Supporting your patientsSupporting your patientsSupporting your patients Supporting your patients with diabetes:with diabetes:

Wh t d t kWhat you need to know…Janice Langley RD, CDE

ll CJames Morrell RN, MN, CDE

Today’s Agenda

What is diabetes?What’s the risk?What s the risk?

You asked about foot care

Why numbers matterWhy numbers matterResourcesTh f l fThe new referral form

What is type 2 Diabetes?What is type 2 Diabetes?

PANCREAS

S

SSS BODY CELLS

RESISTANCE

S

SS

SSS

SS LIVER

Natural History of Type 2 Diabetesy ypUndiagnosed

DiabetesImpaired

Glucose ToleranceKnown

Diabetes

Insulin Resistance

Postmeal GlucoseInsulin Secretion

4-7 YearsMacrovascular complications

Microvascular complications

4-7 Years

Ramlo-Halsted BA, et al. Clinical Diabetes 2000;18:80-85, with permission from The American Diabetes Association

Type 2 Diabetes is NOT a Mild Type 2 Diabetes is NOT a Mild DiseaseDiseaseDiseaseDisease

Stroke2 to 4 fold increase in

Diabetic Retinopathy 2- to 4-fold increase in

cardiovascular mortality and stroke3

p yLeading cause of

blindness in working-age adults1

Cardiovascular Disease8/10 diabetic patients die from CV events4Diabetic die from CV events

Diabetic Neuropathy

NephropathyLeading cause of

end-stage renal disease2 p y

Leading cause of non-traumatic lower extremity amputations5

1. Fong DS et al. Diabetes Care 2003; 26(Suppl 1):S99-S102. 2. Molitch ME et al. Diabetes Care 2003; 26(Suppl 1):S94-S98. 3. Kannel WB et al. Am J Heart 1990; 120:672-6. 4. Gray RP and Yudkin JS. In: Textbook of Diabetes. 1997. 5. Mayfield JA, et al. Diabetes Care 2003; 26(Suppl 1):S78-S79.

Why Do Foot Assessments?Why Do Foot Assessments?

Prevent foot ulcers with associated risk of lower leg amputationg pEarly intervention for foot problems.Improved wound outcomesImproved wound outcomes.Reduce severity of complications.Improve quality of life.

The oneThe one--minute roleminute roleThe oneThe one minute roleminute role

Your role The Doctor’s roleYour roleHave the patient take off shoes and socks

The Doctor s roleFIRST 15 SECONDS:

Ask are your feet ever numb?Look at the feet and shoes, examine

Keeps the Dr’s within the 1-minute assessment

lik lih d f

,the foot for skin condition, color, calluses, toenail condition & structural deformities

NEXT 15 SECONDS:Increases likelihood of having this done

Ask do your feet ever tingle?Palpate the foot for temp and general ROM

FINAL 30 SECONDS: Ask do your feet ever burn?Ask do your feet ever feel like insects are crawling on them?Check for sensory intactness using aCheck for sensory intactness using a 10gm monofilament

A1c (2A1c (2--3 month average)3 month average)A1c (2A1c (2--3 month average)3 month average)A1c (2A1c (2 3 month average)3 month average)Recommended every 3Recommended every 3--4 months4 months

A1c (2A1c (2 3 month average)3 month average)Recommended every 3Recommended every 3--4 months4 months

% A1

Over8 4%

% A1c

7 8 4%

8.4%

7 - 8.4%

Target Range Under7%

Based on a normal A1c range of 4 - 6%

UKPDS: RUKPDS: Reduced Microeduced Micro-- and Macrovascular and Macrovascular Complications for a 1% Decrease in A1CComplications for a 1% Decrease in A1CComplications for a 1% Decrease in A1CComplications for a 1% Decrease in A1C

Any diabetes-related

Diabetes-related All-cause Myocardial

Peripheral vascular

Micro-vascular Cataract

–10

–5

0

sk (%

)ll

in A

1C

endpoint death mortality infarction Stroke disease* disease extraction

19%

12%14%14%

21%21%25

–20

–15

–10

rela

tive

risto

a 1

% fa

37%–35

–30

–25

educ

tion

ines

pond

ing

37%

43%

–50

–45

–40Re

corr

e

Adapted from Stratton IM et al. UKPDS 35. BMJ 2000; 321:405-12.

*Lower extremity amputation or fatal peripheral vascular disease

ResourcesResources

Prediabetes

Just the Basics– For newly diagnosed diabetesy g

Staying Healthy with Diabetes– What patients need to knowWhat patients need to know

Four years of medical school and all you can tell me is “eat less ” ?

 

                    Outpatient Adult Diabetes Services                                       REFERRAL FORM 

 

*Patient Name: ____________________________________  Last  First 

    *Physician Name: _________________________________ 

      Physician Phone #: ________________________________

Our New Referral FormOur New Referral Form*PHN: __________________  *Date of Birth:_____________                                     dd/mm/yy *Patient Phone #s: (H): __________________   (C) or (W):___________________ 

    *Patient Address:  _________________________________     (include postal code) _____________________________        Patient Email:  _______________________________ 

Adult Clinic, RJH, Clinic 7                  Fax:  (250) 370‐8357Phone: (250) 370‐8322 

Diabetes in Pregnancy Clinic,  VGH     Fax: (250) 727‐4168Phone: (250) 727‐4528 

Diagnosis: Type 1          Type 2           Pre‐DiabetesNew Diagnosis?: Yes No

Diagnosis:        Type 1       Type 2        IGTGDM Other

Important things:•Complete the *’s New Diagnosis?:    Yes     No

If No, Year of Diagnosis:  ________________                           GDM       Other  ___________________ Gravida: ______________         Para:___________________  EDC:_________________          Weeks pregnant: _________               dd/mm/yy    

Diagnostic Lab Values:      FBG: _______________ mmol/L (recent diagnosis only)      RBG: _______________ mmol/L                                                      2 hr GTT:____________ mmol/L 

*Please attach all available most recent lab data, as follows:     

Comorbidities:  CVD  Hypertension 

Current Data ‐ Please attach pre‐natal recordDiabetes in past pregnancy?    Yes          NoPrevious LGA?                             Yes          No

•Complete the s•Include diagnostic lab values

•If not diagnostic you’re getting it back

•Attach labs        Fasting BG          A1C           Lipid Profile           eGFR           Creatinine           Albumin/Creatinine Ratio 

 Renal Disease Neuropathy  Retinopathy  Depression  Sexual Dysfunction

       Other: 

For Type 1 or 2:     A1C:  __________ Date: ______________                                                                                   dd/mm/yy 1 Hr GTT (50 g): Result:  __________ Date: ______________                                                                                   dd/mm/yy 2 Hr GTT (75 g): Results: __________ Date: _____________                                             __________                dd/mm/yy                                                 __________ 

Services Required – Adult Clinic (See back of page)  Services Required – Diabetes in PregnancyInitial teaching/education General education

Really important things:If a new diagnosis, is patient “group

t i l” Initial teaching/education BG monitor training/certification  Review regarding: _______________________________ 

                                      _______________________________ 

General education General education and Endocrinology consultation (recommended for pre‐pregnancy Type 1, Type 2  

      Diabetes, and GDM requiring insulin) 

Insulin Start (*orders required)     Insulin Type                Dose                     Timing      _______________     ___________    ________________      _______________     ___________    ________________ 

Adjust HS insulin by units q days until FBG <

Comments:

material”i.e., elderly (over 75 in

general), hearing or visual deficit, or other, such as alien, or “male”…

   Adjust HS insulin by ___units q ___days until FBG <____   Oral antihyperglycemic agents:        Unchanged        Change to: ______________________ Current Treatment: Diet and exercise only                                                         Type / Dose / Timing  Oral Antihyperglycemics: ___________________________________________________________________________ 

                                                   ___________________________________________________________________________  Insulin(s):         ____________________________________________________________________________________ 

  Barriers to Group Learning:   Language barrier   Hearing impairment   Unstable mental illness    Cognitive deficit   Visual impairment                                            Other (specify): 

Physician Signature: 

_____________________________________ 

Office Use Only:Date received (dd/mm/yy): _____________________Date triaged (dd/mm/yy): ________________ Initials:_____ Appointment type: ____________________________