Diabetes - (Suspected) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Diabetes in adults age 18+ including diagnosis and management

This guidance does not cover:

  • Diabetes in people under 18 years of age

Assessment

Signs and Symptoms

  • Diabetes can present as a hyperglycaemic emergency, symptomatically or be discovered during a routine health check
  • Symptoms of diabetes/hyperglycaemia:
    • polydipsia
    • polyuria
    • blurred vision
    • weight loss
    • tiredness
    • recurrent skin infections
  • Type 2 diabetes may not be diagnosed until features of diabetic complications are present
  • Increased screening of patients at a high risk of diabetes may lead to earlier diagnosis before the onset of complications
  • Diabetes may be picked up during a routine health check if:
    • glycosuria or elevated blood glucose is found
    • confirmation will require a diagnostic blood glucose measurement
History
  • Ask about:
    • Symptoms of hyperglycaemia (polydipsia, polyuria and blurred vision)
    • eating habits
    • weight history
    • risk factors for cardio vascular disease - smoking, hypertension, obesity (particularly central obesity) and dyslipidaemia
  • Family history of:
    • Diabetes
    • cardiovascular disease
    • cerebrovascular disease
    • dyslipidaemia
  • physical activity levels
  • previous or current infections, especially; skin, foot, dental and genito-urinary
  • features of any complications:
    • visual impairment
    • CVD
    • renal disease
    • neuropathy
    • foot disease
    • sexual dysfunction
  • current medications (prescribed, over the counter or alternative therapies)
  • gestational history:
    • delivery of a baby weighing more than 4.08kg (9lbs)
    • pre-eclampsia
    • stillbirth
  • history of gestational diabetes
  • history and treatment of other conditions, including endocrine and eating disorders
  • psychosocial, cultural or economic factors that may affect management
  • use of alcohol or drugs
  • contraception, reproductive and sexual history
Initial Examination
  • BMI waist circumference High risk if:
    • more than 88cm in females
    • more than 102cm in males
    • more than 90cm in South Asian/Chinese and Central American males
  • blood pressure
  • foot examination and assessment of pulses and sensation
  • presence of candidiasis

Red Flags

Consider immediate admission to hospital if hyperglycaemic emergency is suspected

Hospital Admission

  • Patient clearly unwell
  • Vomiting without clear cause
  • Moderate or large ketonuria
  • Other severe illness
  • Foot ulcer with spreading sepsis and necrosis

Remember

  • Ketoacidosis may occur in patients with modestly raised blood glucose
  • People with Type 2 diabetes are at risk of hyperosmolar state which has high morbidity and mortality

Seek advice urgently

  • Severe symptoms, blood glucose greater than 25 (particularly with mild ketonuria)
  • Newly diagnosed probable Type 1 diabetes
  • New or infected foot ulcer
  • Pregnant women with diabetes (Type 1 and Type 2)

Investigations

HbA1c for Diagnosis
  • A HbA1c of 48 mmol/mol is recommended as the cut off point for diagnosing diabetes. A value of < 48 mmol/mol does not exclude diabetes diagnosed using glucose tests.
  • In patients without symptoms of diabetes, repeat the laboratory venous HbA1c. If the second sample is < 48 mmol/mol treat as high diabetes risk and repeat the test in 6 months or sooner if symptoms develop
In people for whom HbA1c is not appropriate for Diagnosis of Diabetes:
  • ALL children and young people
  • Patients of any age suspected of having Type 1 diabetes
  • Patients with symptoms of diabetes for less than 2 months
  • Patients at high diabetes risk who are acutely ill (e.g. those requiring hospital admission)
  • Patients taking medication that may cause rapid glucose rise e.g. steroids, antipsychotics
  • Patients with acute pancreatic damage, including pancreatic surgery
  • In pregnancy
Diabetes is diagnosed on the basis of the following WHO criteria;
  • Symptoms of hyperglycaemia (polyuria polydipsia, unexplained weight loss. visual blurring, genital thrush, lethargy) plus raised venous plasma glucose level detected once fasting: 7.0mmol/L or higher or random 11.1 mmol/L or higher

OR

  • In the absence of symptoms 2 abnormal results are required for the diagnosis. A random glucose of 7 – 11 should be followed by fasting blood glucose.
The following is recommended for those at high risk of developing diabetes:
  • High diabetes risk HbA1c 42-47 mmol/mol
  • Refer to the National Diabetes Prevention Programme
  • Provide intensive lifestyle advice
  • Warn patients to report symptoms of diabetes
  • Monitor HbA1c annually

Management

Initial Education and Management
  • NICE guidelines (2015) recommend that structured patient education is made available to all patients with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need.
  • Initial education should include:
    • lifestyle advice including healthy eating, physical activity, smoking cessation and alcohol.
  • Refer newly diagnosed to DESMOND programme if appropriate
  • Appropriate leaflets should be given to support the initial advice given eg. First steps and a healthy eating leaflet
  • An explanation of targets, stressing that a multifactorial approach (eg. looking at BP and cholesterol alongside blood glucose control) is required when negotiating a self-management care plan with the patient.
  • Test urine for microalbuminuria in Type 2 diabetes
  • Ensure that the person with newly diagnosed diabetes is referred to the retinal screening programme.
  • Review dates should be agreed according to each patients individual needs.
  • Link to the single assessment process where appropriate when managing complex long term conditions.

Referral

Referral Criteria

  • Admit to hospital if: the person is at risk of a hyperglycaemic emergency (vomiting, abdominal pain reduced conscious level, heavy ketonuria, dehydration requiring IV fluids, hypotension, serious intercurrent problem)
  • Refer to be seen on the same day if: the patient is acutely ill, consider Type 1 Diabetes if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, polyuria)
  • Early Referral if:
    • Diabetes and pregnancy requires referral to the hospital diabetes team please see pregnancy guidelines
    • Refer to DESMOND Diabetes Structured Education Programme or to Specialist Dietitian if appropriate

Referral Instructions

  • e-consultation is available for diabetes for both the Consultant Diabetologists and the Diabetes Specialist Nurses
  • e-consultation is not available for acutely ill patients
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should to the Diabetes Specialist Team MYHT should be made via ERS
  • Please identify speciality and clinic type

Required forms

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 02.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 03.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: END5 - 02.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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