Introducing the SOLENT DIABETES COMMUNITY TEAM. Spring Issue 28

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1 Spring Issue 28 From the Diabetes Specialist Centre Queen Alexandra Hospital, Portsmouth Introducing the SOLENT DIABETES COMMUNITY TEAM Alison Tier Community Diabetes Specialist Nurse Sarah Moutter Community Diabetes Specialist Nurse Theresa Eves Administrator Dr P Kar Consultant Dr I Cranston Consultant Professor M Cummings Consultant Dr D Meeking Consultant This service commenced in January 2013 following the super six initiative which allowed patients to be seen locally at their GP surgeries as opposed to secondary care. This allowed swifter appointments for patients to access specialist clinics within the diabetes centre. What does the community service offer? Surgery visits to provide support and education to GPs and PNs either within clinics seeing patients or virtual clinics. s are answered Monday to Friday by DSNs where possible. Phone support is available Monday to Friday with additional support from Consultants pm. 1 Community visits to care/nursing /residential homes are offered to support community nursing teams. We can also visit patients within their own homes with community nurses. Education Patients: DESMOND (diabetes education, self management, on going for newly diagnosed) Annual diabetes patient conference. Diabetes refresher half days. Professional education Portsmouth district diabetes network (PDDN) Primary and community care training. Diabetes training for allied health care professionals. The surgeries are entitled to 2 Consultant and DSN visits per year. Which may involve discussing complex cases, update on new medication and general advice. We work collaboratively with the CCG and prescribing pharmacists to encourage cost effective and high quality care across Solent. We have strong links between Secondary Care and Southern Health.

2 UPDATED CARE PATHWAY EDITORIAL TEAM Academic Department of Diabetes & Endocrinology Queen Alexandra Hospital, Portsmouth PO6 3LY Tel: Professor Mike Cummings Consultant, Diabetes & Endocrinology Dee Irish Diabetes Centre Administrator Jo Buchanan Diabetes Specialist Nurse Dr Eveleigh Nicholson Research Registrar 2

3 Diabetes in Pregnancy The Role of the Diabetes Antenatal Team Portsmouth Hospital Trusts have approximately 6,000 deliveries a year, 6% of these pregnancies involve woman with diabetes. Pre-existing type 1 diabetes and pre-existing type 2 diabetes account for 5% and 7% respectively. The remaining 88% pregnancies are complicated by gestational diabetes. Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre-eclampsia and pre-term labours are more common in woman with pre-existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to woman with pre-existing diabetes. Establishing good glycaemic control before conception and continuing this throughout pregnancy will reduce these risks. A pre-conceptual clinic is run alternative Tuesdays in the maternity out patients department at Queen Alexandra Hospital. It is run by Ann Going (DSM) and referrals can be made directly to the DSM s or via the diabetes centre (see diabetes in pregnancy pathway). The aim of pre-conceptual care is to empower woman with diabetes to have a positive experience of pregnancy and childbirth by providing information, advice, and support that will help reduce the risks of adverse pregnancy outcomes (see box 1 below). Antenatal As soon as pregnancy is confirmed immediate referral to the Joint diabetes and antenatal clinic is recommended, this can be via GP, midwife or self-referral. We aim to see woman in the next available clinic following referral, and we usually have contact with the woman every 1-2 weeks throughout pregnancy. On first contact the following is usually discussed: Information, education and advice about how diabetes may affect the pregnancy and birth. Discuss glycaemic control and targets levels during pregnancy. Offer retinal screening. Offer renal assessment. Discuss hypoglycaemia and hypo-unawareness. Give Glucagon pen to woman with type 1 diabetes and instruct the woman and her partner in its use. Timetable of antenatal appointments. Ensure Folic acid 5mg/day has been prescribed. Provide contact numbers for DSM s and named diabetes link midwife. Achieving optimal glycaemic control during pregnancy in woman with diabetes lessens the likelihood of adverse outcomes especially with respect to the fetus/newborn. Increasing glycosylated haemoglobin in early pregnancy is associated with an increasing risk of congenital malformations and miscarriage and in late pregnancy with an increased risk of excessive fetal growth and neonatal morbidity. From 26 week woman are seen by our consultant obstetrician, Mr Salloum, who performs scans every 4 weeks to assess fetal growth and amniotic fluid volume. Timing, mode and management of labour are discussed. Box 1 - Advice and information is given on: Risks of diabetes in pregnancy and how to reduce them with good glycaemic control. Diet, body weight and exercise, including weight loss for woman with a BMI over 27kg/m. Hypoglycaemia and hypoglycaemia unawareness. Pregnancy related nausea/vomiting and glycaemic control. Retinal and renal assessment. When to stop contraception. Taking Folic acid supplements (5mg/day) from pre-conception until 12 weeks gestation. Review of, and possible changes to, medication, glycaemic targets and self-monitoring routine. Frequency of appointment, local support and contact numbers. 3

4 Intrapartum Evidence shows us that maintaining blood glucose levels in the range of 4-7mmols/litre during labour and birth reduces the incidence of neonatal hypoglycaemia and fetal distress. Currently an intravenous insulin and dextrose sliding scale is used at the onset of labour, to maintain optimal glycaemic control. Postnatal Prior to discharge information and advice is given on contraception and the importance of planned pregnancy and pre-conceptual care. Women are offered a 6 week follow up appointment with the diabetes team to discuss on going management of their diabetes. Chris Hall Diabetes Speciality Midwife Diabetes in Pregnancy Pathway Woman of child bearing age with pre-existing diabetes Pregnant woman with pre-existing diabetes. Confirmed pregnancy Pre-conceptual care. Referred to diabetes centre or diabetes specialist midwife Ext 4584/4553 Offer immediate contact to joint diabetes antenatal clinic at QAH. Contact diabetes specialist midwives Chris Hall/Anne Going Ext 4553 The joint diabetic antenatal clinic has three diabetes link midwives: Sally Evans Lesley Attwell Lorna Eves Who attend clinic every week providing routine antenatal care for pregnant woman with diabetes. Woman with diabetes have contact with joint diabetes and antenatal clinic every 2 weeks for assessment of blood glucose control Offer retinal screening in 1st and 3rd trimester and in the 2nd trimester if retinopathy present at their first antenatal clinic visit MEET THE TEAM Joint Diabetic Antenatal Team Professor Mike Cummings Consultant Diabetologist Mr Marwan Salloum Obstetrician Mr Saumitra Sengupta Obstetrician Sarah Moutter - DSN Jeannette Head - Dietitian Chris Hall - DSM Ann Going - DSM 4 Offer nuchal fold screening at 13 weeks Offer an ultrasound scan for detecting fetal structural abnormalities From 26 weeks ultra-scan monitoring of fetal growth and amniotic fluid volume every 4 weeks

5 Antenatal Schedule for Diabetes in Pregnancy Gestation in Weeks Date Seen By Care Provided 1st Visit to Joint Diabetes Clinic Diabetes Link Midwife () Introductions. Ensure 5mg Folic Acid prescribed 8 Counselling for screening tests. Consent and obtain Booking Blood Test Ultrasonographer Nuchal Translucency Scan/Dating Scan 12 Complete Obstetric History 16 Antenatal check inc BP, urine test. File blood test results 20 Ultrasonographer Anomaly Scan 24 Antenatal Check 26 Cons/Ultrasonographer 2-4 weekly scans commence with Cons Review 28 Antenatal Check inc routine FBC. Administration of prophylactic Anti D if req. Introductions made to Gestational Diabetics 32 Antenatal Check Discuss plan for birth. Obtain consent for newborn blood spot test (NBBS) 34 Antenatal Check 36 Antenatal Check. Book IOL for 38 weeks if insulin/metoformin dependant 38 Antenatal Check. Book IOL for 40 weeks if Gestational Diabetes (diet controlled) 5

6 PORTSMOUTH OBESITY SERVICE Welcome to the Integrated Complex Obesity Service (ICOS) for Portsmouth City! ICOS is a new service for Complex Obese and Pre-Bariatric patients. We have been commissioned by Portsmouth CCG for an initial 12 month service. The service operates from Portsmouth Hospitals Dietetic service and clinical contact is held at St Marys Community Health Campus. The service offers a specialist Multi-Disciplinary Service which includes Medical, Dietetic, Psychological and Exercise support for a period of six months, after which the patient will either be referred onto surgical assessment, which may include Bariatric Surgery (Tier 4), or back to Primary care (Tier 2) with a personal treatment plan. The City has been without a specialist weight management service for a number of months, which made it difficult to refer patients onto Bariatric Surgery. Attendance and completion of this service is now a prerequisite to obtaining funding from NHS England for Bariatric Service. Hence patients HAVE to go through this six month treatment plan to qualify for funding. All referrals to this service have to come from Primary Care. The commission is for 100 patients in this 12 month period. The service entry criteria are patients who are BMI 50+ or 35+ who have 2 co-morbidities (e.g. hypertension, sleep apnoea, diabetes, intracranial hypertension, polycystic ovarian syndrome or requiring replacement joint surgery). They need to be non smokers and have been trying to lose weight in the previous 6 months (e.g. with a commercial organisation, practice nurse staff, pharmacy, health trainers or the dietetic service). Further details are available on PIP. The patient is initially seen by the physician Dr Lorraine Albon, psychologist Dr Gina Ingall and specialist dietitian Jilla King. They undergo psychological assessment, anthropometry measurement, and a physical assessment including a 6 minute walk test. If the patient is deemed to require diabetic management then they can have a 1:1 appointment with Alison Tier (Diabetes Specialist Nurse) as part of the ICOS service. Denise Thomas Head of Nutrition & Dietetic 76 If after assessment they are deemed acceptable for the programme they then do monthly groups as listed below: 1. Exercise specialist assessment at Mountbatten Centre with Debbie Hobbs physical trainer 2. Dietary education with Jilla King 3. Dealing with emotions without food with Dr Ingall 4. Diets post surgery with Jilla King 5. Managing a new self image post surgery with Dr Ingall and an expert patient After completion of all of the groups the individual cases are reviewed and IF the patient wants surgery they are referred by the service to the service of their choice. Otherwise their care plan is established and the patient sent back to primary care. If you require further details please contact: Sam Cowpe ICOS administrator on

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10 SPECIALIST DIABETES REFERRALS irect GP access to the following services is available. Emergency referrals we will aim to see within 24 hours and routine referrals will be seen within 4-6 weeks. These services are provided in addition to the traditional diabetes clinics operating at QAH, GWM and Petersfield Hospital. Referrals may be made through a conventional letter/fax or Choose and Book unless otherwise stated. SERVICE COMMENT PROVIDED BY Rapid Access (URGENT) Pregnancy Foot Clinic Type 1 Diabetes Intensified Insulin Education Service (JIGSAW) Young Persons Low Renal Clearance Clinic Insulin Pump Service Cardiovascular Clinics Erectile Dysfunction Clinic Painful Peripheral Neuropathy Groups Desmond (Type 2) Education Sessions Urgent cases eg new onset type 1 diabetes, mild DKA may be discussed with any member of the diabetes team to decide the best course of action. Usually seen within one week of referral. Please refer ASAP x4553 or 4584 since early review is essential. The service also provides pre-pregnancy counselling for all diabetic women of child bearing age. Patients can be referred by any member of the community diabetes team, usually via podiatry. Urgent slots will be kept for urgent cases. Goals-based 22-hour intensive insulin education package open for patients with type 1 diabetes using multiple daily dose insulin therapy, but who are unhappy with their achieved control. Access either by DSN referral or patient self referral (both by proforma to Caroline Parnell). STYLE (Safe Transition to Young Adult Life) is a multidisciplinary transition clinic held monthly at QAH and tri-annually at Gosport War Memorial Hospital. Weekly nurse - led clinics are also held at QAH and six-weekly at Portsmouth University Surgery. SARB (Safe Approach to Risky Behaviour) educational sessions may be accessed at QAH and Portsmouth University to educate on safety measures that can be taken while indulging in behaviours such as drinking alcohol, attending festivals, body tattoos and piercings etc. Assessment and follow-up for optimised metabolic management of patients with diabetes and renal impairment (egfr 20-40) with liaison to renal services in-clinic. Assessment / initiation and follow up service (as per NICE guidelines) for patients wishing to consider pump therapy (after education through the JIGSAW service). For diabetic patients with established CVS disease or who are at high CVS risk who require specialist advice (including patients with microalbuminuria) For any diabetic patient that has not responded to oral therapy. One off group sessions examining the causes of and available treatments for painful peripheral neuropathy. Focus also on foot care and risks associated with sensory loss. Whole day group education sessions for people newly diagnosed with type 2 diabetes. Booked through the Diabetes Centre: Portsmouth City, Tuesday Friday Fareham & Gosport, & East Hampshire. Zoe / Caron. Rotational basis via specialty DSN team. Prof. Mike Cummings Sarah Moutter Anita Thynne Jeannette Head Dr. Darryl Meeking Sharon Steele, Emily Sambrook Dr. Iain Cranston Lisa Skinner Anita Thynne Sue Beaden Jeanette Head Dr Partha Kar Dr Lorraine Albon Anita Thynne Jeanette Head Dr. Iain Cranston Joanne Buchanan Dr. Iain Cranston Lisa Skinner Sue Beaden Prof. Mike Cummings Prof. Mike Cummings Sarah Moutter Mandy Morcombe DSN Sharon Allard Sarah Moutter The following services are also available following initial assessment / review by the Specialist Nursing Team Basal Bolus Insulin Conversion Groups For people with type 1 and type 2 diabetes who wish to change their insulin to a basal bolus regimen. Goals based programme with dietetic and nursing input focussing on carbohydrate counting. Accessed by proforma. Anita Thynne Sarah Moutter Jeanette Head 10 Design: MBD MAY 2015