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VOLUME 14 NUMBER 1 • JULY 2017
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SA JOURNAL OF DIABETES & VASCULAR DISEASE
DIABETES CARE MODEL
Following consultation with the dietetics department at
Edendale Hospital, it was agreed that all clinic patients were to be
consulted annually at a minimum. Diabetes dietary guidelines are
distributed for the different language groups. Dieticians come to
the clinic weekly and provide group patient education.
The above multidisciplinary team provide holistic management
of DM. Having more doctors available at the clinic aimed to
ensure that doctors had more time available to spend consulting
and educating patients.
Staff training
Nursing staff working at the clinic were trained on all aspects of
diabetes care by the specialist clinicians employed at the clinic.
Clinic management
An appointment system was introduced, which was controlled
by the diabetes nurse educator. The number of patients seen per
week is limited to a manageable number, between 30 and 40.
Previously, the large number of clinic patients included mostly
stable diabetic patients who could have been down-referred to
their local clinics. Once proper referral and inclusion from and into
the clinic was achieved, the number of patients seen at the clinic
was maintained at between 30 and 40 per week. A filing system
was introduced where all forms pertaining to diabetes care were
kept and replenished when necessary.
Clinical examination
Computer and printing facilities are scarce in resource-poor clinics.
To address the need for standard data collection in the out-patient
(OP) file, an ink stamp was designed, which creates a form for
collection of relevant data. This stamp includes the following
clinical fields that need to be filled in by the nursing staff:
• sitting and standing BPs as described in the 2011 South African
hypertension guideline
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• resting pulse rate (beats per minute)
• height (cm)
• weight (kg)
• BMI (kg/m
2
)
• waist circumference (cm)
• urine dipsticks, now routinely performed on all patients
attending the clinic and looking for all variables, not restricted
to ketonuria only
• RBG (mmol/l).
Together with nurse training, this ink-based stamp, which created a
page with spaces for all the standard vital readings to be recorded,
ensures that nursing staff perform standardised examinations for
all patients and that they document details in the OP folder.
A comprehensive diabetes datasheet (hereafter referred to
as the datasheet) was designed and implemented (Fig. 2). This
datasheet is completed in triplicate so that one copy is fixed to
the OP file and another copy given to the patient with the explicit
instruction that the patient should present this datasheet if he/
she consults another healthcare profession or institution; the
intention was dissemination of correct patient medical history and
management. The third copy is kept at the clinic and used for data
capturing.
The datasheet ensures that all patients are consulted and
managed in a comprehensive and standardised way, and no
areas of clinical assessment and examination are omitted by the
attending clinician. The principle of the datasheet is based on a
comprehensive diabetes approach where the following aspects
need to be covered:
• patient medical history, including history of retroviral disease
• assessment of lifestyle issues in respect of compliance with
a diabetes diet, exercise regimen, smoking and ethanol
consumption
• performing of SMBG.
The following section of the datasheet requires the patient’s vital
details to be assessed from the OP file. These have already been
completed by nursing staff but need to be transcribed from the OP
file onto the datasheet by the attending clinician, thus ensuring
that the clinician assesses this important part of the examination.
The act of transcribing ensures cognisance is taken of the readings
by the clinician.
Thereafter the clinician’s full diabetes physical examination
needs to be entered onto the datasheet. All clinicians working at
the diabetes clinic are trained on how to perform a comprehensive
diabetes clinical examination and manage patients according to
the local SEMDSA diabetes guideline of 2012.
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Laminated copies
of the 2012 SEMDSA diabetes guideline are fixed to the walls of
each of the three consulting rooms for ease of reference.
Integral to the function of the datasheet is the reminder to
clinicians (via tick boxes) of the need for regular ophthalmological,
blood,podiatry,dieticianandelectrocardiogram(ECG)assessments.
These areas are often forgotten and patients suffer as a result, in
the form of poor control and complications. Previous blood results
are required to be entered on the datasheet, ensuring that the
clinician retrieves and reviews these results.
At the bottom of the datasheet, the patient’s complete list of
medications prescribed is entered. This serves an important role,
to allow the dissemination of patient information to their local
health clinics and private doctors if need be.
Records management
A computer program was designed to correspond to the
datasheet, allowing capture of all variables from the datasheet
onto the program. This program was written using Visual Basic.
net and .net technologies. The program uses the date of birth
(DOB) as the identifier for each patient record. If two patients
have the same DOB then the program automatically assigns
a numerical value after the DOB (i.e. two patients with DOB
of 720511 would then be recorded as 720511 for first patient
and 720511_1 for next patient and so on). Name and gender
requires alphabetical entries while age needs a numerical entry.
The following entries require alphabetical data boxes (Yes/No) to
be completed:
• diet
• exercise
• home glucose monitoring
• smoking
• alcohol
• cerebrovascular accident
• hypertension
• ischaemic heart disease
• myocardial infarction
• coronary artery bypass graft
• intermittent claudication
• carotid bruit
• family history of DM
• retroviral status.