NICE guidance on diagnosis and management of type1 diabetes

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NICE guidance on diagnosis and management of type1 diabetes Author Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times. Abstract Hainsworth, T. (2004) NICE guidance on diagnosis and management of type 1 diabetes. Nursing Times; 100: 32, 28–29. New guidance has been published by the National Institute for Clinical Excellence covering issues for adults and children/young people who have type 1 diabetes (NICE, 2004a). It includes diagnosis, management, education, complications and screening recommendations. It continues the theme of patient-centred care already seen in the national service framework, and is supported by guidance published for patients.

culturally appropriate and implemented without delay. In children and young people, diabetes normally presents with severe symptoms, very high blood sugar and glycosuria. Diagnosis can therefore usually be confirmed without delay (WHO, 1999). The guidelines highlight the need for urgent (same day) referral to a multidisciplinary paediatric diabetic team. A child or young person with ketoacidosis, extra social or emotional need, or who is under two years of age will require inpatient care. However, home-based care with 24-hour access to advice is adequate for most children and young people in the initial stages.

Patient-centred care New National Institute for Clinical Excellence guidance covering issues for children/young people and adults who have type 1 diabetes (NICE, 2004a) has been published this week. The World Health Organization (1999) describes diabetes as a metabolic disorder of multiple aetiology, characterised by chronic hyperglycaemia. It highlights the characteristic symptoms of the disease as being thirst, polyuria, blurred vision and weight loss. Without treatment, in its severe forms diabetes may lead to coma and death. The long-term effects include: ● Retinopathy, which can lead to blindness; ● Nephropathy, which can result in renal failure; ● Neuropathy, which leads to an increased risk of developing foot ulcers; ● Increased risk of cardiovascular, peripheral vascular and/or cerebrovascular disease. Approximately 1.3 million people in the UK are diagnosed as having diabetes and about 15 per cent of these have type 1 diabetes (Department of Health, 2001). The new guidance therefore offers recommendations for a significant patient group. It provides long-awaited treatment targets (Strachan-Bennett, 2004) and when implemented will ensure high-quality care for adults, children and young people with type 1 diabetes, reducing the risks of diabetic complications.

Diagnosis The guidance recommends that the criteria to confirm diagnosis in adults should be a single laboratory blood glucose test if classic symptoms are present, or two laboratory blood glucose tests if they are not. It is suggested that HbA1C measurement may be used to support diagnosis. The evidence for these recommendations is based on expert opinion. In adults, a management plan should be agreed with the patient once a diagnosis has been confirmed. This should be based on individual assessment (Box 1),

The guidance recommends patient involvement both at the time of diagnosis and during ongoing care. Improving patient involvement is a recurring theme in today’s health care policy, and the recommendations in this NICE guidance continue the theme in standard three of the National Service Framework for Diabetes (DoH, 2001), entitled ‘Empowering people with diabetes’. This states that services should encourage partnership in decisionmaking and highlights the need for agreed and shared care plans. The adult guidance offers a concordance approach to diabetic management. Providing good patient information is essential and the guidance makes recommendations regarding lifestyle education in areas such as smoking, physical activity and diet. The principles of ongoing education, continually assessing the patient’s

Box 1. Assessment needed for care plans For a robust, agreed care plan, patient assessment should include: ● A

full assessment of medical history including medication and other conditions;

● Assessment

of family history including diabetes and arterial disease;

● Vascular

risk assessment including smoking;

● General

examination, including body mass index;

● Diabetes-specific

investigations such as foot, eye and urine testing;

● Assessment

of social, work and recreational circumstances including family support and preference for diet and physical activity;

● Cultural

and educational assessment including level of knowledge and understanding of diabetes.

NT 10 August 2004 Vol 100 No 32 www.nursingtimes.net

Keywords

Box 2. Routine screening assessments Assessment

Children and young people

Adults

HbA1c

Every visit 2–6 monthly (2–4 times a year)

Injection sites

Every visit

Yearly

Body mass index Every visit

Yearly

Blood pressure

Yearly from 12 years old

Yearly

Eye screening

Yearly from 12 years old

Yearly

Foot care review Yearly

Yearly

Kidney damage

Yearly from 12 years old

Yearly

Thyroid screen

At diagnosis and None then yearly

Arterial risk

None

Coeliac disease

At diagnosis and None then 3-yearly

Yearly

level of knowledge and building on it at each appointment are evident in the outline algorithm for adult care. This structured patient education approach is also seen in the NICE guidance on patient-education models for diabetes (NICE, 2003). This highlights how programmes such as DAFNE (Dose Adjustment for Normal Eating) can be used to enable people with type 1 diabetes to take better control of their diabetes. There is also additional supportive information for children/young people or adults with diabetes and their parents or carers in the form of understanding NICE guidance documents (NICE 2004b; 2004c. These use simple language to outline the recommendations and highlight the care that those with diabetes should expect. They include a section explaining medical terms (NICE, 2004b; 2004c). There are also useful suggestions in the main guidance for improving communication with patients such as referring to ‘HbA1c’ as ‘A1c’ when discussing test results. The patient-centred approach is also evident in the guidance for children/young people. This recommends providing ongoing education about diabetes to the child and their family to support informed decision-making.

Clinical management The guidance has been praised by nurses for setting clear clinical targets (Strachan-Bennett, 2004). For adults these targets include: ● HbA1c maintained at