Dr Margaret Griffin, Consultant Endocrinologist, with support from the Diabetes Team at the Bon Secours Hospital, Dublin, examines the benefits from having the care of a patient with diabetes managed by a multidisciplinary team
Diabetes mellitus is unique among chronic medical conditions in that 98 per cent of the care directed towards the condition is administered by the patient on a day-to-day basis. Everyday decisions are made by the individual with diabetes that affect the diabetic condition, and daily diabetes mellitus can affect the decisions an individual makes in their life.
People with diabetes are confronted every day with the self-management of their condition. Patient empowerment involves a process of education of the individual to develop a critical awareness of the problems diabetes mellitus raises for them and a readiness to act appropriately on this awareness. Self-management patient education programmes based on a patient-centred approach effectively improve clinical and psychosocial outcomes.
Such patient education is best achieved through a multidisciplinary team approach encompassing an endocrinol-ogist, dietician, diabetes clinical nurse specialist and chiropodist, backed up by ophthalmologists, vascular surgeons, cardiologists and renal physicians as required.
Diabetes team
The Bon Secours Hospital in Glasnevin has been operating a multidisciplinary diabetes team for the past four years. This team is comprised of endocrinologists, a clinical nurse specialist in diabetes, a dietetic team and a podiatrist, with phlebotomy and laboratory support. As the theme for the next five years is education and prevention of diabetes complications, this multidisciplinary team will play an important role in stemming the tide of the diabetes epidemic in Ireland.
The Glasnevin Diabetes Team operates a prompt outpatient service and, if required medically, an inpatient service. The Bon Secours Hospital Diabetic Outpatient Clinic would be similar to that recommended by the Department of Health (DOH) working group on diabetes.
Ultimately we aim to develop shared care between the GP, the hospital and the endocrinologist. It enables both the GP and the patient to have timely access to consultant-provided diabetic care.
The estimation of 86,000 people in Ireland suffering from diabetes in 2000 is set to double by 2030, due to an ageing population and increased obesity rates. The DOH report states that peripheral vascular disease and amputations are major complications of diabetes and much of this is preventable.
The benefits to GPs:
1. The patient can be seen promptly;
2. All required further testing will be scheduled promptly and at the patient’s convenience;
3. The GP receives a copy of the results within seven days, thus enabling the GP to start early intervention if he/she decides;
4. The GP will have the ability to share the care of their private patients directly with one of the endocrinology consultants attached to the Bon Secours Hospital;
5. Patients are automatically referred to a cardiac, vascular, ophthalmological or renal consultant if deemed necessary and are seen promptly.
The benefits to the private patient:
1. Elimination of lengthy waiting lists;
2. Quick and early intervention, thus reducing/preventing the risk of complications developing;
3. Convenient same-day scheduling of appointments to dietician and clinical nurse specialist and laboratory tests;
4. ‘One stop shop’ — minimising time off work and disruption to personal time.
A considerable amount of the work needed to prevent the complications of diabetes rests with the patient taking on board the lifestyle changes necessary. Too often in the past, a patient was diagnosed with diabetes and after some preliminary education, no further follow up for support and re-education was arranged. The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) found that education by nurse specialists and dieticians promoted good glycaemic control when delivered regularly.
Higher risk
It is well known that people with diabetes have a higher risk of a cardiac episode than the general community. Attention to glycaemic control and aggressive management of commonly associated cardiac risk factors such as hypertension and hyperlipidaemia will reduce this risk. Such co-ordinated care is delivered through this multidisciplinary care team.
The recent national guidelines on physical activity launched by the Department of Health and the HSE are always incorporated into the advice the team gives to patients.
In summary, the multidisciplinary team will seek to establish the priorities of an individual patient with diabetes mellitus and help them to formulate a set of reasonable, appropriate goals that can be met in accordance to their needs, values and resources.
Patient assessment includes:
l Height/weight /BMI /waist-to-hip ratio;
l 45-minute assessment and education session with the dietician to receive appropriate advice on weight loss and/or lipids appropriate to results;
l Thyroid, LFTs, U&E, micro albuminemia, fasting lipid profile;
l HbA1C, fasting glucose, 2-hour pp glucose or modified OGTT if diagnosis not yet confirmed;
l As required exercise stress test, chest x-ray, ECG, 24-hour blood pressure monitor;
l Education in use of blood glucose monitor;
l Full advice on good diabetic care;
l General advice on foot care;
l Referral to eye specialist.
Patient action plan includes:
l Working with the patient to develop a diabetes self-management plan best suited to the patient’s lifestyle and to achieve best possible diabetes outcomes for the patient;
l Arrange other tests which may be appropriate;
l Arrange other specialist referrals which may be necessary;
l Education in correct administration of any prescribed medications;
l Education in use of blood glucose meter;
l Tailoring an appropriate exercise plan;
l Tailoring an appropriate dietary plan;
l Target weight loss;
l Regular follow-up visits with dietetic department;
l Visit to podiatrist if necessary;
l In-patient admission if appropriate.
About Greg Baxter
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