7 April 2020
Today’s clinical topic is primary care diabetes management which has undergone a sudden transformation in light of the current pandemic. Routine diabetes care is on hold and practices have moved to remote consultations, which I suspect causes a certain degree of anxiety for both patients and clinicians. So, is it possible to provide good quality diabetes care in a remote way? I spoke to my colleague Paul Sullivan about this. Paul has been a Diabetes Specialist Nurse and a tutor at the training centre for many years (he lost count at around 17 years!) and we co-deliver several diabetes modules. I asked him how his own practice had changed, and if he had any advice to share. We also pulled together various resources to support clinical practice. You can also find these links in our Resources section.
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Diabetes management during a pandemic
by Rebecca Owen
Primary care diabetes management is currently unrecognisable from the usual face-to-face annual reviews (care planning) and interim appointments. Routine diabetes care is on hold and practices have had to very quickly adapt to remote consultations. Not having recent blood/urine results to hand is particularly challenging, and many people with type 2 diabetes don’t have a blood glucose meter. Even if the patient does home glucose monitoring, insulin dose adjustment can be tricky to do remotely. People with diabetes may be understandably anxious about their diabetes control, particularly if they become unwell with coronavirus. So, is it possible to provide good quality diabetes care in a remote way? I spoke to my colleague Paul Sullivan about this. Paul is a Diabetes Specialist Nurse and tutor, and we co-deliver several diabetes modules at the training centre. I asked him how his own practice had changed, and if he had any advice to share:
“I’m mostly doing telephone consultation clinics, all face to face appointments have been deferred unless someone is symptomatic and needs an insulin start. The main thing I’ve found is that patients appreciate that someone has contacted them. A lot are worrying that because their appointments have been cancelled it might be months before anyone speaks to them about their diabetes.”
Paul’s advice is:
Think Safety First
- Remember hypo prevention, awareness and management*
- Keep things simple – stick to minor changes and one thing at a time
- Educate on basic sick day rules
- Contact your local diabetes team for advice if you have any concerns
*see Trend UK in resources list
On the subject of sick day rules, there are some excellent patient leaflets available to download (https://trend-uk.org/). Paul’s practice found a novel way to use these:
“We’d just sent an SMS to over a thousand patients with the Trend type 2 leaflet link. it’s great, they tap on the link in the message and the leaflet launches in their web browser. The following day Trend updated it, which also then changed the link, so we had to send all the messages back out again!”
The Trend type 2 leaflet advises on when medications such as Metformin and SGLT2 inhibitors need to be temporarily stopped, and when patients should seek immediate help. There is also advice on insulin dose adjustment. The Type 1 leaflet includes easy to follow algorithms for insulin dose adjustment with raised blood ketone levels. Your local diabetes specialist team should be able to provide urgent support to type 1 patients with ketones, to ideally prevent hospital admission for DKA.
It’s reassuring to hear that practices are finding ways to support patients in new and very different ways. Technology plays a vital role and there are some high-quality educational resources listed below. For insulin treated patients there are educational videos on injection technique and self-examination of injection sites. We have to accept that things might not be quite as straightforward as having the patient in the same room, particularly if there are any language or learning barriers. Or technology barriers for that matter! Many of the 9-care processes (checks & tests) will have to be postponed, and the system alerts will be an uncomfortable reminder. However, much of the education we give in routine diabetes reviews can still be discussed over the phone, for example medications, lifestyle and foot care advice. We might even find there is a little more time than usual for this compared to time-pressured consultations. For same people with diabetes there might actually be some benefits to a new approach. It’s possible that people might engage better with self-management, and ‘take back’ some of the responsibility clinicians unintentionally take on. It might not be a perfect system but we can still provide diabetes care, and patients will appreciate your support.
I think that at the back of all our minds there is the concern that we will have a lot of catching up to do when things return to normal. It could be all hands on the diabetes deck. Our team is planning for the best ways we can support primary care further down the line with educational updates. We might even do some of this remotely!
Recommended resources (also available in the COVID-19 section of our Resources)
At a glance factsheet: COVID-19 and diabetes
This quick reference guide reviews a number of issues that healthcare professionals may need to consider when caring for people with diabetes
Resources related to diabetes and the COVID-19 pandemic
Injection Technique Matters
Educational videos include: injection technique, correct use of a pen device, and self-examination of injection sites
Leicester Diabetes Centre
The Leicester team have created a bank of videos, information, resources and publications
Extensive range of downloadable patient leaflets including ‘What to do when you are ill’ and ‘Why do I sometimes feel shaky, dizzy and sweaty?’