Living With Diabetes
Organization of A Diabetic Service
The primary responsibility of the public health-care system is organizing diabetes care.
The cooperation between primary health care and specialized medical care should be improved with an appropriate division of labor.
The specialized medical care system includes the diabetic care of children, young people and pregnant women, as well as the treatment of severe complications. As the primary health-care system has overall responsibility for the population in each region, the other forms of basic care such as for infections for these diabetic groups are generally provided in health-care centres.
The diabetes working groups of the hospital districts have a significant role in the improvement of regional diabetes care. A working diabetes group should be appointed in each hospital district. A representative of people with diabetes as well as the different professionals should be included in the group. It is the duty of the working diabetes group to act as the regional coordinator of diabetes care and its development, as well as the organizer of regional training for health-care professionals.
It is appropriate for the central policies concerning the improvement of diabetes care to be worked out individually in each hospital district, as the care of people with diabetes requires cooperation among many different players. The districts must take into account the sharing of the care, the functionality of the care chains, both problem-oriented and client-centered approaches and process thinking.
Resources and Division of Responsibilities
Improving diabetes care is mandatory in order to ensure a better quality of life for people with diabetes and for the prevention of costly complications. The care organization holds an essential position in improving care. Reassessment of current resources is essential at all levels of diabetes care as the resources of the health-care system will also be limited in the future. Appropriate use of existing resources possible is the first step in care improvement.
A sufficient number of specialists working within specialized medical care must be ensured in order to organize and further develop the care of people with diabetes. The units responsible for the care of children with diabetes must be guaranteed the required resources.
The diabetes team should include at least a physician responsible for diabetes care, a diabetes nurse, a nutritionist (depending on the size of the population), an ophthalmologist and a podiatrist. A psychologist, a physical therapist or a physical education instructor could be included where necessary.
This team coordinates diabetes care, evaluates and improves the quality of care and trains other personnel. The person with diabetes is an equal member of the team with regard to his/her own care.
Services such as those rendered by a nutritionist or a podiatrist is not always possible for the units of the primary health-care system to arrange on their own, these services can also be established jointly among several health-care centres or contracted out to private service providers.
The diabetes care unit is also responsible for organizing regular check-ups of oral health, whereas the primary health-care system treats possible illnesses and conditions.
Improving the Quality of Care
The improvement of the quality of diabetes care must receive attention in all units in both primary health care and specialized medical care. Establishing a smooth care chain, quality criteria for each care unit and a diabetes registry provides efficient tools for the improvement and assessment of the quality of the care.
The quality system of each unit should be simple and clear. It should consist of a general description of the unit and guidelines for the care process of a person with diabetes, such as
→ Resources (staff, etc)
→ Description of activities
→ Patient satisfaction
→ Glycemic control
Emphasis on increasing knowledge about diabetes is the main aspect of the basic and extended training of physicians and other care personnel. Through diabetes education for health-care professionals, know-how on modern diabetes care is ensured at all levels of the health-care system. Training should be organized both nationally and regionally, with regional training ensuring that local circumstances are taken into account.
The working diabetes groups of the hospital districts should bear the main responsibility for the organization and content of the regional training. Outside sponsorship is an option for funding. It is also important that employers enable personnel to participate in diabetes education for health-care professionals by reserving adequate financial allowances and substitute work staff.
Monitoring in Diabetes
Maintaining optimal glycemic control implies that the blood glucose levels throughout the 24 hours, on each day, are at the target levels determined for each individual patient.
The primary goal of blood sugar monitoring is to reduce the blood glucose levels to as close as possible to normal levels. The diabetic can achieve this in a responsible manner using diet revision as the primary strategy and self-monitoring blood glucose levels at home.
Self-monitoring also includes treating the complications of diabetes if present. This requires annual eye exams to detect retinopathy, annual urinalysis to search for early signs of nephropathy, periodic foot examinations, regular blood pressure and cholesterol and triglyceride testing to warn of impending heart disease.
Patient education and motivation must be the central component of quality diabetes care, as the patient must provide daily self-care by
- Managing food selection, meal planning & following the planned diet.
- Practicing the routine exercise
- Self-monitoring blood glucose
- Taking medication, if required
- Avoiding smoking and drinking
Blood Sugar Monitoring
A self-managing diabetic best does his role in testing the blood glucose levels by himself.
Several testing units are available and all are relatively easy to use.
Two blood sugar scales in use are
- The metric system mmol/l and
- The older mg/dl scale
The most important number is 7mmol/l = 120mg/dl - the upper limits of normal range for fasting blood sugar and 2 hours after-eating blood sugar.
Normal blood sugar values are based on venous blood samples - i.e. blood drawn from the arm and tested in the laboratory. The home practice involves pricking of the fingertip and testing blood from capillaries under the skin. The sugar content of capillary blood is higher than venous blood. Hence a correction is necessary. Capillary blood sugar values may be 1 to 3 mmol/L or 20 to 70 mg/dl higher than venous blood. For practical purposes, subtract 1.5 mmol or 30 mg/dl from the capillary values to compare home test values to venous blood values.
Sugar measurements for various reasons
The sugar measurements are useful for different reasons. For example:
Fasting blood sugar levels: This is taken in the morning before eating and should have a value in a normal range. The goal is to keep this value under 7 mmol/L or 120 mg/dl. (Finger test values 8.5mmol or 150 mg)
Two hours after eating: Blood sugar rises and then falls to a baseline level. The sugar level peaks in 30-60 minutes and the falls back to a baseline level. The timing and height of the peak level will vary with the composition of the meal and activity levels.
By sampling blood sugar levels two hours after eating, it can be observed that glucose is being removed from the blood in a reasonable period. The main aim is to achieve values less than 7 mmol or 120 mg. (Finger test values 8.5mmol or 150 mg) at two hours. Higher values indicate a requirement for change of food or meal that caused high sugar level and exercise after the meal to increase glucose utilization.
Checking symptomatic episodes: Measuring blood sugar not feeling well to find help in correlating symptoms related to blood sugar level. High levels are associated with an intoxicated feeling, drowsiness, difficulty in concentration and impaired judgment. Levels above 17 mmol or 300 mg are dangerously high. Most diabetics are likely to want to sleep at this level but the most effective way to reduce the sugar levels is to exercise as vigorously as possible.
Levels below 4.0 capillary (60 mg) may be associated with hypoglycemic symptoms such as feeling strange, anxious and irritable. A tremor develops when the blood sugar value decreases with the urge to eat something. A quick sugar hit such as a glass of orange juice helps in determining the sugar level in the blood immediately.