Long Term Conditions Pyramid The prevalence of diabetes in the West - PDF document

15/03/2017 Long Term Conditions Pyramid • The prevalence of diabetes in the West Midlands is one of highest in the UK. • Current data indicates there are approximately 16,000 people with diabetes in the city of Wolverhampton. • TREND data suggests that the diabetes prevalence is INCREASING in Wolverhampton & is consistently ABOVE national comparisons. Wolverhampton Integrated Diabetes ABOUT US Service • Our specialist team is based at the Diabetes & Dean Gritton – Directorate/Service Manager Endocrinology Centre (WDC) at New Cross Dr A Viswanath – C.D Debbie Edwards - Matron Hospital. Consultant Medical Team – 7 x Permanent Dr H N Buch, Professor B M Singh, Dr C Hariman, Jenny Dudley Brett Healey Sonya Smith Dr J Young, Dr R Raghavan, Dr V N Cherukuri, Dr K Jadoon • Our team consists of Doctors, Specialist In-Patient Stream Intensive Insulin Community Stream Lead Pump Stream lead Lead 1x Locum Dr R Bellan Kannan Nurses, Specialist Podiatrists, Dietetic Services, Retinal Screeners and Researchers. Research Fellow x 1 Dr S Gillani Clinical Nursing team x 5 Diabetes Specialist Nurse’ Band 6 x 6 Toni Shaw, Allison Spencer, Registrars/Clinical Fellows x 8 Claire Bevan, Susan Fullwood, Pauline Beach, Emily Cothey, Dr A Vijay, Dr F Babwah, Dr R Chaudhary, Dr R Chopra, Vacancy Gaynor Curtis, Jodie O’Hagan, Dr C Gherman-Ciolac, Dr T Kalaria, Dr F Hatta, Dr I Clark Lorna Smart, Elisabeth Wilson Education Support x 1 GP Clinical assistant x 2 Satbinder Suman Dr D Macdonald Dr M Sidhu Integrated Working WDC Services Provided with Allied Health Professionals • Specialist Clinics • Sue Huddart & Team – High Risk Chiropody  Insulin Pump Services.  Transitional & Adolescent clinic  Joint Diabetes Antenatal Clinic • Lynsey Richards & Team – Dietetic Services  Joint Renal Clinic • Retinal Screening Service Team  High Risk Foot Services  Nurse Led ‘Hypo’ Clinic • Research Nurses  Case Management Bariatric Surgery • Community Focus • Tertiary Services To work closely with Practice Nurses’ to up skill - Medication management Islet cell transplantation - Insulin titration/commencement - GLP1 initiation 1

15/03/2017 Community Services In-Patient Services (care closer to home initiative)  Community Specialist Nurse led clinics  Identification of diabetic patients via clinical web portal  Bilston Health Centre (Mon AM) system.  Pendeford Health Centre (Wed AM)  Diabetes risk flag on PAS system  Warstones Health Centre (Wed PM)  COBAS referral system  Whitmore Reans Health Centre (Thurs AM)  Pro- Active Ward Triage  Phoenix centre (Wed PM) - Safety 1) Think GLUCOSE insulin safety.  Mayfields (Tues pm) 2) Insulin passports, redesigned  Home Visits prescription charts. For those patients that are housebound & would otherwise not be able 3) Audit. to access diabetes specialist services. 4) Feedback. ASSESS, PLAN, IMPLEMENT. Multidisciplinary Team Meetings Community MDT Meetings  Monthly: alternating between NW; SE and • Diabetes Specialist (linked consultant and SW diabetes specialist nurse) work closely with local services including the community team. • Each GP will be contacted & consultant will meet – Community Matrons – District Nurses with them to discuss complex patients. – Specialist Nurses Management Plans will be formulated & follow up agreed (consideration for case management). – Social services – Dietetics • Communication has been encouraged by – CCG representative whatever means (Tel; email;letter etc). Education & Training Screening Services • Type 1 Education Programme  Diabetes Eye Screening – offered annually to • Insulin titration programme all diabetic patients. • Professional education  Diabetes Foot Health – offered annually to all diabetic patients. WE DO NOT OFFER BASIC DIABETES EDUCATION This should be done either: - within GP practice  Diabeta_3 Or via the X-pert Diabetes programme. 2

15/03/2017 Duty Nurse Service  Telephone queries/Advice Referrals and  Urgent assessment (Hot Clinics)  ‘ Walk –ins’ Criteria's.  Telephone clinics (01902 695310) Requiring referral to Emergency Same Day Referrals Services • Newly diagnosed Type 1 Diabetes/suspected Accident & Emergency/Medical Assessment Unit Type-1 diabetes • Patients with infected foot/ulceration or • Suspected Diabetes Ketoacidosis/Non-ketosis suspected Charcot Foot. Hyperosmolar state • Women with pre-existing diabetes (type-1 or • Severe hypoglycaemia (unconscious) 2) who become pregnant • Sudden loss of vision (Eye casualty) • Newly diagnosed Gestational Diabetes • Critical limb ischemia Urgent Referrals Routine Referrals • Recurrent/Severe hypoglycaemia •Poor glycaemic control despite intensive management •Consideration for intensive insulin/pump therapy • Symptomatic hyperglycaemia •Obesity management • Significant ‘at risk’ feet •Optimisation of cardiovascular risk factors (BP, Lipids) • Significant decline in renal functions/ •Type -1 structured education programme worsening proteinuria •Painful peripheral neuropathy not responding to standard treatment • Pre-surgical optimisation of glycaemic control •Patients with CKD stage 3b & 4 for optimisation of metabolic parameters •Self management/insulin adjustment training and support •Women with diabetes contemplating pregnancy 3

15/03/2017 Same Day Referrals • Same Day Referrals: Diabetes Specialist Team at New Cross Hospital: can be contacted Monday to Friday directly on 01902 695310 (9:00 to 5:00 PM) (Out of Hours diabetes advice: contact on-call medical team at New Cross Hospital via switchboard) Urgent / Routine Referrals: Via Choose & Book or direct referral to the Diabetes Centre • Useful Contact Numbers: • Diabetes Administration Team: 01902 307999; Ext: 5310/12/13/14/15; Fax: 01902 695325 • Diabetes Reception & Appointments: 01902 695310; Fax: 01902 695628 4

3/15/2017 Outline • Background Diabetes in • Challenges Pregnancy • Pre-conception care • Antenatal care • Post natal follow-up Dr. Ananth Viswanath Consultant WDC Diabetes Mellitus and Pregnancy After Insulin Before Insulin • Insulin improved • 40% women died during outcome pregnancy (usually DKA) • Maternal mortality fell to • Remainder died within 2 2-3% • years of delivery Foetal loss rates remained high • Foetal loss rate >50% • Impact of abnormal glucose levels on foetus identified in 1970’s • Optimisation of maternal control and foetal surveillance lead to improvement in perinatal mortality • Recent studies show PNMR still double compared to women without diabetes Diabetes in Pregnancy: Epidemiology Diabetes NSF • 650,000 births in England & Wales per year • 35,000 women have either pre-existing or GDM • Around 4000 births in Wolverhampton Pre-existing DM Gestational DM • Glucose intolerance first • Type-1 diagnosed in pregnancy • Type-2 • Includes pre-existing DM first detected in pregnancy 25-30/year 300-350/year 1

3/15/2017 Normal glucose metabolism Pregnancy- ‘stress test’! • Glucose enters • Physiological change - INSULIN RESISTANCE bloodstream from food • Facilitates transfer of glucose to the fetus source • Decrease in insulin sensitivity by late pregnancy • Insulin aids in storage • Increased lipolysis (preferential use of fat for fuel, in order to of glucose as fuel for preserve glucose and protein) cells • Mechanisms • Insulin resistance is • Insulin desensitizing placental hormones defined as insensitivity • Increasing maternal adiposity of cells to insulin, therefore resulting in increased levels of To maintain euglycaemia insulin production insulin and glucose in should increase by 2-3 fold the bloodstream Pedersen hypothesis Macrosomia ‘ Maternal hyperglycaemia leads to foetal hyperglycaemia which evokes an exaggerated response to insulin which causes increased neonatal fat deposition and abdominal girth with increased birth weight ’ Potential problems for the baby Shoulder dystocia • Congenital malformation • Large for gestational dates (macrosomia) • Shoulder dystocia (difficult birth) • Birth trauma • Unexplained IUD • Prematurity and Respiratory distress syndrome • Neonatal metabolic abnormalities: • Hypoglycemia • Hyperbilirubinemia/jaundice • Polycythemia • Long term predisposition to childhood obesity and metabolic syndrome 2