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Type 1 Diabetes in Adults Glos Care Pathway Overview

This pathway will support GP’s to diagnose Type 1 diabetes and refer appropriately to secondary care.

Please click the relevant flowchart box to be taken directly to textual information
                                          

Red Flags
Diabetic Ketoacidosis (DKA)
Commonly presents with symptoms of:
  • polydipsia, polyuria, nausea, vomiting, weakness, and lethargy
  • dehydration, Kussmaul's respirations (deep respirations), fruity odour on breath, and mental status changes
Presentation
  • often, but not always, relatively short history of symptoms which may include, thirst, polyuria, nocturia, weight loss, blurred vision, tiredness.
  • blood glucose elevated but may not be significantly high
  • ketones in blood/urine

Age does not preclude a diagnosis- please get advice if unsure

Differential Diagnosis
  • Type 2 diabetes - If unsure telephone hospital Specialist Diabetes Team for advice
    • the team can be contacted Monday to Friday 8am-4pm on the following numbers:
    • GRH: 0300 422 8602/8606 or fax 0300 422 8604
    • CGH: 0300 422 3157/3680 or fax 0300 422 2570
    • Out of hours: Contact secondary care on call medical team via hospital switchboard on 0300 422 2222
  • Other less common causes of thirst if capillary blood glucose (CBG) is normal e.g. hypercalcaemia, diabetes insipidus
Initial Primary Care Assessment
  • capillary blood glucose
  • blood or urine for ketones

Please take blood for glucose, glycated haemoglobin (HbA1c), renal function etc

** do not delay referral in patient with symptoms and elevated capillary glucose waiting for bloods to come back**

Initial Primary Care Management

Refer to acute medical on call via hospital switchboard on 0300 422 2222

Please contact secondary care diabetes team directly on:

GRH: 0300 422 8602 / 8606 or fax 0300 422 8604

CGH: 0300 422 3157 / 3680 or fax 0300 422 2570

Monday-Friday 8am-4pm

Out of Hours: Contact secondary care on call medical team via hospital switchboard on 0300 422 2222

Patient may be managed as an outpatient following consultation with team. 

Please contact secondary care diabetes team directly on:

GRH: 0300 422 8602 / 8606 or fax 0300 422 8604

CGH: 0300 422 3157 / 3680 or fax 0300 422 2570

Monday-Friday 8am-4pm

Out of Hours: Contact secondary care on call medical team via hospital switchboard on 0300 422 2222

Patient may be managed as an outpatient following consultation with team.

Refer ALL Type 1 Diabetic Patients to Secondary Care

All patients with suspected type 1 diabetes or diabetes that is not clearly type 2 should be referred to the secondary care diabetes team.

Following initial discussion the secondary care team may deem that primary care can manage patients and in this instance will provide advice and guidance.

Primary Care Management

Please liaise with the secondary care diabetes team for advice on the best way to manage patients on an independent basis. There is unlikely to be one size fits all approach to care and therefore each patient should have a plan created in collaboration with secondary care

Contraception

Effective care before pregnancy improves pregnancy outcomes in women with diabetes. The National Institute for Health and Clinical Excellence (NICE) lists preconception care as a 'key priority' to improving pregnancy outcomes in women with diabetes. Contraception should be considered for all diabetic females in order to decrease risk of accidental pregnancy. Please consider contraception and type of contraception with your patient.

Pregnancy

Should a diabetic patient that is normally cared for in secondary care present to you wanting to plan pregnancy or is already pregnant please liaise immediately with the Specialist Diabetes Team. 

Patients can self-refer by calling 0300 422 4266 or by emailing ghn-tr.diabetespregnancy@nhs.net

'Planning a family and diabetes' leaflet can be found here.

'Gestational Diabetes Mellitus (GDM)' leaflet can be found here.

Practices are aware that diabetic patients being referred and then screened in the diabetic eye clinic on an annual basis forms 1 of 9 care processes for people with diabetes, against which the practice is monitored as part of the National Diabetes Audit and forms part of the Community Enhanced Service.

For children over the age of 12 annual screening should be arranged by the GP. Screening for diabetic retinopathy should occur annually to allow early detection and management of any problems.

For more information on this service please click here.

Secondary Care Management

The patient remains under the care of the specialist team unless otherwise notified to the GP practice.

Ongoing Care

Do not change an aspect of a patient's diabetes treatment without consultation with the specialist team.

If a patient has presented to you with any problems that you feel should result in altering an aspect of their diabetic care please liaise with Specialist Diabetes Team prior to making any changes.

The team can be contacted on the following numbers:

  • GRH: 0300 422 8602/8606 or fax 0300 422 8604
  • CGH: 0300 422 3157/3680 or fax 0300 422 2570
  • Monday-Friday 8am-4pm
  • Out of Hours: contact secondary care on call medical team via hospital switchboard on 0300 422 2222.

Patients may be managed as an outpatient following consultation with the team.

Services

Please refer to guidance below prior ro referring to GHNHSFT's Specialist Diabetes Service

Exclusion Criteria:

  • not registered with a Gloucestershire GP
  • stable/non-complex Type 2 diabetes

Indications for Referral:

  • assessment/management of those on Insulin Pump Therapy
  • specialist diabetic foot care
  • type 1 diabetes for : 1) adolescents in transition and 2) those with poor blood glucose control
  • specialist nephropathy (including. those on dialysis)
  • specialist antenatal diabetes care (women with diabetes contemplating pregnancy)
  • Other reason for referral- e.g. significant or worsening complications requiring acute/specialist input (please provide information below)

For women with diabetes who are pregnant please fax the referral  (to ensure it is seen immediately) and also send an e-mail.

GRH: 0300 422 8602/8606 or fax 0300 422 8604

CGH: 0300 422 3157/3680 or fax 0300 422 2570

Email Specialist Diabetes Referral Form to ghn-tr.DiabetesPregnancy@nhs.net

The Specialist Diabetes Service referral form can be found here.

Practices are aware that patients with diabetes being referred and then screened in the diabetic eye screening clinic on an annual basis forms 1 of the 9 care processes for people with diabetes, against which the practice is monitored as part of the National Diabetes Audit and forms part of the Community Enhanced Service.

For children over the age of 12 annual screening should be arranged by the GP. Screening for diabetic retinopathy should occur annually to allow early detection and management of any problems.

The GHNHSFT website page for Diabetic Eye Screening can be accessed here.

Notifications

Practice Diabetic Leads should:

  • ensure that all patients newly diagnosed with Diabetes Mellitus (DM) and patients with DM newly registered at the surgery are notified to Gloucestershire Diabetic Eye Screening Programme (GDESP) within one month of diagnosis of DM or registration at practice.
  • ensure that changes to patient information (moved out of area, change of address, etc.) are notified to GDESP within one month.
  • submit a full register of patients diagnosed with DM to GDESP bi-annually.

Eligibility for Screening

GDESP will invite the following patients for screening:

  • patients with a definite diagnosis of DM (type 1 or type 2)
  • patients who are ‘diabetes resolved’ where there has been a previous definite diagnosis of DM
  • patients with steroid-induced DM

GDESP will not invite the following patients for screening:

  • patients with gestational diabetes
  • people with pre-diabetes or non-diabetic hyperglycaemia
  • patients who have impaired glucose tolerance (not in diabetes range)
  • patients who have never had diabetes and were coded in error

Invitation to Screening

  • when notification of a new patient is received, GDESP will register the patient and invite them to attend for diabetic eye screening at an appropriate clinic.

if a phone call is received from a patient requesting an appointment before notification has been received of their diagnosis, GDESP will contact the patient’s surgery to confirm diagnosis before an appointment is made.

Any patients requesting to be excluded from screening as medically unfit or not diabetic will require signed consent from a GP or the Clinical Lead at GDESP.   Any such requests will only be actioned by GDESP if accompanied by a GP signature and GMC registration number.

Please follow this link to the NHS Choices website for further information on Diabetic eye screening

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