Leicester General Hospital, University Hospitals of Leicester NHS Trust;Anita Khulpateea, RGN, is diabetes specialist nurse, Leicester General Hospital, University Hospitals of Leicester NHS Trust;Andrew Burden, MD, FRCP, is consultant diabetologist and reader in medical and social care education, Sandwell and West Birmingham Hospitals Trust and University of Leicester

When people with established type 2 diabetes need to begin taking insulin therapy there is often a delay in them receiving treatment. This therapy has traditionally been seen as requiring specialist hospital-based care and some GPs and practice nurses feel that they do not have the necessary skills or time to teach patients how to take insulin. There is often insufficient knowledge in primary care about which insulin to use, how much to use and what device and prescriptions are needed.

Abstract

VOL: 101, ISSUE: 47, PAGE NO: 28

Mary Burden, RGN, MPH, is nurse consultant, Heart of Birmingham Primary Care Trust

When people with established type 2 diabetes need to begin taking insulin therapy there is often a delay in them receiving treatment. This therapy has traditionally been seen as requiring specialist hospital-based care and some GPs and practice nurses feel that they do not have the necessary skills or time to teach patients how to take insulin. There is often insufficient knowledge in primary care about which insulin to use, how much to use and what device and prescriptions are needed. A progressive disease
Since the publication of the report by the UK Prospective Diabetes Study Group (UKPDS, 1998) it has been recognised that people with type 2 diabetes have a progressive disease and need increasing levels of treatment. The condition may well initially respond to lifestyle changes, such as losing weight and taking regular exercise, but the progressive reduction in the number of insulin-secreting cells means further treatments will need to be added in the form of increasing doses of oral hypoglycaemic agents (OHAs) and in increasing combinations to maintain the glycated haemoglobin (HbA1c) below seven per cent. When this is no longer effective insulin is required, either alone or in combination with OHAs. Jarvis et al (2004) found that starting on insulin using an individually calculated methodology in patients with type 2 diabetes is more effective than the classical technique of beginning with a ‘safe’ dose of 10 units twice daily and gradually increasing it until the target HbA1c level is reached. The new system led to quicker follow-up by diabetes specialist nurses and faster achievement of HbA1c targets and resulted in no significant adverse outcomes for patients. Having examined this research, the authors set up a fast-track nurse-led service in the diabetes centre at Leicester General Hospital to which GPs and practice nurses could refer patients. The fast-track clinic
The aim was to set up a fast-track nurse-led diabetes clinic without a waiting list to prevent the delay often associated with starting insulin therapy. This was made possible by the reduction in follow-up and the faster discharge back to the primary care team. Method
In June 2000 Leicestershire GPs and practice nurses were informed by letter of the new service. Referral forms were enclosed with the letters - these could be photocopied and posted or faxed directly to the diabetes centre when filled in. The referral was for people with type 2 diabetes who were taking maximum doses of oral therapy and now needed insulin to improve their diabetes control. As this was a new service, telephone numbers and e-mail contacts were given in case of queries about the suitability of a referral. The referral form could be completed by the practice nurse but the GP was required to read and sign it as this was a prescription decision. The information required consisted of patient details, including date of birth, current medication, current HbA1c, height, weight and a recent laboratory fasting plasma-glucose measurement. The diabetes nursing team at the diabetes centre had experience using the dose calculator method both during the UKPDS (Holman and Turner, 1985) and in the research comparing different methodologies for starting patients on insulin therapy (Jarvis et al, 2004). The diabetes specialist nurses, supported by the consultant diabetologists, used information supplied by the GPs and practice nurses to calculate the dose and type of insulin and the prescription was made by a medical member of the diabetes team in accordance with the local protocol. At the end of the first consultation and after the patient had started on insulin therapy, a letter was printed for the patient and a copy was sent to the GP and practice nurse. Follow-up was undertaken with support from the diabetes specialist dietitian and diabetologist if necessary. The nurses ran clinics at which they could see patients face to face, while follow-up was by arranged telephone contact. Patients were also offered small-group education within a month of starting insulin. The regular nurse follow-up was discontinued when patients were confident about their injection technique and close to their HbA1c target. They were then discharged back to the primary care team with contact numbers and information about the drop-in service available at the diabetes centre. Audit of the fast-track clinic
An audit was undertaken after the clinic had been operating for one year. This covered changes in HbA1c, rates and severity of hypoglycaemia, weight gain and patients’ waiting time for appointments. Results
Sixty patients were referred to the clinic (21 male and 23 female), of whom 15 were South Asian (Box 1). There were 16 inappropriate referrals (Box 2). As patients were discharged early, some HbA1c data was missing at review and full information was obtained on 35 patients. This showed a mean 2.4 per cent reduction in HbA1c since the referral (p<0.0001) (Table 1). Some data on weight was missing and there was a mean increase of 1.8kg in 29 patients who started insulin (p=0.51) (Table 2). The average waiting time for patients was 14 days (range 1-31). This compared with a waiting time in the main diabetes clinic of 13 weeks (Box 3, p30). Summary
In summary, 20 patients achieved an HbA1c below eight per cent, with six achieving below seven per cent. There were mild, self-treated hypoglycaemic episodes in 29 (66 per cent) patients but no severe hypoglycaemic episodes. There was one death in this cohort during the audit but this was unrelated to diabetes. No patient waited more than four weeks for an appointment at the fast-track clinic (Box 4, p30). Discussion
Referrals The audit of the fast-track clinic started from the beginning of the service. Some practical difficulties did occur but have now been addressed. Some referral forms were incomplete - this was mainly due to difficulties obtaining laboratory fasting plasma glucose results because GPs and practice nurses were unwilling to send patients for this test or patients failed to attend. This fasting plasma glucose result was important to calculate the individual’s dose requirement, which estimates insulin resistance factor using height, weight, fasting plasma glucose and presence of ketones. Attempts were made to obtain missing information from the GPs concerned but failing this and with more use of this method of calculation, it proved possible to estimate the fasting plasma glucose from the patients’ own blood or urine tests when we were confident that these reflected their HbA1c results. The other factor in estimating using urine tests is renal threshold. If this was normal, then a positive prebreakfast urine glucose was taken to reflect at least a fasting plasma glucose of 10mmol/L. The insulin start was not delayed because of lack of this result if the patient’s history and HbA1c indicated a need, although a more cautious prescription was given until the ideal dose was established. It was found that some GPs and practice nurses had not told patients why they were being referred to the fast-track clinic and they were unprepared for the fact that they needed insulin. This sometimes led to the need to delay the appointment although some patients agreed to start with the assurance that they would receive support. Discharge A further problem was that in a minority of cases GPs and practice nurses did not review patients on discharge from the fast-track clinic. This appeared to be due to the change in practice - they were accustomed to diabetes specialist nurses continuing to follow up patients. Although the letter explained that their role would be to continue routine follow-up and seek support if needed they had not really understood their responsibilities. This was overcome by giving patients contact numbers and access to the diabetes team if they felt their care was not what they required. Missing data To overcome the problem of missing data for audit of this clinic, patients were asked to attend a review clinic at three months, even though they may have been discharged from regular diabetes specialist nurse follow-up. Patients’ experiences were reviewed and HbA1c, weight, blood pressure and hypoglycaemic episodes were measured at this review. Conclusion
Putting research into practice Previous research undertaken in the department was put into routine practice and audited. Changes to the service have been and will continue to be made to reduce the practical difficulties that primary care staff experience when referring patients needing to start insulin therapy, to reduce inappropriate referrals. It was felt that this framework could be used to start insulin in primary care as GPs and practice nurses gain skills in starting and maintaining insulin therapy. Weight gain In the original research, possible adverse outcomes of hypoglycaemia and weight gain (not statistically significant) were identified. The diabetes specialist nurses received increased training on dietary prescriptions before the research led to routine practice, and the weight gain observed in this study was not significant and represented the amount expected from improved glycaemic control. We believe that using this calculated dose for starting insulin in type 2 diabetes provided a useful and safe framework that would prove useful in primary and secondary care. - This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net

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