Diabetes Referral Pathways

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Diabetes In-Patient
Pathways for Increased
Effectiveness
Credits
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(Click anywhere to continue)
Instructions
For Use
To use the most appropriate pathway click the
coloured circle most closely describing your
patient’s problem on the menu screen, and
continue to follow the advice on screen
(all coloured circles are hyperlinks)
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This tool has been developed by the diabetes team to try and provide
diabetes-related information and management advice to improve the care of
patients with Diabetes whilst they are in hospital and to assist with planning
their longer-term care. A diabetes specialist nurse will be available to provide
help and advice for problems not covered by the pathway, the referral process
for accessing the DSN is embedded within this tool
Credits
Design and Editorial –
Iain Cranston & Anita Thynne
Policies and
Clinical Content
–
The Diabetes Clinical Team
Portsmouth Hospitals NHS Trust
Web Maintenance
–
Mark Harvey
Ward Support Team –
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Sharon Allard, Anita Thynne
& Jo Newell
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Type 2 Patient
requiring insulin
Admission
Unrelated to
Diabetes
New Diagnosis
In Hospital
Diabetes and
Pregnancy
Menu
(click the most appropriate button)
(eg surgery)
General
Diabetes
Management
Or…
Acute Diabetic
Emergency
Contents List
Device-related
Problems
Complications
Of Diabetes
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This is how to use it!!!!
• This is a power-point presentation that links many
clinical documents relating to the in-patient
management of diabetes
• Circular shapes will, if clicked, link you to the
information described.
• Use the mouse to click (with the left mouse button)
on the most appropriate clinical problem to follow a
pathway, or if you need a specific piece of
information click a topic from the contents page
• You can navigate the presentation either using the
menu/back and quit buttons or via the forward / back
arrows on the toolbar (top left of screen)
• You can view or print as much as you need
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Contents
How to use this tool
Diagnosis
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Diagnosis of Diabetes
Type 1 or Type 2 Diabetes
Letter to GP for new diagnosis
Management of New Type 2 Diabetes
Acute management
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DKA (Ketoacidosis) Management
DKA (Ketoacidosis) Monitoring Standards
HONK Pathway
Hyperglycaemia Flowchart
How to prescribe insulin
When To Start a Sliding Scale
When to stop a sliding scale
How to write a sliding scale
Sliding Scale Prescription Grid
Sliding Scale PHT Policy
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Hypoglycaemia flowchart
Hypoglycaemia PHT Policy
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MI therapy Rationale
Hyperglycaemia after an MI
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Acute Foot Pathway
Assessment of the diabetic foot
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Referral Criteria for specialist input
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Surgical Info
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Guidelines for medical/surgical
procedures
Pre-operative Diabetes Assessment
proforma
Emergency Surgery
Pre-Operative Glucose Management
Peri-Operative Glucose Management
Post Operative Glucose Management
Incidental New Diagnosis pre-operatively
Suitability Criteria for day-case
procedures
Wound care management (general)
Insulin Therapies
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Indications for Acute Insulin Use
Insulin Action Profiles
Insulin Regimens
Insulin Dosing Advice in type 2 diabetes
Insulin Adjustment
Insulin Storage
Teaching Self Injection
Insulin Injection Sites
Insulin Injection Devices
Problem solving for injection devices
Insulin Injections PHT Policy
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Routine Care
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Glycaemic Management of Diabetes
Glucose Monitoring Standards
Interpreting Blood Glucose Results
Blood Glucose Meter Problems
Medications for Type 2 Diabetes
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CV Risk assessment in diabetes
Treatment of Lipids in Diabetes
Treatment of BP in Diabetes
Management of renal disease in diabetes
Eye Screening Pathway
Diabetes and Pregnancy
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Dietary Information for In-patients
Dietary Information to take home
Hospital Meal Menus and Diabetes
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Discharge from Hospital Checklist
Patient Literature
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Diabetes Centre Support for In Patients
External Links / Support Groups
Foot Care Information
Information for New Type 2 Diabetes
Information for New Type 1 Diabetes
Starting with Insulin Manual (SWIM)
Newly Diagnosed Type 2 Diabetes Manual
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Type 1 Diabetes
Not Sure!
Type 2 Diabetes
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Type 1 or Type 2 Diabetes?
Type 1
•
Autoimmune destruction of the beta cells
causing sudden cessation of insulin secretion
leading to hyperglycaemia
•
Characteristics at diagnosis:
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Dramatic weight loss
Ketonuria (ketones present on urinalysis)
Lethargy (extreme tiredness)
Polydipsia (excessive thirst)
Polyuria (excessive urine production)
Blurred vision
Genital / oral thrush
Vasculitis of legs causing burning/pins & needles
Most likely to be slim in appearance
Type 2
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Metabolic disease characterised by relative
insulin deficiency and insulin resistance leading
to hypoglycaemia
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Characteristics at diagnosis:
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People most at risk
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Lethargy (slow progression of over time)
Polydipsia (slow progression of over time)
Polyuria (slow progression of over time)
Blurred vision
Genital / oral thrush
Vasculitis of legs causing burning/pins & needles
Most likely to be obese in appearance
Family history
People who are overweight
Of Asian/Afro Caribbean origin
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Ensure accurate
diagnosis, as per
WHO guidelines
Teach patients
To self-inject
Insulin
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Insulin
Sliding Scale
Information
Starting
Insulin
- Which one?
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Give initial
information and
education
Refer to
diabetes
specialist nurse
A Thynne
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Sorry! – this link is still under
construction
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TEACHING SELF INJECTION
Step 1
Identify insulin type
and appropriate
pen device
Which
Insulin?
Step 2
Educate on use
of pen
How to
use
a pen
Injection
sites
Principle:
Which
Pen?
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Step 3
Educate and choose
appropriate
injection site
Injection sites
must be varied to
prevent a build up
of fatty lumps
Hosp Policy
Document
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Step 4
Roll pen between hands
to mix insulin. Dial
insulin dose and uncap
needle Hold pen at a 90o
angle to the skin
Step 5
‘Lift up’ fold of skin
between thumb and
forefinger. Insert
needle firmly into skin
Step 6
Steadily depress plunger
When insulin administered
Count to 10; remove needle
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Which insulin regimen ?
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There are various insulin regimens
and insulin types which may be
Insulin
adopted to suit all patient lifestyles. Products
Generally, the more injections a
person administers the more
flexible the regime.
Insulin
Profiles
BD insulin regimen
Twice daily injections before
breakfast and evening meal using
an insulin such as Mixtard 30/70 or
Humulin M3 will provide 30% quick
acting and 70% long acting insulin.
Usually divided 60% am and 40%
evening injection
Regimes encompass a combination
of long acting insulin; providing a
constant background maintenance
dose of insulin, and quick acting
QDS insulin regimen
insulin to provide a boost matching Injection
Quick acting insulin such as Actrapid
the rise in glucose following a meal. Times
or Humulin S may be injected prior
Opposite are two common
to each meal with a long acting
regimens, the top one being
insulin such as Insulatard or
appropriate for a more routine
Insulin Humulin I injected at bed time to
lifestyle, the bottom one is more
Doses
provide background coverage.
suitable for an active, unpredictable
Usually divided 30% at night and
lifestyle.
20% with each meal
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Which Pen Device?
Device
Images
Insulin pen devices vary. Certain insulin cartridges will only fit certain pens.
PEN DEVICE
INSULIN TYPE
Novopen 3 or Innovo
All Mixtard insulins (pen fill 3ml cartridges)
Insulatard (pen fill 3ml cartridges)
Actrapid (pen fill 3ml cartridges)
Novorapid (pen fill 3ml cartridges)
(Pre-filled disposable pens also available on
request if patient cannot manage Novopen 3)
Humapen or Autopen
(Pre-filled disposable pens also available on
request if patient cannot manage Humapen)
Optipen or Autopen24
(Pre-filled disposable pens also available on
request if patient cannot manage Optipen)
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All Humulin M insulins (3ml cartridges)
Humulin I (3ml cartridges)
Humulin S (3ml cartridges)
Humalog / Humalog Mix 25 (3ml cartridges)
All Insuman Comb insulins (3ml cartridges)
Insuman Basal (3ml cartridges)
Insuman Rapid (3ml cartridges)
Insulin Glargine (Lantus)
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Available Devices
Novo Disposable Pen
Novo Innolet
Optiset Device
Novo Flexpen (disposable)
Innovo Device
Optipen Pro
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HOW TO USE PEN DEVICES
• Please refer to instruction leaflets within the pen
device box for step by step guide
• USEFUL HINTS
– All brand of needles fit all of the pen devices. The diabetes centre will
supply the patient with needles while they are an inpatient but the GP must
be made aware that they need to be prescribed after discharge. Needles
must be changed at least daily
– To ensure the pen device is working prior to administration an ‘air shot’ but
must be completed to prime the needle and show that insulin is being
delivered
– The numbers shown on the barrel of the pen device indicate approximately
how much insulin is left in the cartridge. If there is uncertainty on whether
there is enough insulin to give a full dose, change the cartridge
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How to prescribe Insulin
Previously
on
Insulin
New to Insulin
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Previously on Insulin
• Check that previous insulin regimen was adequate
(home BM control, recent HbA1c)
• If adequate and not requiring >1.5X usual TDD
whilst on IV insulin then restart usual regimen as
soon as eating & drinking
Stopping
IV Insulin
Insulin
Adjustment
• If previous control inadequate, use TDD whilst on IV
insulin as a guide to dose adjustment (consult DSN or
Diabetes Registrar if unsure)
• The insulin doses should be reviewed (increased)
daily to reduce the need for ‘prn’ doses
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New to Insulin
• Anyone starting insulin in hospital (ie an ill patient) is likely to
need at least bd insulin
• Recommend Mixtard 30 Insulin pre breakfast and evening meal
and usually 10units at each injection unless information from a
recently used sliding scale is available (total dose in 24hrs split
for bd dosing)
• Additional ‘prn’ actrapid 4-6units may be used for BGL > 18
• The mixtard doses should be reviewed (increased) daily to
reduce the need for ‘prn’ doses
Stopping
IV Insulin
Insulin
Adjustment
• Prior to discharge the DSN’s and Dietitian should have been
given the opportunity to review and GP informed
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Blood Glucose Meter Problems
Replacement meter procedure
Replacement test solution
• For replacement QID or PCX
meters please call:
• Please obtain replacement
control test solution from either
Technical Helpline 0500 467466
Biochemistry Laboratory or Diabetes
Or Claire or Carrie 01628 678827/8
Centre
•
Please have the following
available when calling:
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Meter error or problem
Meter Serial No.
Account number 34893
Hospital post code PO6 3LY
Replacement control record books
• Please obtain from Diabetes Centre
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INJECTIONS SITES AND ‘LIFT UP’
•
Recommended sites for
injection are as follows:
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Abdomen. Lateral to the umbilicus
but avoiding above or below it and
the extreme flanks
Thigh. Upper anterior and lateral
parts of the thigh
Buttocks. Upper external parts of
the buttocks
Arms. Upper lateral and external
parts of the arms avoiding the
muscle areas
Absorption rates vary as
follows:
– Abdomen – FAST
– Arms – MEDIUM
– Thighs and Buttocks - SLOW
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Diagnosis suspected? Undertake blood test
Link to WHO
Diagnostic
Criteria
Reference
Random plasma glucose (RPG)  11.1 mmol/l
or
Fasting plasma glucose (FPG)  7. 0 mmol/l
yes
no
Hyperosmolar symptoms
eg polydipsia or polyuria
Is RPG or FPG < 6mmol/l
no
no
yes
Repeat fasting
plasma glucose
Repeat blood
test
no
yes
RPG  11.1 mmol/l
or
FPG  7.0 mmol/l
FPG > 6.0 - <7.0mmol/l
yes
yes
Diagnosis of
Diabetes Mellitus
confirmed
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Impaired FPG*
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no
Diabetes
Unlikely
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Link to full
WHO Diagnostic
Criteria Reference
Link to local
‘short’ version
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SORRY
Electronic Referrals are not yet
implemented in DIPPIE to refer to the
DSN please go into the “OCM” system
and refer as previously
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Expect Insulin
To be Required
only as an
in-patient
Why is Insulin
Required?
(patient leaflet)
Insulin
Sliding Scale
Information
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Expect
Insulin to be
Continued after
Discharge
Starting
Insulin
- Which one?
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Indications for
Acute insulin
Use
Insulin Dosing
Policies in
T2DM
What to do
At/before
discharge
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Device-Related
Problem
Diabetes
Complication
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Device-Related
Problem
Diabetes
Complication
Patient Request
To talk
with a DSN
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Patient Glucose
Monitoring
Device
Ward Glucose
Monitoring
Device
Ward
Meter
Policy
Insulin
Injection Device
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Foot Problems
Renal Problems
Eye Problems
Cardiovascular
Problems
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Eye screening pathway
Is your
patient
registered
with the
diabetes
Eye screening
programme?
YES
NO
Consult with Jane Cansfield
(X6655) diabetes centre
for details of their most
Recent retinal photography
(on Diabeta 3 database)
Does the patient
Require screening
While an inpatient
YES
NO
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Refer to
Eye Department
Give details of local
District program
(press for details)
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Portsmouth District Diabetes
Retinal Screening
• Contact centre at SJH coordinates appointments
– 02392 815051
• Pt will need to know their NHS number as well as demographic
details when ringing
• Pt will need to sign consent to data being held on computer
when attending for screening
• Cameras are based at:
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St Mary’s Hospital (ISTC)
Gosport War Memorial Hospital
Emsworth Hospital
Coldeast Centre (late 2008)
• Results of screening are accessible via Diabeta 3
Database in Diabetes & ophthalmology Departments
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Acute Foot
Pathway
Infection
Management
Guideline
Wound Care
Guidelines
Community
Podiatry Clinics
Principles of
Foot Care
(leaflet)
How to assess
The foot in
Patients with
Diabetes
In-Patient
Podiatry
Referral
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Hypertension
Management
Cardiovascular
Risk Assessment
Lipid
Management
Acute MI
Protocol
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Print a patient
MI Pathway
(including glucose
recording charts)
View clinical
Guideline and
Rationale
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“Peri-MI” Diabetes Therapy
• Acute IV insulin therapy (with glucose and potassium) for 48hrs
followed by s/c insulin in those presenting with an MI and
hyperglycaemia (>10mmol/L) has a dramatic effect on morbidity
and mortality from MI (NNT to save a life = 9!!)
• Therapy needs to be started EARLY (ie on first measurement of
hyperglycaemia) for this effect – we should develop a
thrombolysis-like approach to this therapy
• For safety (and following the evidence-base), IV insulin should
be prescribed with iv glucose & K+ infusion (if volume is a
concern use higher strength glucose at lower infusion rates)
• Common Sense needs to be applied to those who will continue
to require insulin after the initial 48 hrs, to avoid unnecessary
intervention
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MI
Pathway
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Diabetic &
Pregnant
Pregnancy
Patient Leaflets
Gestational
Diabetes
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Diabetes &
Labour
Management
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Diabetic &
Planning
Pregnancy
Post Partum
Gestational
Diabetes
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Pregnancy Patient Leaflets
Type 1
Mother
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Type 2
Mother
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Diabetic
Keto-Acidosis
(DKA)
Hypoglycaemia
Widely
Swinging
Sugars
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Hyper-Osmolar
Non-Ketotic
(HONK)
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H.O.N.K.
Immediate
Management
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Ongoing
Management
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Immediate Management of HONK
Similar to DKA in most respects but higher risks:
1) Involve specialist input early
2) Beware of development of hypernatraemia
1)
2)
3)
4)
5)
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Consider use of ½ normal saline if Na > 160
Switch earlier to 5% dextrose infusion
Use DKA
proforma
Patient
Monitoring
Guidelines
Patients are usually older and frailer – consider
early HDU/ITU placement
Hyperosmolarity increases thrombotic risk – in most
cases consider therapeutic heparinisation
Over-rapid osmotic and electrolyte shifts can result
in neurological deficit – aim for 10% reduction per
hour – no more
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Flowchart for Hyperosmolar Non Ketotic Coma Patients –
Post Initial Emergency Treatment
Is patient known
to have Type 2
diabetes?
NO
YES
Consider cause
such as illness,
omission of
treatment and
address as
appropriate
If patient usually administering
oral hypoglycaemic agents,
consider need for long term
insulin therapy
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WHO
Diagnostic
Criteria
Diagnose as per
WHO criteria
Insulin in
T2DM
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Consider treatment options:
Oral hypoglycaemic agents may
be suitable longterm but insulin
therapy may be required
temporarily for a few months to
gain adequate glucose control
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Patient
Monitoring
Guidelines
DKA
Print a Clerking
Proforma
Clinical
Management
Guidelines
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Insulin
Sliding Scale
Information
(with recording charts
and guideline info)
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Glucose
Monitoring
Standards in
Hospital
Variable Control
Insulin
Sliding Scale
Information
‘Routine’ Glucose
Management
Hypoglycaemia
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Hyperglycaemia
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Glucose Monitoring Standards
In Patients
Out Patients
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In-Patient Glucose Monitoring
Standards
Remember, a patient who is in hospital is either acutely ill or about to be subjected to a
stressful procedure – both of these situations can be expected to affect glucose control
•On IV insulin
– Measure capillary blood glucose (CBG) levels hourly for adjustment of IV
insulin therapy (half-life of IV insulin <5mins, changes can occur rapidly).
•On S/C insulin
– Measure CBG at least 4 times daily – routinely pre-meals and at 22.00
(more frequently if the clinical situation demands it)
•On Oral Therapy as an IP
– Initially measure CBG as for patients on S/C insulin (as therapy changes
may be required)
– once glucose levels are stable and acceptable for 48hrs the frequency can
be adjusted downwards – eventually to a pre-meal daily test
•Peri-operatively
– Once starved measure CBG at least 2 hourly (hourly if on sliding scale)
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Hypoglycaemia
View a flow chart
Insulin
Adjustment
Information
View the full
policy statement
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Hypoglycaemia Flow Chart
Acknowledgement
of occurring
hypoglycaemic
event via
evident symptoms
or patient
Is patient
Conscious ?
No
Give 25-50ml
of 50%
glucose IV
information
Yes
Give 10-20g of glucose orally.
Granulated sugar in clear
fluid is recommended
(10g = 2 tsp). Alternatively give
non-diet fizzy drinks,
full sugar squash, etc. Repeat at
10-15min intervals as necessary
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If oral or IV glucose
would be difficult
to administer,
Glucagon can be given
as an alternative via
S/C Glucagen Kit 1mg
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Maintenance carbohydrates
such as bread, potato, pasta,
rice must be given following
glucose.
(a) If hypo has occurred prior
to a meal ensure satisfactory
amounts of food are consumed.
(b) If hypo has occurred
between meals give 2-3
biscuits, crackers, toast, etc
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Variable Control
Interpreting
Glucose Monitoring
Results
(how to analyse
the problem)
Insulin
Adjustment
Information
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Interpreting Blood Glucose Results
• A capillary blood glucose level taken at a given time
is a reflection of the hours preceding the recording
• A capillary blood glucose level taken at a given time
has little bearing on control for the forthcoming
hours
• Capillary blood glucose level results should be used
to reflect on the past in order to make decisions for
the future
• Know your patients target glucose levels. If the
glucose trend is consistently out of target refer
to…
Insulin
Adjustment
Information
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Hyperglycaemia
View a
management
flow chart
Insulin
Adjustment
Information
View the full
policy statement
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How long has the patient been hyperglycaemic ?
One off /
Unusual
for patient
YES
YES
Is the patient unusually
suffering from
hyperosmolar symptoms
(i.e. polyuria, polydipsia,
lethargy or headache)
Consider administering 4 - 8units of
short-acting insulin and monitor effect.
Repeat 4 hourly as required
Review possible causes. If > 1dose used
in a 24 hour period adjust usual
medications
NO
Persistently
Since
admission but
normally good
glycaemic
control
YES
Consider
possible causes
(i.e. stress, pain,
steroid
treatment,
infection) and
treat where
possible
No immediate action to be taken.
Monitor glucose levels to ensure
a ‘one off’ and review possible
causes
Review current anti-hyperglycaemic medication
and adjust as necessary.
If controlled with dietary management only,
consider introduction of oral anti-hyperglycaemic
agents or insulin therapy as appropriate.
REMEMBER additional treatment may only need
to be temporary
YES
Long-term poor
glycaemic
control prior
to admission
YES
Does the patient have a
healing wound or are they
peri-operative?
NO
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Insulin
Adjustment
Information
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Consider referral to
diabetes team if
adjustments do not
give improved effect
and telephone
advice required
Please refer to diabetes
team for advice re:
medication initiation or
adjustment
Refer patient to their usual diabetes
management team (i.e. GP, Practice
Nurse or Diabetes specialist team for
an outpatient review
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Elective Surgical
Admission
Procedure /
Investigation
Insulin
Sliding Scale
Information
Emergency
Surgical
Admission
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Other
(eg Routine in-patient
glucose monitoring &
management)
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Elective Surgical Pathway Planner
Click Here to link
To the Surgical Pre-Admission
Planning Pathway, which will produce an
Individualised plan depending on the
Characteristics of the patient
You are advising
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Referral Criteria
In-patient
Specialist Input
Out-patient
Specialist Input
Out-patient
Primary Care
Input
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Spec
In-pt
Spec
Out-pt
REFER TO DIABETES CENTRE FOR SPECIALIST INPUT:
Person with newly diagnosed Type 1 diabetes
GP
T1DM?
Person admitted with recurrent hypoglycaemic
events
Person at high risk:
Poor glycaemic control (HbA1c >7.5)and another
complication eg MI, amputation
Person commencing insulin therapy
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Hypo
Start
Insulin
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Spec
In-pt
Spec
Out-pt
GP
REFER TO DIABETES CENTRE FOR AN OUTPATIENT
APPOINTMENT:
Person who is known to have recurrent
admissions of similar nature,or complications
associated with their diabetes that need input
Person with long-term poor glycaemic control
who requires further, on-going glycaemic support
and does not have regular follow-up elsewhere
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Spec
Out-pt
GP
Spec
In-pt
REFER TO PRIMARY CARE (GP AND PRACTICE NURSE):
Person newly diagnosed with Type 2 diabetes
Person with uncomplicated type 2 diabetes
GP
Referral
Letter
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Patient
Info
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When to start a
Sliding scale
PHT
Sliding
Scale
Policy
When to stop a
Sliding scale
Print PHT
Sliding Scale
Prescription
Chart
How to prescribe
An individualised
sliding scale
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Prescribing
S/C
Insulin
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How to stop a
Sliding scale
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When to stop a sliding scale
In principle – as soon as possible!
How to
stop a
Sliding
scale
• Post operatively – once eating and drinking
• Post DKA – once eating and ketone-free
• Post sepsis – as soon as a regular subcutaneous dose can be reliably predicted
• Special Circumstances (eg MI, pregnancy) –
as per individual guideline
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Start a sliding scale in the following
circumstances:
Print
A scale
• Diabetic Emergencies (DKA/HONK)
• Type 1 diabetic being starved
• Person with Diabetes vomiting (>12 hrs or
with abnormal U&E’s or with significant
ketones)
• Unwell with hyperglycaemia (>20, especially
if abnormal U&E’s)
• Special circumstances (MI/labour/sepsis and
hyperglycaemia/post op hyperglycaemia)
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How to stop sliding scale insulin
STEP ONE
STEP TWO
(a) Inject soluble insulin 30 minutes
prior to the meal
DO NOT STOP A SLIDING SCALE
INFUSION UNTIL THE PATIENT
OR
CAN TOLERATE DIETARY
(b) If using analogue insulin inject
INTAKE AND ADEQUATE
immediately prior to the meal
FLUIDS
Insulin
Products
STEP THREE
STEP FOUR
(a) Stop infusion 30 minutes after
If normal insulin injection not due
the soluble insulin is
to be given at time of wishing to
administered
discontinue infusion – Administer
OR
6u of soluble insulin subcutaneously
(b) Stop infusion immediately after
30mins prior to the meal and follow
administering analogue insulin
Step 2 (a) and 3 (a)
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ADJUSTMENT OF INSULIN
Principle:
Nocte
Insulin
Regimen
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Insulin should be
adjusted
according to
trends in glucose,
not one-off levels
QDS
Basal Bolus
Regimen Using
Soluble
Insulin
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BD
Insulin
Regimen
QDS
Basal Bolus
Regimen Using
Analogue
Insulin
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NOCTE INSULIN REGIMEN
ADJUSTMENT
• Nocte insulin regimens usually comprise a slow long
acting insulin. Therefore the insulin will peak in the
small hours and start to wane during the morning
Insulin
Profiles
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Products
• If glucose levels are above target before breakfast,
increase nocte insulin by 2-4 units. Repeat until
optimum levels achieved. Usually target fasting
glucose of ~8mmol/L
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BD MIXED INSULIN REGIMEN
ADJUSTMENT
• If glucose levels are elevated before bed and
before breakfast – increase EVENING dose of
insulin by 2 – 4 units. Repeat until optimum
levels achieved. Ideally 60% am, 40% pm.
• If glucose levels are elevated before lunch
and before evening meal – increase
MORNING dose of insulin by 2 – 4units.
Repeat until optimum levels achieved
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Profiles
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QDS BASAL BOLUS REGIMEN ADJUSTMENT
- USING SOLUBLE INSULIN AND ISOPHANE
• If glucose levels are
elevated before
breakfast - increase
NOCTE insulin dose
by 2-4 units
• If glucose levels are
elevated before lunch
– increase MORNING
MEAL insulin dose by
2 units
• If glucose levels are
elevated before
evening meal –
increase LUNCH MEAL
insulin dose by 2 units
• If glucose levels are
elevated before bed –
increase EVENING
MEAL insulin dose by
2 units
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Profiles
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Products
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QDS BASAL BOLUS REGIMEN ADJUSTMENT –
USING ANALOGUE INSULIN AND ISOPHANE
• If glucose levels before meals or before
bed are elevated – increase the
Isophane background insulin by 2-4
units
• If glucose levels are elevated two hours
post a meal – increase the Analogue
insulin prior to that particular meal by 2
units
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Profiles
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Products
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Insulin Action Profiles
Insulin
Products
Rapid-acting (analogue) Insulin Short-acting (soluble) insulin
0
3-4 hrs
Intermediate insulin
0
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4
0 2 4
6- 8 hrs
Mixture Insulin
12-18 hrs
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Insulin
Profiles
Insulin Products
Injection
Times
Rapid-Acting (Analogue) Insulin
Short-Acting (soluble) Insulin
•
•
•
•
•
Humalog (Lispro)
Novorapid (Asparte)
Mixed Insulin
(Ratio of Short: Intermediate Insulin)
•
•
•
•
•
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Humulin M (2 / 3 / 5)
Mixtard (10 / 20 / 30 / 40 / 50)
Insuman Comb (15 / 25 / 50)
Humalog Mix 25 (analogue mix)
Novomix 30 (analogue mix)
Humulin S
Actrapid
Insuman Rapid
Intermediate/Long Acting
Insulin
•
•
•
•
•
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Humulin I
Insulatard
Insuman Basal
Lente / Ultra Lente
Monotard
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STORAGE OF INSULIN
If the manufacturers expiry date printed on the vial has not passed, insulin expires:
At room temperature: 4 weeks after first use
In the fridge: 3 months after first use
DO
DON’T
• Store spare insulin in the
• Use insulin if date of first
fridge
use is not known – discard
• Store current insulin used • Freeze or heat insulin. If
in pen devices at room
this happens – discard
temperature
• Store patients’ own insulin • Use insulin that is lumpy, a
strange colour or will not
separately from ward stock
mix – discard
and use only for the
named patient
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Insulin Injection Times
Rapid-Acting (Analogue) Insulin
Short-Acting (soluble) Insulin
•
•
•
•
Immediately prior to all meals or
During all meals - or
Up to 15mins post all meals
20 – 30 mins prior to all meals
Mixed Insulin
Intermediate/Long Acting Insulin
•
•
•
•
•
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20 – 30 mins prior to breakfast
and evening meal
Humalog Mix 25 or Novomix 30
– as analogue timing prior to
breakfast and evening meal
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Prior to bed - or
Prior to breakfast – or
Split dose prior to bed and
breakfast
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Products
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Example
1.
2.
Writing a Sliding Scale
Print
a Grid
Print a grid to prescribe the scale
How much insulin does the patient normally inject each 24 hours?
(= Total Daily Dose or TDD)
(if unknown, assume a 70kg man with type 1 DM requires 48units/day)
3.
What Blood Glucose Level would you like to run them at? (‘ideal’)
(for example if aiming for sugars to run 6.1-10mmol/L)
4.
The starting point for writing the scale is to put steps 1&2 together
eg to maintain BG @ 6-10mmol/L, they will require 2 units per hour (TDD/24).
5.
Next write glucose ranges either side of the ideal which will include
a full range of glucose levels (mmol/L)
eg 0-3;
5.
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6.1-10;
10.1-15;
15.1-24;
>24
Prescribe insulin doses (units per hour) corresponding to the
glucose ranges as increments: low doses for low glucose ranges!
eg 0.5;
6.
3.1-6;
1;
2;
3;
4;
6
Prescribe appropriate fluids to cover the insulin infusion (generally
dextrose WILL be required to counteract the effects of insulin!)
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Example Grid
Step 1
Print the Grid
Step 2
Weight 70kg
Step 5
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Step 3
TDD 48units
BM
Units/hr
0-3
0.5
3.1-6
1
6.1-10
2
10.1-15
3
15.1-24
4
>24
6
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Step 4
Step 6
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Pre-Operative
Assessment
Peri-operative
Management
Post-operative
Management
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? Suitable
for day-case
surgery
? Needs specialist
input
Print an
assessment
proforma
New Diagnosis
of diabetes
at assessment
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Pre-operative
Management
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Colonoscopy
Gastroscopy
Metformin and
Radiological
Procedures
Other
(& barium studies)
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(general principles)
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Screening for
Renal Disease
In Diabetes
Renal Guidelines
In-Patient
Management
Guidelines
(Renal)
Renal/Diabetes
Out-patient
Joint Policies
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In-Patient Renal Guidelines
(under construction)
•
•
•
•
•
•
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Safe Use of Metformin
Oral Diabetes Therapies in Renal Failure
Insulin use in Renal Failure
Insulin and CAPD
Insulin and Haemodialysis
Interpreting results in renal Failure
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Ensure accurate
diagnosis, as per
WHO guidelines
Print Short
Patient
Information
Leaflet
View full
‘starting out
With Diabetes’
Document
Dietetic
Information
& Referral
(over 40 pages)
Type 2 Diabetes
Management
Statement
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Therapies
& strategies for
glucose
Management
Insulin
Sliding Scale
Information
Print
Referral Letter
To Primary Care
Other Diabetic
Problem
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Step-Wise
Management of
Type 2 Diabetes
Principles of
Glucose Control
“rules of thumb”
Medications
for
Type 2 Diabetes
Strategies for
glucose
Management
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MEDICATIONS FOR PEOPLE WITH TYPE 2 DIABETES
Sulphonylureas
Metformin
e.g. Gliclazide 40 – 160mg bd,
Glimepiride 1 – 6mg daily
Increases insulin secretion
Associated with weight gain. Not
recommended as first line with
overweight patients
Associated with hypoglycaemia
due to long duration of action
Caution with renal and hepatic
impairment
To be taken 20mins before food
A – Glucosidase Inhibitors
e.g. Acarbose 50mg – 100mg tds
Slows absorption of starchy foods
reducing post meal glucose levels
Neutral weight gain.
Low incidence of hypoglycaemia
GI side effects, doses should start
low and be titrated up weekly
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e.g. Metformin 500mg – 1g bd/tds
Improves insulin sensitivity
Neutral weight gain. Drug of
choice for overweight patients
Low incidence of hypoglycaemia
GI side effects, doses should start
low and be titrated up weekly
Taken after food
Post Prandial Regulators
e.g. Repaglinide 0.5 – 4mg tds,
Nateglinide 60mg – 180mg tds
Stimulate insulin secretion post
meals reducing mealtime spikes
Some association to weight gain
Caution with hepatic impairment
or those of over 75yrs
To be taken just before meals
Low incidence of hypoglycaemia
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Thiazolidinediones
e.g. Pioglitazone 15 – 45mg once
daily, Rosiglitazone 4 – 8mg once
daily
Improves insulin sensitivity
Not licensed in monotherapy or
with insulin
Small association with weight gain
Require regular liver enzyme tests
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MANAGEMENT STATEMENT:
PERSON WITH NEWLY DIAGNOSED TYPE 2
DIABETES WHILST IN HOSPITAL
Most of the management decisions in type 2 diabetes will be
undertaken in primary care (who therefore need to be
adequately informed of the patients diagnostic status – see
“referral letter to primary care”) however during acute
illness some patients with type 2 diabetes will need acute
management decisions to be made including some in whom
short-term insulin therapy will be required. For these
patients there are management guidelines (shown within
this tool) and liaison with the diabetes team may be
required.
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Management
Guidelines
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Criteria for
Diabetes
referral
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Stepwise Management of Newly Diagnosed
Type 2 Diabetes in Hospital
• Diagnose as per WHO guidelines and exclude ketonuria
• Refer to dietitian. Attempt dietary modifications alone for up to three months
• If patient has marked hyperosmolar symptoms and their level of glycaemia is
detrimental to patient status in hospital therapies may be required, otherwise no
specific in-patient medical intervention is necessary.
• Refer to Primary care team for ongoing diabetes management, education and
support (see “referral letter to primary care”)
• After three months: if dietary modifications are not sufficient to maintain
glycaemic control commence Metformin 500mg OD initially and titrate if the
person is obese (BMI >27). Commence Gliclazide 40 – 80mg OD / BD initially
and titrate if the person is of normal weight.
• Only refer to Secondary care if the person has, or is at increased risk of major
complications (see drive guidelines for referral criteria to secondary care)
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Give initial
information and
education
Insulin Dosing
Policy for type 2
Diabetes
Teach Patients
To self-inject
Insulin
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Refer to
diabetes
specialist nurse
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“Starting with
Insulin Manual”
SWIM – over 50 pages
Short
Information
Leaflet
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Insulin
Starting Insulin in Type 2 DM Products
Options:
•
Add once daily night-time intermediate insulin to all
usual daily tablets (usually start at 10units)
•
Give twice daily mixed insulin (usually 10units bd)
instead of sulphonylurea - maintain metformin use
•
Stop all oral agents and use a basal bolus regimen
TDD 20-30 units (seek DSN/specialist advice)
Remember: “I SMILE”
“Starting with
Insulin & pen
Insulin Manual”
SWIM – over 50 pages
Strips/Meter/Information/Letter/Education
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Dietary
Information
In hospital
‘Diabetic’
Menu Stickers
Dietary
Information
To take
home
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Dietetic
Referral
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Red Diabetic Stickers and Menus
Kitchen ‘police’
What is the purpose ?




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Diabetic stickers alert the
kitchen to the patient status
A low sugar version of the
chosen pudding will be
provided rather than a full sugar
one
Plainer biscuits will be provided
than chocolate or crème filled
varieties
Reduced fat milk will be used in
the meals/puddings


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If a patient who has diabetes
chooses a food not marked with
a ‘D’ even with a red sticker
present, the kitchen will no
longer change it. It will be the
responsibility of the ward nurse
to ensure the patient is aware
of appropriate choices to make
an informed decision.
Cakes and snack foods are
available throughout the day so
assess patient need to avoid
hypos and encourage people to
bring in their own hypo
management foods that can be
preserved in the lockers
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Diabetes UK
Web Site
QAH
Diabetes Centre
Web Site
Local Podiatrists
List
Local
Optometrists
List
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Thank you for using the Diabetes Pathway Document
If you have comments regarding its content please contact
Dr Iain Cranston or DSN Anita Thynne
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www.
Further
Information
END
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