NHS Highland Diabetes Managed Clinical Network Newsletter. Welcome to this issue of the NHS Highland Diabetes MCN Newsletter. (October 2016).

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1 Welcome to this issue of the NHS Highland Diabetes MCN Newsletter In this issue: (October 2016). 1. Local Diabetes MCN Update 2. SCI Diabetes 3. Education Sessions for HbA1c for Diagnosis Agreed Local Guidelines 5. Gestational Diabetes Management (GDM) 6. Diabetes UK Local Diary Dates 1. Local Diabetes MCN Update The diabetes MCN continues to meet on a quarterly basis in order to maintain a forum for all stakeholders involved in the local services to discuss matters relevant to care provision throughout the NHS Highland region. In this newsletter, we have highlighted items for review throughout the clinical and support services community. As usual, please feel free to distribute this information within your area. The issue will be available on the main NHS Highland Diabetes Website at the address below. There is currently some considerable work getting underway in order to establish an online platform for therapeutic portals which will make accessing information much easier than the current format. The aim is to link patient information, acute management, local resources etc. back to shared clinical guidelines and BNF advisories across all services both in primary and secondary care. All guidelines and disciplines will follow the same pattern and will involve considerable testing of links before going live. A representative is sought from each of the services, including diabetes to participate in the project steering group. The local diabetes guidelines group will provide and update the information via the Portal Group which will in turn replace the current online policy/guidelines remit. Work on this will be ongoing over the coming months. If you have any materials or updates which need to be included on the existing website, please get in touch with Lisa Steele (lisa.steele@nhs.net). The Highland diabetes website URL is:

2 2. SCI Diabetes In the March newsletter we highlighted the 9 specific measurements in relation to diabetes care that the Health Board has to report on to the Scottish Government. This information is collated directly from clinical data input into the SCI Diabetes system, not all of which is an automatic feed from the primary care systems. We have tried to provide as much support recently via the Regional Facilitator (Lisa Steele) and the designated SCI Diabetes support team based in Tayside in order for practitioners to ensure that they are aware of the requirement to audit information in the individual practice registers for diabetic patients, and to query any discrepancies if they arise for resolution. As a result, it is very important that each practice has a designated system person who will check data in the SCI Diabetes system and report any data anomalies to us, or update data where necessary directly into the SCI Diabetes clinical record. There are an increasing number of patients accessing their clinical data directly within the My Diabetes My Way system, which health care professionals have actively encouraged them to do. This patient online portal also depends on the accuracy of information held in SCI Diabetes which is why we need to work towards a robust reporting mechanism. Not all the measurements are recorded in primary care clinics however, your help is needed to ensure that overall, the information is accurate. The key measurements to consider data checking in SCI Diabetes are as follows: 1. Up to date HbA1c record 2. Recording if the patient smokes or not 3. Up to date cholesterol measurement 4. Up to date foot ulcer record management if appropriate 5. Diabetes retinopathy screening result this is automatic from the DRS system 6. Record of anyone with end stage renal disease or requiring renal replacement therapy 7. People on Insulin Pump Therapy 8. Up to date BMI 9. A record of having attended a structured education session If staff require any assistance in getting access to SCI Diabetes or any other queries, please contact Lisa Steele on lisa.steele@nhs.net in the first instance to progress.

3 3. Education Sessions for 2016 Please note that the previous dates circulated for Insulin Pump Training in October to December are no longer available. We will list new training dates as soon as possible. Professional Education Funding If you are interested in pursuing specific professional training in relation to diabetes care, you may be eligible for funding. Please contact Lorna Grant, Diabetes Specialist Nurse by in the first instance for further information; Management of High Risk Foot Disease in Diabetes Diary Date: Thursday 17 th November 2016; 13:00 to 13.50pm. Venue: Education Room, Diabetes Centre, Centre for Health Science Building, Inverness. VC Links also available (Caithness General Hospital, Conference Room Booked) Skin & Nail Conditions Affecting the Foot in Diabetes Dr Louise MacFarlane, Consultant Dermatologist, NHS Highland Aims To provide networked education for those concerned with the care and treatment of those with diabetes. To increase awareness of existing guidelines for the early referral of those with diabetes foot ulceration To provide opportunity for at distance staff networking and sharing best practice.

4 To promote inter-professional learning and working To promote early referral of all persons with diabetes and at risk of foot ulceration Audience All staff concerned with the assessment, care and treatment of persons with diabetes foot problems are encouraged to book into these networked education sessions, improving access to evidence based approaches to improving early referral. To register for this event please complete attached application form and return to: Argyll & Bute Training Education is available for patients in the Argyll & Bute area. People with Type 1 diabetes can access the Highland Education In Diet and Insulin (HEIDI) course. People with Type 2 diabetes can access the X-PERT course. If you would like more information or dates on the courses available; please contact Juliet Finnie, Diabetes Specialist Dietician on or ; or Seonaid Morrison, Advanced Nurse Diabetes on HbA1c for Diagnosis Agreed Local Guidelines The online shared clinical guideline has been updated as follows: Screening for or suspected type 2 diabetes (T2DM) Check HbA1c HbA1c <41mmol/mol: T2DM unlikely - Review limitations of HbA1c testing HbA1c 42-47mmol/mol: Impaired or Pre-diabetes HbA1c 48mmol/mol or above Diagnostic of T2DM

5 To avoid diagnostic confusion do not measure blood glucose after an HbA1c of mmol/mol. When not to use HbA1c to diagnose Type 2 diabetes The following are the most common situations where HbA1c is not suitable. In these situations diagnose diabetes by fasting glucose 7.0 mmol/l twice, or once with symptoms. 1. Rapid onset of diabetes an increase in HbA1c may not be detected until a few weeks later. a. Suspected type 1 diabetes rapid onset of symptoms, weight loss, ketosis. b. Children because most will have type 1 diabetes. Both these conditions require urgent (same day input) from specialist diabetes teams c. Steroids. Antipsychotic & immunosuppressant drugs can raise blood glucose, rarely precipitously. d. After pancreatitis or pancreatic surgery. 2. Pregnancy. Multiple factors make HbA1c lower in pregnancy. The diagnosis of gestational diabetes should be made by using glucose measurements in line with SIGN guidance: Fasting glucose mmol/l or above 2 hr glucose in GTT mmol/l or above 3. Conditions with reduced red survival may lower HbA1c markedly: a. Haemoglobinopathy which will normally be detected by the lab, but should be suspected in racial groups where there is a high prevalence of sickle trait, sickle disease or thalassaemia. b. Haemolytic anaemia c. Severe blood loss d. Splenomegaly e. Antiretroviral drugs 4. Increased red cell survival may increase HbA1c e.g. splenectomy. 5. Renal dialysis patients have a markedly reduced HbA1c especially if treated with erythropoietin. 6. Iron and B12 deficiency and their treatment. May raise or lower HbA1c, but the effect is small.

6 5. Gestational Diabetes Management (GDM) There have been significant changes in GDM management due to the HbA1c threshold levels being lowered. This in turn has had a huge impact in numbers of women being diagnosed with GDM. Although there is some online guidance, there is no detailed referral process included at present. Whilst we are seeking clarification on this, we would stress that there has been an impact on the resources in secondary care with an increase of patient referrals from primary care which is not part of the existing guidance. The concern is that someone will get missed due to the volume of referrals from all areas. The skill sets to manage this are already in place within staff in primary care so we would ask for your support until the appropriate pathway and referral criteria is determined. 6. Diabetes UK Local Diary Dates 2016 Wednesday 7th December 2016 at 6.30pm. Spectrum Centre, Inverness. Pre-Christmas Healthy Eating Event. (Members Event.) 2017 Wednesday 25th January 2017at 2.15pm Spectrum Centre, Inverness. Seated exercises with Pam Watson from the Fitness League. Thursday 30th March 2017 at 6.30pm. Community Centre, Nairn. Speaker:- Alistair Boyd-Orr, Chief Pharmacist from Boots - Inverness. Thursday 6th April 2017 at 6.30pm. Spectrum Centre, Inverness. (Our AGM will also be held this evening.) Speaker:- Alistair Boyd-Orr, Chief Pharmacist from Boots - Inverness.

7 Wednesday 14th June 2017 at 2.15pm. Spectrum Centre, Inverness. Last meeting for Details to be announced.

8 If you have any items you would like us to include in the next Diabetes MCN Newsletter, please get in touch by to