Type 1 Diabetes -Adult Patients' Pathway

A guide designed to help patients understand their care plan.

Diagnosis

If you have recently been diagnosed with Type 1 diabetes it may have come as quite a shock or as a relief, if you have been feeling tired and unwell. Your GP or practice nurse will have informed you of the diagnosis and explained about the elevated level of glucose in your blood. Type 1 diabetes occurs when the insulin secreting cells in the pancreas have been destroyed; it is not known exactly why this happens but it is thought that the immune system reacts abnormally to an infection and attacks these cells. When insulin is not produced, the body is unable to process glucose for energy which results in elevated levels of glucose in the blood and lack of energy. High levels of glucose in the blood will cause symptoms of frequent urination, dehydration and thirst.

A specimen of your urine will need to be tested for ketones. Ketones are chemicals, which are produced by the breakdown of fat and protein; this can occur when the glucose level in the blood is extremely high. Ketones in the urine indicate that the diabetes is uncontrolled and serious so that a more urgent referral for specialist care will be made.

You are probably feeling quite unsure of what will happen next. This information will try to explain what you can do yourself and how you will be cared for, in order to keep the diabetes under control, and enable you to lead a normal and active life.

After diagnosis you will be referred, usually by telephone on the same day, to the Diabetes and Vascular Health Centre at the Royal Devon and Exeter Hospital at Wonford. The Specialist nurses will teach you Blood Glucose Monitoring and initiate treatment with injections of Insulin. You will be given information on the technique, timing and site of injections and storage of insulin and disposal of sharps (used needles and lancets).

Some further blood will be tested which will include: -

HbA1C - this test measures the average glucose level over the past 3 months.
Cholesterol level – This helps to assess to the risk of heart disease.
Full Blood Count, Thyroid, Liver and Kidney Function tests.

These blood tests are usually done to exclude other health problems. Your nurse will check your blood pressure, weight and height and discuss the results with you. She will ask you about your normal activity level and smoking and alcohol intake.

Specialist Examination

You will have a full examination with one of the diabetes consultants.
The consultant will discuss your blood test results with you and may introduce some other treatments e.g. for your blood pressure or cholesterol.
You will also have a foot examination to assess the circulation and sensation level.
You will have the opportunity to ask any questions and discuss all aspects of your care.
You may be referred for retinal screening (described later in this information)

Dietitian

You will have an appointment with a dietitian to discuss your normal eating and how your food can be adapted to fit in with your activity and the insulin regime prescribed for you.

Education

During this time you will receive a lot of information and you may feel rather swamped at times. You will need to learn about all aspects of balancing your food, activity and insulin. You will also learn about preventing the glucose levels becoming too high or too low which could cause hypoglycaemia (hypo). You will be given many different leaflets and it is a good idea to keep them all together in a folder or file so that you can quickly refer to them if you are worried.

Also included will be information on: -

Driving
Insurance and notification of DVLA
Identification card or emblem
Contraception
Free prescriptions
Effects of alcohol
Illness and infections
Testing the urine for ketones when the level of glucose in the blood is >15
High blood glucose levels and when to seek help
Travel
Complications

Follow Up Care

Once you are confident of your own management and the diabetes consultants feel that your general practice team can continue your care, you will be referred back to them.

Annual Review

Each year you will have an Annual Review. It may take place in the Diabetes and Vascular Health Centre or at the surgery. This information describes how it is done at Wyndham House Surgery where Trish Brown, senior practice nurse who has undertaken extensive training in diabetes, will provide much of your care. All the GPs have an interest in diabetes, working together to provide a high quality service.

You will have the blood test taken two weeks beforehand and will need to take an early morning specimen of urine with you. Your blood will be tested for glucose, HbA1C, cholesterol, kidney and sometimes-liver function.
The annual review appointment takes about half an hour and will be with your practice nurse first and then a combined appointment with your GP.
It is important to bring your Blood Glucose Monitoring records with you to show your practice nurse. It is always helpful to do some extra tests before the appointment and record them in a booklet in case any adjustments need to be made to your insulin regime. Also make a note of any episodes of hypoglycaemia (hypos).
Your eyes will need to be checked. Your vision will be tested and some eye drops used to enlarge the pupil so that the retina at the back of the eye can be examined. The drops will prevent you from being able to drive for a few hours and may cause discomfort if the day is bright. Dark glasses are helpful, and arrangements made to have a lift or take the bus.
The results of your blood and urine tests will be discussed with you, also any other prescribed medications to ensure that you are taking them correctly and not getting any side effects or problems.
Your blood pressure, weight and height will be measured and your feet and footwear examined.
Your injection sites may be examined and injection technique and timing discussed.
The annual Review is a good time to ask questions and agree some goals for your self-management plan for the coming year.

Specialist Advice

If your practice team is concerned about any aspect of your care, they have speedy access to a diabetes specialist. This system has been designed to address problems with diabetes itself, but also particular problems, which sometimes occur with the heart, blood circulation, feet, eyes, nerves and kidneys. The specialist appointments are usually at the Diabetes and Vascular Health Centre at the RD& E Hospital Wonford, but sometimes at community hospitals. Your practice team will continue with your care, supported with the advice from the specialist.

Follow- Up

Most patients should be monitored again at 4- 6 months. This is usually with your practice nurse using a 15-minute appointment. It will involve a blood test for HbA1C, blood pressure and weight measurement. Again your home monitoring record is always useful. Your practice nurse will advise you of when the appointment is due and we suggest you make a note in your diary. It is important to keep regular appointments even if you are feeling well.

You can always see your GP or practice nurse between these appointments if you are having any problems.

Retinal Screening

Every two years you will be invited to have a retinal photograph. This usually takes place at your Health Centre and is exactly like the retinal examination, but a photograph is taken with a digital camera. This will be examined by the ophthalmologist and then stored in your notes as a record. The digital photographs can be enlarged to show much more detail than the regular eye examination.

Vaccinations

All people with Diabetes are advised to have an annual Influenza vaccination, also a Pneumonia vaccination, which will last for 10 years.

Help lines

You can contact your GP or Practice Nurse during normal working hours At Wyndham House Surgery 01392 860034

The Diabetes and Vascular Health Centre day time help line number is 01392 402281.

It is important to have an out of hours help telephone number in case of emergency.

You can call GP out of hours service Devon Doctors on Call 01392 824600. A message with this number will be given out by calling your own surgery out of normal working hours.

NHS Direct 08454647

Novo Nordisk Help line 0845 600 5055 for people using their insulin products
5.30 pm –11pm Mon to Fri and 8.30 am – 11pm Weekends and Public Holidays

For information about membership, leaflets, etc: -
Diabetes UK, 10 Parkway, London NW1 7AA (Telephone 020 7424 1000)
For help and advice – Careline -Tel: 0845 120 2960
Website: www.diabetes.org.uk
Email: info@diabetes.org.uk

Local website with a page specifically for patients www.devondiabetes.org.uk and information about the diabetes UK Exeter and district Voluntary Group, including dates, venues and subjects of meetings.