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Diabetes: a team approach to insulin transfer

Carole Dempsey
DipPP RGN FETC
Primary Care Diabetes Specialist Nurse
Diabetes Centre
Worthing Hospital
Worthing

Global prevalence of type 2 diabetes will more than double by the year 2025.(1) In the UK there are 1.38 million adults with diabetes; 85% of those have type 2 diabetes.(2)
All health professionals involved in the care of people with diabetes should be following evidence-based guidelines in the management of type 2 diabetes, reducing the risk of complications by improving glycaemic control, including the timely transfer to insulin, which is the focus of this article. The benefits of such strategies for type 2 patients were demonstrated by the UK Prospective Diabetes Study (UKPDS).(3)
Type 2 diabetes can initially be managed with diet and exercise. However, due to the progressive nature of the disease, most patients will require oral medication to control glucose levels. An increasing number of people will eventually need insulin to maintain satisfactory glycaemic control.
Regular review of their diabetic medication is vital, as many patients eventually require multiple oral hypoglycaemic agents to achieve optimal control (HbA(1c) 6.0-7.0% DCCT). If these target HbA(1c) levels are not achieved, despite maximal oral therapy, patients should be seen early to discuss the results and what the implications may be for their future health. Patients may be able to make some changes to their lifestyle that could improve their glycaemic control through diet and exercise. Insulin therapy should be discussed as an option, but it should be made clear that it's not a punishment for poor compliance.(4)
In our health community in Worthing, Sussex, the majority of patients with type 2 diabetes are referred to the diabetes specialist nurses (DSNs) at Worthing Hospital for insulin transfer, then are seen approximately eight weeks later.
The growing number of referrals for insulin transfer, and the increasing waiting list of up to 12 weeks, led the diabetes team to adopt new strategies to meet the demands within the current resources. This led to the development of group insulin transfer sessions, replacing the individual consultations with a DSN for insulin start and follow-up.
Group education is increasingly recognised as an effective and efficient way of delivering diabetes education, providing an environment that enables individuals to support one another.(4,5)
When we first started group insulin transfer, the session led by the DSN lasted two hours and included the same information as the one-to-one consultations plus the group sharing of fears and concerns about insulin therapy.
It became apparent, however, that the patients in the group had varying knowledge of diabetes, knew little about the risk of complications and had misconceptions about the use of insulin - and some people were not told by their GP why they were referred to the diabetes team. Consequently, we changed this process in terms of referral criteria and increased the programme from one to four group sessions.
We reviewed the referral process and developed a form to ensure appropriate referral through correct information being obtained: Is the patient on maximal oral hypoglycaemic therapy? Is HbA(1c) >7.5%? Has insulin been discussed and agreed by the patient? Weight and biomedical measures were also included and form the basis for an ongoing research study (currently unpublished). Patients who are unsuitable for a group or do not wish to participate in a group were identified and offered an individual appointment with the DSN.
The four sessions are outlined below.

Session one - pre-insulin
This session begins with an explanation of what is hoped to be achieved through changing to insulin therapy. Participants are invited to ask questions and share their concerns at any time during the session. Patients often feel well despite deteriorating glycaemic control and therefore find it difficult to accept the need for a change in treatment when they have not experienced symptoms severe enough to cause discomfort or disruption to daily life.
Topics discussed are:

  • Complications and implications of poor glycaemic control.
  • Blood glucose monitoring: aims and frequency of testing; interpreting blood glucose results and disposing of sharps.
  • Hypoglycaemia: signs and symptoms; causes and treatment.
  • Driving and diabetes: contacting the DVLA, and insurance issues; carrying identification.
  • Types of insulin regimens.

The dietician discusses the effects of meal/snacks on blood glucose levels, principles of carbohydrate distribution and potential risk of weight gain.
A variety of information leaflets and a booklet about the type of insulin and device are provided for further reading and reference.

Session two - insulin transfer
The patients are seated around a table with a tray containing a prefilled demonstration insulin pen, a reusable insulin pen, a saline cartridge and pen needles.
The practical demonstration includes:

  • How to assemble the pens and dial a dose.
  • Injection technique; patients are encouraged to practise an injection.
  • Dismantling the pen and disposing of sharps.

Each step of the demonstration is taken slowly to enable patients to follow the instructions and allow the DSN to assess the patient's capabilities or identify any difficulties they may have. Patients then choose which pen device they wish to use.
If patients are worried about injecting at home alone, or if the DSN assesses that a patient requires extra support, patients will be referred to district nurses, who will supervise initial injections until the patients become confident.
Experience has shown that few patients require this support; generally they are able to manage independently with telephone support for dose adjustments.
DSNs provide telephone triage each weekday, answering a variety of queries, including dose adjustment advice.

Session three - dietetic
The dietician continues education on meal planning, alcohol, hyper/hypoglycaemia, symptoms and treatment. The DSN answers any queries that have arisen since the last session, and dose adjustment guidelines are provided and discussed with the group.

Session four - post-insulin
The purpose of this session is to review existing knowledge, discuss current glycaemic control and how that can be improved through altering insulin doses and looking at insulin profiles.
Situations where doses may need to be altered, such as travel, sickness and change to routine, are discussed, and patients are encouraged to share their experiences.
Throughout the insulin transfer programme, patients are encouraged to consider the change in their treatment to insulin as a positive step rather than a "last resort".
Achieving optimum glycaemic control may take up to three months, sometimes longer. Patients will often become despondent with the increasing doses of insulin and are keen to see the results of their efforts early on. Reassurance and support throughout this period of adjustment is vital to enable patients to gain maximal benefit from the change in treatment and achieve their goals of improved glycaemic control and reduced risks of complications.

Conclusion
The National Framework for Diabetes, standard 3, states that:
"The provision of information, education and psychological support that facilitates self-management is therefore the cornerstone of diabetes care. People with diabetes need the knowledge, skills and motivation to assess their risks, to understand what they will gain from changing their behaviour or lifestyle and to act on that understanding by engaging in appropriate behaviours."(6)
Group sessions have become integral in the way diabetes care is managed in the hospital setting; the success of the insulin transfer groups has led the Worthing team to look at other areas of our practice where groups can be utilised, such as type 2 education sessions, patients transferring to more complex basal/bolus insulin regimens and teenage clinics.
Evaluation of our groups by participants revealed that they prefer groups to one-to-one consultations; they enjoyed the feeling of camaraderie and mutual support from their peers and learned more, not only from the health professionals involved but from each other's experiences as well.
Group sessions are not appropriate for all patients. Patients who are visually or hearing impaired, have learning difficulties or a mental health condition are invited to an individual consultation with the diabetes specialist nurse. These patients may also require extra support to manage their diabetes and are referred to district nurses. Liaison with our community colleagues provides ongoing support and effective clinical networks.
The increasing numbers of people diagnosed with type 2 diabetes will impact on nurses working in community settings. Complications, often as a result of poor control, will lead to more hospital admissions and patients being referred for district nurse support at home.
It is essential that nurses refer dibates patients to specialist services to provide practical and educational support, to improve the quality of care given to this high-risk group of patients.

Resource
Diabetes UK
W:www.diabetes.org.uk