Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes Developed by Department of Health - Loddon Mallee Region Department of Health
Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes
Developed by Department of Health - Loddon Mallee Region
Department
of Health
Pathways for prediabetes, type 1, type 2 and gestational diabetes were developed by Department of Health, Loddon Mallee Region.
The pathways were prepared by Collaborative Health Education and Research Centre (CHERC), a business unit of Bendigo Health.
© DH Loddon Mallee 2009This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Department of Health, Loddon Mallee Region.
Graphic Design - www.youngbloodink.com.au
These evidence - based pathways have been developed to help guide clinicians in the Loddon Mallee region in the appropriate care and management of people with prediabetes and diabetes.
The pathways provide guidelines for the identification and management of prediabetes, type 1, type 2 and gestational diabetes, and are not intended to replace professional judgement or clinical expertise.
National and international guidelines have informed the development of these pathways and it is anticipated that they will be reviewed and updated as changes to national guidelines arise.
These pathways are endorsed by Diabetes Australia - Victoria.
Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes
Acknowledgements ................................................................................................. 4
Glossary of Acronyms & Abbreviations ......................................................... 5
Explanatory Notes.................................................................................................... 6
Prediabetes:
- Prediabetes Clinical Pathway .................................................................................... 8
- Prediabetes Ongoing Self-Management Pathway ................................................. 9
Type 1 Diabetes:
- Type 1 Diabetes Clinical Pathway ........................................................................... 10
- Type 1 Ongoing Self-Management Pathway ......................................................... 11
Type 2 Diabetes:
- Type 2 Diabetes Clinical Pathway ........................................................................... 12
- Type 2 Diabetes Ongoing Self-Management Pathway ........................................ 13
Gestational Diabetes:
- Gestational Diabetes Clinical Pathway .................................................................. 14
- Gestational Diabetes Ongoing Self-Management Pathway ............................... 15
References .................................................................................................................. 16
Table of Contents
August, 2009 PAGE 3
Design of the Loddon Mallee Regional Diabetes Pathways has been based on the collective contribution of all members of the working party. The working party consisted of clinical experts from within the region, who have freely given of their time to guide and direct the development of these four pathways. Their enthusiasm, expertise and willingness to participate has ensured successful development of the pathways.
Members of the LMR Regional Diabetes Model Pathway project working party:
Professor Frank Alford .................Endocrinologist St. Vincent’s Hospital, Melbourne
Jacqui Cesco .................................Diabetes Educator/Care Co-ordinator, Sunraysia Community Health Services, Mildura
Michelle Chappel ..........................Practice Nurse, Central Victorian General Practice Network, Bendigo
Fran Degrandi ................................Pharmacist, Central Highlands General Pratice Network, Gisborne
Kate Edwards ................................Dietitian, Bendigo Community Health Services, Bendigo
Lyn Flavell ......................................CDE, Sunraysia Community Health Services, Mildura
Raelene Gibson .............................Diabetes Educator, Mildura Base Hospital, Mildura
Linley Grylls ...................................CDE, Diabetes Team Leader, Bendigo Health, Bendigo
Dr. Greg Harris ..............................Physician, Bendigo
Ange Jewson ................................Community Health Nurse / CDE, Swan Hill District Health, Swan Hill
Tracy Kemp ....................................Podiatrist, Sunraysia Community Health Services, Mildura
Susan Kennett ...............................Podiatrist, Bendigo Community Health Services, Bendigo
Claire Kerslake ..............................Diabetes Educator, Deniliquin
Elizabeth Lacey .............................Diabetes Educator, Kyneton District Health Service, Kyneton
Robyn Lindsay ...............................Physiotherapist, Bendigo Health, Bendigo
Jane McCaig .................................Exercise Physiologist, Bendigo Health, Bendigo
Dr. Sydney Paul .............................General Practitioner, Deniliquin
Wendy Pogue ................................CDE, Kyabram and District Health Service, Kyabram
Angela Roney ................................Diabetes Educator, Northern District Community Health Service, Kerang
Christine Schaller .........................Dietitian, Bendigo Health, Bendigo
Catherine Shultz ............................Diabetes Educator (acute) Swan Hill District Health, Swan Hill
Katrina Sparrow ............................Registered Nurse Div 1, Bendigo Health, Bendigo
Fiona Williams ...............................Practice Nurse/Diabetes Educator, Maldon Medical Clinic, Maldon
Janette Woolley ............................CDE, Bendigo Community Health Services, Bendigo
Acknowledgements
August, 2009 PAGE 4
ADEA ......................Australian Diabetes Educators Association
ADIPS .....................The Australasian Diabetes in Pregnancy Society
ATSI .........................Aboriginal and Torres Strait Islander
AUSDRISK .............The Australian type 2 diabetes risk assessment tool
BGL ..........................Blood glucose level
BMI .........................Body mass index
BP ............................Blood pressure
CDE ..........................Credentialled diabetes educator
CHO .........................Carbohydrate
CVD .........................Cardiovascular disease
DAA .........................Dietitians Association of Australia
DAFNE ....................Dose adjustment for normal eating
DA Ltd .....................Diabetes Australia (national organization)
DAV .........................Diabetes Australia (Victoria)
DE ............................Diabetes educator
DMMR ....................Domiciliary medication management review
EPC ..........................Enhanced primary care
FBG ..........................Fasting blood glucose
GAD .........................Glutamic acid decarboxylase
GCT ..........................Glucose challenge test
GDM ........................Gestational diabetes mellitus
GP ............................General practitioner
HbA1c .....................Glycated haemoglobin
HDL ..........................High density lipoprotein
HMR ........................Home medicines review
Ht ..............................Height
Hx .............................History
ICU ...........................Intensive care unit
IFG ...........................Impaired fasting glucose/glycaemia
IGT ...........................Impaired glucose tolerance
K10 ...........................Kessler psychological distress scale
Kg/m2 ......................Kilograms/metres2
LDL ...........................Low density lipoprotein
LSMP ......................Lifestyle modification program
MBS ........................Medical benefits schedule
mmol/L ....................Millimoles per litre
NCCCC ....................National Collaborating Centre for Chronic Conditions
NCCWCH ...............National Collaborating Centre for Women’s and Children’s Health
NDSS ......................National Diabetes Services Scheme
NHMRC ..................National Health and Medical Research Council
NHPAC ...................National Health Priority Action Council
NICE ........................National Institute for Health and Clinical Excellence
OGTT .......................Oral glucose tolerance test
OHA .........................Oral hypoglycaemic agent
PD ............................Prediabetes
PG ............................Plasma glucose
PWD ........................Person with diabetes
RACGP ....................Royal Australian College of General Practitioners
RBG .........................Random blood glucose
SBGM .....................Self blood glucose monitoring
T1DM ......................Type 1 diabetes mellitus
T2DM ......................Type 2 diabetes mellitus
TCA ..........................Team care arrangement
WHO .......................World Health Organisation
Wt ............................Weight
2hrG .........................2 hour OGTT
Glossary of Acronyms & Abbreviations
August, 2009 PAGE 5
= Decision = Action
PREDIABETES
TYPE 1 DIABETES
TYPE 2 DIABETES
GESTATIONAL DIABETES
Annual Cycle of CareThe Annual Cycle of Care (Diabetes) provides minimum guidelines of care for a person with diabetes. General practitioners working in an accredited practice, can apply for the Practice Incentive Program (PIP) with Medicare Australia and receive a Service Incentive Payment (SIP) for each cycle of care completed for a person with diabetes, within an 11 to 13 month period. It would be anticipated that most people with T1DM and T2DM require more frequent monitoring and review. 7 24
The minimum requirements include:
Activity Frequency / Description
Assess diabetes control by measuring HbA1c At least once every cycle
Ensure that a dilated fundus examination and visual acuity assessment is carried out by an ophthalmologist or optometrist
At least every two years
Measure weight, height & calculate BMI At least twice every cycle
Measure blood pressure At least twice every cycle
Examine feet At least twice every cycle
Measure total cholesterol, triglycerides and HDL At least once a cycle
Test for microalbuminuria At least once a cycle
Provide self-care education Assess self-management practices ( at least once a year) & review feedback from diabetes educator
Review diet Reinforce key messages from dietitian and review nutrition (at least once a year)
Review levels of physical activity Reinforce importance of regular and appropriate levels of physical activity (at least once a year)
Review smoking status At least once a year
Review medication At least once a year and consider referral for DMMR / HMR
Diabetes Educators Credentialled Diabetes Educators’ (CDE) are nationally accepted as providing quality assured provision of diabetes self-management education. An ADEA CDE is recognised as having met the following criteria:• Authorisationtopracticeinaneligiblehealthdiscipline• CompletionofanADEAaccreditedgraduatecertificatecourseofstudyindiabeteseducationandcare• 1800hoursofexperienceinprovidingdiabetesself-managementeducationasdefinedbyADEAandinaccordwiththeStandardsofPracticeidentifiedbyADEA• SubmissionofarefereedreportbyaCDE• Completionofamentoringprogram• EvidenceofcontinuingeducationacrossalldomainsofpracticeforCDEs• CommitmenttotheADEACodeofConductforDiabetesEducators40
The following disciplines are eligible for recognition as a CDE• Registerednurse(inVictoriathisappliestodivisiononeregisterednursesonly)• Accreditedpractisingdietitian(APD)• Registeredmedicalpractitioner• RegisteredpharmacistwhoisalsoaccreditedbyeithertheAustralianAssociationof Consultant pharmacy (AACP) or the Society of Hospital Pharmacists Australia (SHPA) While recognising Credentialled Diabetes Educators (CDE) as the ‘gold standard’ in the provision of diabetes self-management education, the term diabetes educator forthepurposeofthesepathwaysistakentomeanapersonwhohassuccessfullycompletedanADEAaccreditedgraduatecertificateindiabeteseducationandmanagement.
The term diabetes resource nurse and Aboriginal health worker, applies to a person employed within a health care service who has undertaken an appropriate and recognisedleveloftrainingindiabetes.Anumberofdiabetescoursesareavailable,including2daydiabetesworkshopsconductedbyDiabetesAustralia(Victoria)and an online training course Diabetes Management in the General Care Setting, developed by the National Association of Diabetes Centres (NADC) a joint initiative between the Australian Diabetes Educators Association (ADEA) and the Australian Diabetes Society (ADS). Neither of these courses, on completion, entitles a person to use the title Diabetes Educator.
KesslerPsychologicalDistressScale(K10)A simple screening tool, which can be used during a consultation to assess the mental health state of a person with diabetes18
Explanatory Notes
August,2009PAGE6
PrediabetesImpaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are conditions in which blood glucose levels are elevated but not high enough for a diagnosis of diabetes to be made. People with prediabetes are at increased risk of developing diabetes, cardiovascular and other macrovascular disease12
Self-ManagementSelf-management is the cornerstone of diabetes care. Actively encouraging, supporting and involving people with diabetes in their self-management, promotes healthandwellbeing,improvesqualityoflife,reducesdepressionandanxiety,significantlyincreasessatisfactionwiththeirtreatmentandreducesutilisationofhealth services 6 Optimal and effective self-management of diabetes is best supported by an evidence-based and collaborative approach to care involving ongoing feedback and communication between all parties.
Systems for CarePeople with diabetes require a systematic approach to their management, particularly annual review, from all members of a multi-disciplinary team. A systematic approach for GPs is facilitated by the use of:• Adiseaseregister• Anactiverecallsystemtofacilitatetimelyrecallofallpeoplewhenaspectsofdiabetes• managementrequirereview(pathology,complicationscreening,monitoring,reviewsandcareplanning).• Flowcharts• Reviewcharts
The RACGP and General Practice networks have resources to assist practices in establishing such systematic approaches to the care of their patients with diabetes 6 7
Explanatory Notes
August,2009PAGE7
AUSDRISK scoreLow risk < 5
Intermediate risk 6 – 14High risk > 15 4
People at risk of developing T2DM and PD- A family history of T2DM- Aged 55 years and over- Aged 45 years and over with 1 or more associated CVD risk factor- Aboriginal and Torres Strait Islanders (ATSI)- From culturally and linguistically diverse backgrounds aged 35 years and
over – Pacific Islanders, Maltese, people from the Middle East, North Africa, Indian sub-continent, China, Vietnam
- Overweight or obese (BMI > 25kg/m2). Waist circumference is an indicator of abdominal fat which increases risk of T2DM and CVD
- Women who have had GDM- Women with Polycystic Ovarian Syndrome who are overweight- Smokers- Physical inactivity- Those taking certain medications, antipsychotic medication & steroids
Everyone can be screened using AUSDRISK tool but people identified at high risk of T2DM should be screened 1 2
Prediabetes Clinical Pathway
The Australian Type 2 Diabetes Risk Assessment (AUSDRISK) is a questionnaire screening tool which accurately predicts a person’s risk of
developingT2DM within the next five years 2 3 5
Person performs self-assessment of T2DM risk using AUSDRISK tool3
GP/health professional confirms AUSDRISK score 4
diabetes uncertain
diabetes likely
diabetes unlikely*
Promote importance of healthy lifestyle choices for prevention of T2DM, PD and CVD. Provide information on local community based
LSMP/self-management interventions. Encourage continued good health5
Person diagnosed with prediabetes. Refer to - LSMP- Diabetes educator- Dietitian LINK TO REVERSE Link to Type 2 Diabetes
Clinical Pathway
Are symptoms of diabetes present?
Recheck FBG > 24 hours. In the presence of illness wait
until well *2
Result of FBG
Perform FBG (laboratory tested) if not done in last 12 months. Results indicate:
< 5.5 (diabetes unlikely) 5.5 – 6.9 (diabetes uncertain)
> 7.0 (diabetes likely)*2
Perform OGTT Results indicate:FBG < 6.1 or 2hrG < 7.8 (diabetes unlikely)
FBG 6.1 – 6.9 or 2hrG < 7.8 (IFG)FBG < 7.0 or 2hrG 7.8 – 11.0 (IGT)
FBG > 7.0 or 2hrG > 11.1 (diabetes)*2
* People with AUSDRISK score of 15 or more with a FBG of < 5.5 are eligible for Life! Program
YES
NO
< 7.0
5.5 - 6.9
Low Risk
F. > 7.0
< 5
< 5.5
> 7.0
6 - 14> 15
Are there identified risk factors for T2DM & PD?
Recheck FBG 3
yearly 2
No
Yes
August, 2009 PAGE 8
A person with PD understands T2DM may be prevented
or delayed by adopting
healthier lifestyle modifications
T2DM has been excluded with recent FBG 3
Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with prediabetes 6
Prediabetes Ongoing Self-Management Pathway
Consider referral to appropriate and locally agreed allied health professional:- dietitian- diabetes educator- exercise physiologist/physiotherapist
Lifestyle Modification Program- if aged 40 years & over, eligible for
subsidised LSMP eg. Life! Program.- an ATSI adult person aged 15 –
54 years is also eligible for Life! Program
- a person of any age is also eligible for Life! Program, under WorkHealth initiative
- consider referral to other locally available self-management interventions & LSMPs
REFERENCES:1Diabetes Australia Victoria 2009 2 NHMRC 2001. 3 Diabetes Australia 2009 4 Diabetes Australia Victoria 2009 5 Royal Australian College of General Practitioners 2009 6 National Health Priority Action Council 2006 7 Royal Australian College of General Practitioners 2008 8 9 10 Department of Health and Ageing 2009. 11 Department of Health (WA) Diabetes Australia (WA) 2005 12 Twigg et al 2007
Reassess AUSDRISK score – Prediabetes adds 6 points to
initial AUSDRISK score 4
Role of GP:- provide a systematic approach to PD management
with systems for care - annual review of modifiable lifestyle risk factors for
T2DM and CVD- annually perform a clinical CVD risk assessment
including BMI, waist circumference, BP, FBG & fasting lipids
- consider referral to other allied health professionals based on local community availability and person’s need
- psychosocial stress may increase individual risk of developing T2DM. Screening with K10 tool can identify people with depression and anxiety
- support and promote self-management practices
People with Prediabetes should receive same target goals of BP and lipid management as people with T2DM.
consider using these MBS Item numbers
Item 710 ATSI adult health check if person is aged 15 - 54 years (inclusive)Item 713 T2DM Risk Evaluation if aged 40 - 49 years (inclusive).Item 717 45 year old health check
Refer to MBS for full item descriptor and explanatory notes on all these item numbers 5 6 7 8 9 10 11 12
Role of LMP FACILITATOR/DIABETES EDUCATOR Provide evidence-based interventions which promote and support healthier lifestyle change & choices in prevention of T2DM. LSMPs promote self-management and self-determination by addressing modifiable lifestyle risk factors for T2DM using behaviour change techniques, counselling and goal setting. eg. - The Life! Program - diabetes educators (based on local agreement) - other community based diabetes self-management groups and LSMP’s available in the Loddon Mallee region
Contact local Division of General Practice and Community Health Centres for available programs in your area
Role of ABORIGINAL HEALTH WORKERProvide culturally appropriate support and counselling to promote understanding of PD and T2DM prevention 7
Role of PRACTICE NURSE, COMMUNITY HEALTH NURSE & DIABETES RESOURCE NURSE
- Establish and maintain systems for care and identify people who may be at risk of T2DM and PD and access for aged-related health checks.
- promote healthy lifestyle modification with high emphasis placed on T2DM being preventable
- consistent with Dietary Guidelines for Australian Adults & Physical Activity Guidelines for Australian Adults
- support ongoing self-management practices with advice and information which is current & appropriate.
- reinforce feedback key messages from LSMP facilitators and other members of the multi-disciplinary team. 7 12
Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPISTProvide individual assessment, exercise prescription and behaviour-change counselling
- regular physical activity is a key message, and should be provided by all members of the multi-disciplinary team.
- exploring individual preference for physical activity and providing information about local exercise interventions, and advise appropriate to the person’s age and level of fitness. 5
Role of DIETITIAN Assess nutritional needs, develop personalised eating plans, offer nutritional counselling, support, weight management and specific nutritional advice for people with PD, dyslipidaemia & hypertension 21
Score 15 & over
A person with prediabetes requires referral for intensive LSMP by GP
DESIRED OUTCOMES- identify and screen for T2DM & PD- diagnosis and early intervention for people
diagnosed with PD - prevent and delay progression to T2DM with
intensive, evidence based lifestyle modification interventions
- annual screening for T2DM and CVD
Score 14 & less
Lifestyle Modification ProgramNot eligible for Life! Program. Consider referral to other locally available LSMPs- Consider ‘Life on Line’ or telephone coaching
August, 2009 PAGE 9
Type 1 Diabetes Clinical Pathway
Person with initial diagnosis of T1DM requires immediate referral to medical
practitioner
Refer to diabetes educatorPerson seen 1-2 hrs daily
over 4-5 days
Refer to endocrinologist/physician (adults) and
paediatric endocrinologist/paediatric physician (children
and adolescents)
Refer to mental health worker/social worker
If assessed at high priority, to be seen within one week. If at low priority,
within one month of diagnosis. Up to 1 hr consultations several sessions over first month and then annually unless
indicated more frequently 32
Refer to dietitianInitial contact within first
week then 4-6 sessions over first month 32
All people with T1DM, family & carers should receive immediate referral for survival skills education and self-management support
Following survival skills phase and initial management, GP to refer all people with T1DM, family and carers for assessment, education and treatment within the first 12 months. Feedback between GP, PWD, carers and multi-disciplinary team
Refer to: - podiatrist - ophthalmologist/optometrist - exercise physiologist/physiotherapist - community Health/Sexual Health worker(adults only)
Paediatric clients-emergency department admissionCriteria includes:- all children under 5
years of age to be admitted to a paediatric acute setting or consider ICU 31
Person well – ambulatory service provisionCriteria include:- BGL elevated- no acute illness- no signs of ketoacidosis- 24 hr access to clinical advice 31 33
Person well – acute hospital admissionCriteria includes:- geographically isolated- physical/mental disability which may impede
self-management- no telephone available in the home- language or communication difficulties- profound grief reaction in family- individual dependant on a carer who is unable to take
responsibility for safe insulin administration 32 33 37
Person acutely unwell –emergency department admission
Person presents with:- hyperglycaemia (RBG
> 11.1 mmol/L)- polyuria- polydipsia 31
Link to Type 2 Diabetes Clinical Pathway
Options
Criteria includes:- BGL >11.1mmol/L- ketoacidosis - admission to ICU/acute
settingClinical findings- polyuria- polydipsia- weight loss- abdominal pain- weakness- vomiting- confusion
Clinical signs- dehydration- deep sighing (kussmaul)
respirations- smell of ketones- lethargy, drowsinessBiochemical signs- ketones in urine or blood- acidaemia pH<7.3 13 14 31
Link to Type 1 Diabetes Ongoing Self-Management Pathway
Does person have? - non-fasting ketonuria - marked weight loss *30
YES
YES
NO
August, 2009 PAGE 10
Ignoring age & BGL, are there symptoms of:• ketonuria (may be absent)• polyuria, polydipsia & weight loss• no other features of the metabolic
syndrome & BMI < 25• family hx of autoimmune disease• in 80% of people GAD & IA2
antiibodies will be present 13 14
NO
Type 1 Diabetes Ongoing Self-Management Pathway
TYPE 2 DIABETES ONGOING MANAGEMENT PATHWAY
DESIRED OUTCOMES:- achieve optimal target management goals of BGL’s,
BP and lipid control - support optimal psychosocial adjustment to diabetes- monitor growth and development (children and
adolescents)- prevent / early detection of macrovascular and
microvascular complications with screening- promote self-management practices- quality of life 6 7 14 15 18 21 26 27
REFERENCES:6. NHPAC (2006) 7. DA & RACGP (2008) 13. NCCCC adult (2004) 26. NHMRC 2008 30. Bristol, North Somerset and South Gloucestershire (2009). 32. National Institute for Clinical Excellence (NICE) 2004 33. ADEA 2004 31. NHMRC 2005 38. ADEA (2006)
Optimal adjustment to living for a
person with T1DM, their family and
carers *18
Role of DIABETES EDUCATORInitial contact – survival education - describing the diabetes disease process
and treatment options - monitoring blood glucose, urine/blood
ketones (when appropriate) discuss and demonstrate
- insulin initiation and skill acquisition - preventing, detecting and treating
acute complications eg.hypoglycaemia/hyperglycaemia
- VicRoads notification- NDSS registration - on-going self-management plan - peer support - sick day managementOngoing contact – minimum of annual review- pathophysiology of diabetes- agreed self-management plan- insulin adjustment- long term complications- glycaemic control- effects of physical activity- hypoglycaemia- travel and diabetes- promoting pre-conception care and
management during pregnancy (if appropriate)
- children & carers (discuss childcare, preschool and school sick day management)
- age-appropriate education on sexuality, smoking, alcohol and drugs, employment, fitness to drive
- re-assess education requirements - establish and maintain a system of recall
and review 6 31 38
Role of DIETITIANInitial contact- survival education- family Hx, including beliefs about T1DM- medical Hx, conditions that may impact on diet- social situation, family structure, cultural issues- diet Hx (establish usual diet, energy intake, total and saturated fat, CHO
intake and distribution, appetite and food preferences)- usual routine and activity- motivation and ability to ensure appropriate nutritional intervention such
as hypoglycaemic measuresOngoing contact- minimum of annual review- height, weight, BMI- usual nutritional intake and appetite- meal planning/carb counting/DAFNE- self management- management of life activities and growth- method of treatment of hypoglycaemia- CHO intake & adjustment pre and post exercise- alcohol intake and advice- consideration of new medical conditions- re-educate where required- establish and maintain a system of recall and review 6 31 32
Role of MENTAL HEALTH WORKERInitial contact- assess for client adjustment issues, limited social supports, needle
phobia, depression, anger, anxiety.- assess the typical range of emotional reactions to the diagnosis of T1DM- guilt and grief- marital/personal stress- treatment adherence- anxiety and depression assessment and increased risk factors- children and adolescents need age-related assessment
- establish and maintain a system of recall and review- provide support for family & carers 6 30 31
Role of GP- annual cycle of care - systems for care- management planning, TCA & mental health care plan (as
needed)- ensure recommended annual screening completed- assess sexual health, discuss contraception and
provide pre-conception advice as needed- support for family & carers- ATSI people should receive culturally appropriate
interventions - assess oral health & refer to oral health professional
under available Medicare Australia dental items 7 31
Role of PHARMACIST- conduct an annual DMMR/HMR 22
Role of OPHTHALMOLOGIST/OPTOMETRIST- on diagnosis and yearly assessment for adults.
adolescents after 2 years of diabetes and 5 years for children
- assess visual acuity, new vessel formation- urgent referral to ophthamologist if sudden changes
occur 13
Role of PODIATRIST- annual structured foot surveillance as minimum for
adults, children and adolescents- check for skin conditions, shape and deformity, shoes,
impaired sensory nerve function and vascular supply- establish and maintain a system of recall and review 6 13
Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPISTEducate on - the link between physical activity and arterial risk- exercise in relation to insulin, nutritional needs pre and
post exercise - establish and maintain a system of recall and review 6 13
Role of ENDOCRINOLOGIST/PHYSICIAN/PAEDIATRICIANReview - 3 monthly for children and adolescents & minimum of annually for adults.
Initial contact-assessment of client including medical history, complications, recent diabetes history, family history, vascular risk factors, foot/eye/vision examination, urine albumin excretion, urine protein, serum creatinine, BP & fasting lipids- insulin initiation and adjustment as required
Ongoing contact- HbA1c measurements based on individual
need. - screening for microvascular and macrovascular
complications.- assess sexual health, discuss contraception and provide pre-conception advice as needed 13 31
Mircrovascular complications screening is critical for person with T1DM.
August, 2009 PAGE 11
Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T1DM, their family and carers. 6
Type 2 Diabetes Clinical Pathway
Agreed individualised target goals of weight management, BGL’s, BP and lipid management. Identify individual health priority and needs.
Information resources should be current, consistent and consider culture, language, literacy, age and special learning needs.
Person with initial diagnosis of T2DM
First visit to GP
Assess modifiable lifestyle risk factors 5
Clinical assessment & screening for CVD risk factors 5 6 1 4
Explore and identify psychosocial issues, reaction to diagnosis, factors
affecting coping, adjustment & barriers to learning. Screen for depression
Assess individual needs Annual Cycle of Care
GP management planning Refer to multi-disciplinary team members using TCA & allied healthgroup services
to promote and support self-management practices 7 16 17
Refer to diabetes educator within one month of diagnosis. Based on priority of need should be
seen within 6 weeks. May require earlier
appointment
Ongoing multi-disciplinary review based on clinical assessment and individual need, with feedback between PWD, GP & multi-disciplinary team. 19
Refer to dietitian within one month of diagnosis 21
Refer to exercise
physiologist / physiotherapist
Refer to podiatrist 27
Refer to ophthalmologist
/optometrist 26
Review by GP following 3 months trial of lifestyle modification. Recheck HbA1c,BMI, waist circumference and other investigations based on clinical assessment and individual need.
Review medication management - consider referral for DMMR/HMR
Refer toMental health worker
Social workerSmoking cessation program
Aboriginal health workerOral health professional
(based on individual need assessment)
Ignoring age & BGL, are there symptoms of:• ketonuria (may be absent)• polyuria, polydipsia & weight loss• no other features of the metabolic
syndrome & BMI < 25• family hx of autoimmune disease• in 80% of people GAD & IA2
antiibodies will be present 13 14
Link to Type 1 Diabetes Clinical Pathway
Provide information and registration / notification forms for NDSS & VicRoads
Children & adolescents with T2DM need referral to paediatric endocrinologist / physician.CONSIDER
YESYES
Assess for 3 month trial of lifestyle modification only, with assistance from multi-disciplinary team. Are there symptoms of hyperglycaemia with BGL >
20mmol/L? 7
Does person have T2DM?
Consider commencing Metformin as first line OHA of choice 7
Are individualised, agreed goals of management being achieved?
Link to reverse for Type 2 Diabetes Ongoing Self-
Management Pathway
YES NO
YES
NO
August, 2009 PAGE 12
Type 2 Diabetes Ongoing Self-Management Pathway
REFERENCES:6 NHPAC 2006 7 RACGP 2008 14 Cohen,M 2007 15 NHMRC 2004 16, 17 Department of Health and Ageing 2009 18 Eigenmann C & Colagiuri R 2007 19 ADEA 2004 20 ADEA & ADA 2005 21 ADA 2006 22 23 Department of Health and Ageing 2009 24 Medicare Australia 2009 25 MIMS Australia 2008 26 NHMRC 2008 27 NHMRC 2005 28 AAESS 2008
Optimal adjustment
to living for a person with
T2DM 18
Role of DIETITIAN- provide nutritional assessment and nutrition prescription,
education, goal setting and ongoing reviews- annual review is part of care- establish and maintain a system of recall and review * 6 20 21
Role of OPHTHALMOLOGIST / OPTOMETRIST - ensure all PWD receive a dilated fundus examination
and visual acuity assessment at initial diagnosis and at least every 2 years 7 22
Role of ENDOCRINOLOGIST / PHYSICIAN- ensure all people with complicated problems related
to their diabetes receive expert clinical advice and management
- reviews are based on clinical judgment and individual need.
Role of GP- provide continuity and coordination of care - annual cycle of care- management planning & TCA - multi-disciplinary referrals using allied health service MBS
items- review metabolic control (HbA1c, self-monitoring of BGLs) - surveillance and screening for macrovascular &
microvascular complications, annual fasting lipids, U&E’s & microalbuminuria
- explore psychosocial issues, particularly depression, social isolation, sexual health, family stress. Screen using K10 screening tool and refer to appropriate allied mental health professional
- people with an HbA1c > 8% for 6 months should be referred to an endocrinologist /physician for assesment and management
Role of PRACTICE NURSE- establish & maintain systems for care, and under direction
from GP assist with GP management planning, TCA and annual cycle of care.
- conduct annual nursing review 6 7 8 14 15 16 17 19 23 24 26
Role of PHARMACIST - conduct an annual Domiciliary Medication Management
Review (DMMR) for people with diabetes living at home, who meet eligible criteria, using MBS Item 990 22
Role of ABORIGINAL HEALTH WORKER- provide culturally appropriate practical support and
counselling to promote understanding of T2DM amongst Indigenous people
- establish and maintain a system of recall and review * 6 7
Role of COMMUNITY HEALTH NURSE- promote and support optimal health and well being and
assist with optimal adjustment to living with diabetes- establish and maintain a system of recall and review * 6
Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPIST- provide individual assessment, physical activity
advice, exercise prescription and behaviour-change counselling
- annual review is part of care- establish and maintain a system of recall and review
6 7 28
Role of PODIATRIST - perform initial foot assessment, at diagnosis- following initial assessment, a podiatrist may consider
a PWD at “low risk” of foot complications and able to receive ongoing foot screening from an appropriately trained health professional
- people with ‘high risk’ feet should be managed and assessed by a podiatrist
- annual foot assessment should be conducted by a podiatrist, and is part of ongoing care
- establish and maintain a system of recall and review 6 27
Role of DIABETES EDUCATOR- provide & consolidate knowledge and understanding of diabetes. - identify and address gaps in learning and provide ongoing support and counselling, facilitating optimal
adjustment to living with diabetes. - annual review is part of care and a minimum requirement. - establish and maintain a system of recall and review. 6 18 19 20
Role of ORAL HEALTH PROFESSIONAL- provide optimal dental care for people
with chronic and complex care needs who require assistance with oral health.. Medicare dental items (85011 – 87777) are currently available for people with diabetes using the EPC program
Role of SOCIAL WORKER- assist a person with T2DM address
social, emotional, financial and practical issues that may affect daily living.
- establish and maintain a system of recall and review 6
Role of ALLIED MENTAL HEALTH PROFESSIONAL- provide psychological assessment and therapy from
eligible clinicians using Medicare GP mental health care items and better outcomes in mental health care program.
- establish and maintain a system of recall and review 2 3 6
DESIRED OUTCOMES:- achieve optimal target management goals of
BGL’s, BP and lipid control - support optimal psychosocial adjustment to
diabetes- prevent / early detection of macrovascular and
microvascular complications with screening- promote self-management practices- quality of life 6 7 14 15 18 21 26 27
August, 2009 PAGE 13
Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T2DM 6
Gestational Diabetes Clinical Pathway
A woman with GDM is considered a high risk pregnancy *14
Woman requires BGL monitoring in the first 24 hrs post delivery and an appointment with GP at 6 weeks.Essential part of hospital discharge plan - provide woman with OGTT pathology request form with results to
be followed up with GP at first postnatal appointment
If FBG <5.5 and 2 hrs postprandial <7.0
Woman to continue with diet and exercise management 35
Woman requires OGTT (75g glucose load) at 26-28 weeks gestation, or if persistent glycosuria during pregnancy. F >5.5 2hrs or PG >8.0, confirms diagnosis 35
Follow up with GP/obstetrician for
routine care during pregnancy.
Persistant hyperglycaemia (on more than 2 occasions) FBG>5.5 or
2 hour postprandial >7.0Woman referred to obstetrician/endocrinologist
for initiation of insulin 35
At 26-28 weeks gestation woman requires GCT (50g oral glucose load) if PG > 7.8 at 1 hr
indicates an elevated result 35
At 12 - 16 weeks gestation woman requires OGTT (75g
glucose load) if F>5.5 or 2hr PG>8.0, confirms diagnosis 35
Refer to diabetes educator
Clinically uncomplicatedUsual pregnancy care
with close BGL and clinical monitoring 35
Good controland no mccrosomia or complications -
consider delivery full term 35
Clinically complicatedObstetric
management and consider delivery <38
weeks 35
- GDM in previous pregnancy- Previous baby > 4.5kg- Previous unexplained stillbirth- BMI > 30kg/m2
- Over 30 years- Indigenous Australians- Certain high risk ethnic groups
– Chinese, Vietnamese,
North African, women from Indian sub-continent, Polynesian & Middle Eastern
- Prediabetes (IFG & IGT) 35 36
Poor controlmacrosomia or complications -
consider delivery <38 weeks 35
Refer to dietitian Refer to obstetrician
Elevated SBGM
Risk factorsidentified *2
Review SBGM
ReviewSBGM
This pathway is not designed for women with pre existing T1DM or T2DM
YES
NO YES NO NO
YES
NO
YES
NO
Is diagnosisconfirmed?
Is GCTelevated?
Is diagnosisconfirmed?
Woman has Pregnancy Confirmed
YESNO
Perform Risk Screening for GDM
August, 2009 PAGE 14
Gestational Diabetes Ongoing Self-Management Pathway
Role of DIETITIANDietary therapy is the primary therapeutic strategy for the achievement of acceptable glycaemic control in GDM and should :- conform with the principles of dietary
management of diabetes in general- meet the nutritional requirements of
pregnancy- be individualised for each person
depending on maternal weight and BMI- be culturally appropriate - moderate exercise is an adjunct therapy
with benefits, when used with dietary modifications and / or insulin 35
Role of DIABETES EDUCATORProvide information, advice, support and assist with diabetes management. Important aspects of education for the woman and her partner include:- the implications of GDM to herself and her baby- the dietary and exercise recommendations - SBGM is the optimal choice of monitoring glycaemic
control with one fasting and one postprandial BGL obtained daily as a minimum.
- the frequency of testing can be increased or decreased depending on results and progress of pregnancy
- insulin initiation and skill acquisition - survival skills and sick day management- contraception and pre-conception advice for future
pregnancy- peer support 35
Minimum goals of SBGM:- fasting capillary BGL < 5.5- 1hr postprandial capillary BGL< 8.0- 2 hr postprandial capillary BGL < 7.0 35
Role of GP & PRACTICE NURSE- establish & maintain systems for care to ensure
recommended ongoing follow up & screening. - at first postnatal visit ensure OGTT has been
performed and results reviewed. If OGTT normal, rescreen with FBG in 3 years. If OGTT abnormal rescreen FBG annually and link to appropriate pathway
- screen with AUSDRISK tool to determine risk of T2DM. Link to appropriate pathway
- provide contraception advice and pre-conception counselling and consider OGTT prior to future conceptions 7 35
Optimal adjustment for a women with Gestational
Diabetes *18
Role of OBSTETRICIAN & MIDWIFEAll women with GDM are considered to have a high risk pregnancyManage and monitor a woman through pregnancy. Timing and frequency of foetal monitoring depends on other complications such as pre-eclampsia, hypertension, ante-partum haemorrhage, intrauterine growth retardation. Ultrasonography should be considered at around 34 weeks gestation to detect abnormalities of foetal growth and polyhydramnios. Encourage breast feeding. Consider referral to a lactation consultant 35
Role of PAEDIATRICIAN- BGL should be checked 1 hour post delivery then before
the first 4 feeds for up to 24 hours. - a paediatrician should be present at delivery if significant
neonatal morbidity is suspected 35
Role of ENDOCRINOLOGIST / PHYSICIAN- Medically manage and monitor diabetes during
pregnancy. Initiate insulin if blood glucose goals are exceeded on 2 or more occasions within a 1 – 2 week period, particularly in association with clinical or investigational suspicion of macrosomia 35
Role of LSMP/SELF-MANAGEMENT INTERVENTION- address modifiable lifestyle risk factors using
behaviour change techniques, counselling and goal settings to prevent T2DM
- refer to locally available community health self management and LSMP’s 6
Role of ABORIGINAL HEALTH WORKER - provide culturally appropriate practical support
and counselling to promote understanding of GDM and long term prevention of T2DM amongst indigenous people 7
REFERENCES:7 RACGP 2008 35 Australasian Diabetes in Pregancy Society (ADIPS) 2003.
DESIRED OUTCOMES:- achieves optimal glycaemic control through
pregnancy- delivers a healthy baby- provision of ongoing advice, information and
screening for prevention of T2DM *35
August, 2009 PAGE 15
Feedback and communication between all parties is crucial to achieving optimal health and well being for a woman with gestational diabetes 6
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