Background

People with diabetes who are housebound, in residential care, nursing homes or long stay hospital ward settings are often frail, vulnerable and unable to advocate their own care needs.

 

It is estimated that the average stay in nursing homes is two years for elderly residents therefore appropriate diabetes management is important to reduce the risk of the development of visual loss, neuropathy and macrovascular disease.

 

Appropriate clinical screening for glycaemic control and micro and macrovascular complications should be undertaken in line with national guidance to detect and mitigate the risks of long term complications of diabetes.

 

Glycaemic goals can vary depending on individual circumstances and should be sufficient to reduce the risk of hypoglycaemia and the lethargy, osmotic symptoms and acute emergencies and Diabetic Ketoacidosis (DKA)/Hyperosmolar Hyperglycaemic State associated with hyperglycaemia.

 

Assessment

Tayside Diabetes Managed Clinical Network guidance for the follow up of patients with established diabetes

• HbA1c measurement: a minimum of every six months and for some three-monthly HbA1c testing may be of some clinical utility in monitoring metabolic control
• The Diabetes UK ‘15 Healthcare Essentials Checklist’ should be used to assist individualised priorities in diabetes care
• You tube link
• Patient information link
• Individualised nutritional assessment and medication review
• Foot screening and eye screening

  

Near patient testing

• The frequency and need for monitoring should be agreed according to individual clinical need i.e in people who are treated with insulin, glucose testing should be carried out prior to each injection
• ‘Tight’ glucose targets should be avoided in older patients e.g. aim for BG > 6mmol/L and HbA1c target range 53–64 mmol/mol with an HbA1c target up to 70 mmol/mol (8.5%) may be appropriate in those who are frail or demented ¹
• Test glucose in people treated with corticosteroid for example prednisolone or dexamethasone as there is a risk of problematic hyperglycaemia
• Test glucose in people initiated on enteral feeding regimens as treatment requirements may change
• Test glucose levels during illness to detect /exclude problems with glycaemia and to assess treatment requirements/adjustments

• Test for ketones in blood or urine during acute illness/infection in people with diabetes to detect/exclude risk of DKA. link to hyperglycaemia in community

• Review and act to mitigate risk of hypoglycaemia (blood glucose < 4mmol/L) in people treated with insulin and/or sulphonylureas e.g. gliclazide, glipizide, glimepiride, glibenclamide by reviewing glucose levels and facilitating adjustment of medications if required

     

Recommendation

The following recommendations should be prerequisite for caring for a person with diabetes

• Appropriately trained staff* (see below)                                                                                      
• Quality controlled blood glucose meter available for near patient testing                                    
• Ketone meter or urine strips for detection of ketones in the blood or urine during illness            
• ‘Hypo’ box suitably stocked with treatment for hypoglycaemia and management information  
• Individualised diabetes management plan                                                                                    
• Individualised record of diabetes treatment                                                                                  
• Documentation to record glucose levels and medication administration                                                      
• Individualised nutrition plan                                                                                                           
• Insulin syringes                                                                                                                              
• Sharps disposal                                                                                                                             
• Foot CPR (check protect refer) resources and foot protection     
• Contact details for Diabetes Team                                                                                                      

 

There are currently no mandatory requirements for diabetes skills or training for care home staff. Residential care for older people divided into nursing and social care. Nursing homes have care provided in part by registered nursing staff whilst residential (non-nursing) care homes are usually staffed by carers without nursing qualifications, (but who may have NVQ/QCF certificates from basic to advanced level).

                                                                         

Recommended resources for staff education and support

 

TREND Diabetes UK nursing competency framework

 

Competency framework to support insulin and glucose monitoring for non registered staff

 

TREND Diabetes UK glucose and ketone monitoring

 

Care home priorities are outlined by Diabetes UK

 

COVID-19 Care homes represent a major challenge to ensuring that Covid-19 prevention and control issues are optimal. Advice on special precautions:

 

The Tayside Managed Clinical Network website has information and guidance for healthcare professionals and people with diabetes. All healthcare professionals can access the Handbook  for diabetes care guidelines.

The Diabetes Managed Clinical Network provides educational Forum meetings in various locations across Tayside.

Link to professional education

Link to hyperglycaemia in community

and hypoglycaemia management in community

 

Telephone contact details for Diabetes Specialist Nurse Team

Mon – Fri 09.00 - 17.00 (24 hour answering machine)

• Ninewells healthcare professional tel. 01382 496431 or 01382 632293
• Perth Royal Infirmary healthcare professional tel. 01738 473976 or 01738 473476
• Abbey Health Centre, Arbroath tel. 01241 447811

 

Reference

1. Diabetes UK END OF LIFE DIABETES CARE Clinical Care Recommendations 3rd Edition March 2018  (last accessed February 2021)