Derbyshire Community Health Services
NHS Foundation Trust
Michelle Denyer
Lead Community Diabetes Specialist Nurse
16 February 2018
The Diabetes Specialist Nursing (DSN) Team at Derbyshire Community Health Services NHS Foundation Trust (DCHS) provides services for patients with Type 1 & Type 2 diabetes in the north of Derbyshire. The team supports patients with overall management of their condition, helping to avoid both short and long term complications. The DSN team assist patients by altering existing treatment plans and initiating new ones, as well as providing advice around lifestyle, diet and so on. The team also provides a selection of short educational courses to patients and other practitioners & care staff to improve knowledge and understanding of diabetes.
Michelle Denyer, Lead Specialist Nurse with the DSN team has captured some of her patient’s experiences to share with the Simple Telehealth Community.The stories below highlight examples of how clinicians have used Flo to augment best practice care, the positive impact this has had on patient’s lives and the value that Flo adds to the team as an enabling tool to support their patients in a different way.
Case study 1 BG remote monitoring results in no further hospital admissions or ambulance call outs Patient 1 was a 77 year old with type 2 diabetes. The patient lived in a residential care home, and their diabetes was difficult to control, with blood glucose readings anywhere between 2mmol and 30mmol being recorded. This poor control led to the patient being hospitalised for a total of four weeks from 14th August 2017, while various methods were attempted to control their blood glucose. The patient’s HbA1c in June 2017 was 8.4%. Upon discharge and returning to the residential home, it was requested by the hospital that the patients’ blood glucose be monitored four times a day, and these readings continued to fluctuate. To counteract high blood glucose levels, the home was advised to administer quick acting insulin. The diabetes specialist nurse visited the care home and found that the patient’s care plan was very complicated, and felt somewhat uneasy about this. The patients’ blood glucose before going bed was around 2.4mmol, and this rose to between 24-30mmol in the morning – no explanation could be found for this as the patient had no access to food during the night time. As of 18th September, the patient’s blood glucose remained unstable, leading to an ambulance being called out and a subsequent hospital admission on 20th September. The patient began a basal bolus regime, which meant that the patient was having 4 injections daily – not particularly ideal for a patient of this age. At this point, the DSN spoke to the patient’s son about having a mobile phone to use with Florence, and also spoke to the care home about telehealth. The patient was set up on Flo via a telephone call, and the patient’s son did the initial text confirmation to opt in. The patient was put on to a simple protocol which asked for readings and recorded them. This enabled the DSN to remotely monitor the patient’s blood glucose levels, and contact the care home to provide advice and support when necessary. The care home staff reacted positively to the use of Florence, as they felt reassured that a clinician was checking the patient’s readings remotely. From the clinician’s perspective, using Flo has created time savings, as they can now log into Florence and check the patient’s readings. If the readings are within range the DSN nurse doesn’t need to contact the home, whereas before this was necessary to find out what the readings were. On the other hand, if the DSN sees that the readings are too high or low, they can intervene in a timely manner, and avoid further ambulance call outs or hospital admissions for the patient. There have been no further admissions or ambulance call outs to the patient to date. Main benefits:
Case study 2 BG control allowed surgery to go ahead as planned The patient was a 53 year old with type 2 diabetes, who was found to have a tumour in their bladder. Surgery was scheduled for 29th August 2017 to remove the tumour, and the patient began to take insulin. As the patient was going in for surgery, it was key that their blood glucose was kept within tight targets. At this time, the patient’s HbA1c was 9%. The DSN did not need to arrange any face to face appointments with the patient due to the fact that she was able to remotely monitor their readings using Florence. Instead, the DSN made three phone calls to the patient to give them extra advice based on their readings. This saved time for the DSN, and also meant that the patient didn’t need to go to further appointments, which was more convenient for them. The patient has also commented that using Florence was helpful and reassuring for them. Main benefits:
Case study 3 Carers and DSN help patient to reduce hypoglycaemia episodes and as a result reduce ambulance call outs The patient was a 53 year old with type 1 diabetes. The patient lived in a supported unit, and had previously had problems with alcohol. They were experiencing episodes of hypoglycaemia leading to unconsciousness. Staff at the supported unit would then have to handle these incidents. The patient’s HbA1c was measured at 6.4%. The patient began to use Flo in July 2015 and initially carers were texting Florence on their behalf. The carers found using Florence to be a positive experience; they felt reassured that the diabetes specialist nurse could monitor the results, and that Florence would let them know if they should contact the DSN. They also found the advice such as when to check for ketones, or treatment of hypos helpful. Prior to using Florence the ambulance service had attended the patient during their episodes of hypoglycaemia, but since using Florence this has not been necessary as the DSN can react to the patient’s readings and provide support. Recently the DSN and carers have been looking into providing the patient with their own phone to text Florence to increase their independence. The DSN still has face to face appointments with the patient, as it can be difficult communicating with carers, but these are appropriate, and resources are being saved by the fact that paramedics are no longer having to be called to the patient. Further investigation into weight loss lead to supplements being used which raised the glucose level significantly, which the DSN has been able to monitor remotely and alter insulin doses as needed. Main benefits:
| Case study 4 Improved medication compliance results in BG within target range and avoidance of insulin The patient was a 52 year old woman with type 2 diabetes. She was seen jointly by the GP and the diabetes specialist nurse. The GP wanted the patient to start taking either GLP-1 or insulin, but the GLP1 medication can cause nausea. At the time of the consultation, the patient’s HbA1c was 10.3%. The patient was set up on Florence for medication reminders, as she were having difficulty remembering to take her tablets during the day. The patient did not want to use Florence to monitor their blood glucose levels, so they were set up on a meter to monitor this, which would automatically download to the patient’s mobile phone, these readings could then be sent to DSN. The DSN has received 2 sets of readings for the patient since the beginning of August. Having used Florence to improve medication adherence, the patient’s BG readings have been below 10mmol, which was within her target range, HbA1c 7.6% within 3 months. The patient has also started to remember to take her medication, as shown by her blood glucose being within the target range. The patient’s blood glucose is mostly controlled now thanks to the medication prompts from Florence. This means that there is a cost saving as the lady has not needed to start taking insulin or GLP-1. Additionally, the patient feels that having Florence is like having someone keeping an eye on her and her health. Main benefits:
Case study 5 Timely and appropriate intervention reduces A&E admissions and consultations
Case study 6 Patient caring for her sister regains control of her diabetes leading to a stop in taking insulin, weight loss and enabling her to live a healthier life DSN: “Many patients with type 2 diabetes are treated with insulin; the doses are increased over a period of time and patients fall into a cycle of more insulin, increasing weight and increasing insulin. The change in Diane’s confidence has been amazing; she felt very supported with the telehealth system [Flo] and having both her Practice Nurse, Louise, for support in surgery and having regular phone calls from DSN. She was delighted when she stopped insulin. The outcomes are not just about improved HbA1c and the associated health benefits of this, but also the quality of patients’ lives. When I spoke to Diane this week she told me how thrilled she was as she had been able to repaint her own garden fence; she has more energy for activities and also for continuing the care of her sister.” Michelle Denyer, Lead Community Diabetes Nurse (May 2017) Main benefits:
| Case study 7 Previously disengaged patient reduces HbA1c from 13.5% to 6.9% with Flo Main benefits:
Case study 8 Patient controls diabetes and reaches weight loss goal Mick was diagnosed with type 2 diabetes 10 years ago. He first started taking tablets for his diabetes, at which point he began to gain weight. He continued to gain weight which resulted in Mick needing to begin to inject insulin, which in turn caused further weight gain. Mick also had problems with his driving license due to his health, and he was issued a temporary one by the DVLA. His HbA1c was 9.4%. Main benefits:
Case study 9 Improved glycaemic control and weight loss has given patient confidence and more self-esteem While using Flo, the patient also started to use carb counting to help his glycaemic control, and also to try and lose some weight. The patient was able to reduce his weight from 14st 12lb to 13st, and has said “…it’s wonderful I have self-esteem for the first time in years!”. From the patient’s perspective, it is reassuring to know that his blood glucose levels are okay, and if they are not then a clinician will be able to intervene in a timely manner. Flo has given the patient the confidence he needed to self-manage his condition. From a clinician’s perspective, using Flo is great because it means that patients can receive the best ongoing care; if a clinician is on annual leave, it is easy for a colleague to check the patient’s readings and provide continuity of care. Main benefits:
Case study 10 After losing Flo due to funding, patient is now disengaged with her health Flo was used by Naomi to remind her to take her insulin and to help her keep track of her medications. At its highest in 2011, Naomi’s HbA1c was 16.4%. In June 2015 her HbA1c was 13.2%, but after using Flo for four months, Naomi’s HbA1c dropped to 8.6% which was a fantastic result. Using Flo really helped Naomi to self-manage her condition, and gave her the confidence and support she needed. However, since Naomi’s story was shared, there have been some developments. Naomi was told that Flo was likely to be stopped due to funding. Although Naomi was offered to continue with Flo until it was actually stopped she decided to stop immediately, saying that Flo was the only thing that had really helped her. This caused Naomi to become withdrawn and upset. Since then, Naomi has not engaged with the specialist diabetes team, and her HbA1c has risen back up to 13%. Naomi’s story highlights how patients can be put at risk if services they have found useful in managing their health, such as Flo, are withdrawn – especially if the patient is particularly vulnerable. The DSN continues to try to re-engage with Naomi. |
#Diabetes Specialist Nurse #DSN #Derbyshire Community Health Services #TotallyUnique
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