Diagnosing diabetes can be a complex process, and the diagnosis will have an impact on the individual for the rest of their life. Moreover, it is important to recognise symptoms quickly to avoid escalation to diabetic ketoacidosis, which requires immediate admission to hospital and is often a very traumatic experience.
What is diabetes?
Type 1 diabetes mellitus (T1DM) is an autoimmune disease that occurs when a person's pancreas stops producing insulin, the hormone that controls blood-sugar levels. T1DM develops when the insulin-producing pancreatic beta cells are mistakenly destroyed by the body's immune system.
T1DM often presents itself very suddenly and unexpectedly and can be mistaken for a cold or flu. Signs and symptoms can include frequent urination, extreme thirst, dry mouth, fatigue, weakness, unexplained weight loss, slow healing of cuts and blurred vision.
The World Health Organization (WHO) (2006) published its criteria for the diagnosis of diabetes mellitus, and in 2011 recommended the acceptability of glycated haemoglobin (HbA1c) as an additional test to diagnose diabetes (WHO, 2011). However, the use of HbA1c to diagnose diabetes is not suitable in every situation as increase in HbA1c may not be detected until a few weeks after the onset of diabetes and so diagnosis of T1DM with acute onset of symptoms could be missed.
Box 1.Diagnosis criteria for type 1 diabetes
| Diabetes symptoms (eg polyuria, polydipsia and unexplained weight loss) plus: |
|---|
| A random venous plasma glucose concentration ≥11.1 mmol/litre or |
| A fasting plasma glucose concentration ≥7.0 mmol/litre (whole blood ≥ 6.1 mmol/litre) |
Source: World Health Organization, 2011
Diagnosis
Breaking the news of a diagnosis of diabetes should be done in a quiet, stress-free surrounding, which busy emergency departments do not allow for. It can be a lot of information for a patient to absorb especially as it means such a big change to a patient's life. Many people will report they can remember the exact time, date and year of their diagnosis and how they were diagnosed or informed. This can be a major factor in their lifelong management and how the person connects with the team and acknowledges and accepts their diagnosis. The diabetes specialist nurse (DSN) plays an important role in this, but exposure to the whole multidisciplinary team (MDT) is paramount.
Diagnosis has to be done in stages as information and introductions to many health professionals can be overwhelming. The DSN is often the support for the first few months and provides the link with the MDT. Many DSNs are independent prescribers so can assess, diagnose and treat the person promptly, often on the same day of symptomatic presentation. Their role has been defined as a nurse clinician with extended knowledge and skills in diabetes management, as an educator, counsellor, manager, researcher, communicator and innovator (Castledine, 1991).
Once a diagnosis has been confirmed the DSN will immediately begin to teach the person how to self-administer insulin and monitor their blood glucose levels. This again has to be done in an empathetic way as the person with diabetes will be dependent on injections and glucose monitoring for the rest of their lives. The National Institute for Health and Care Excellence (NICE) (2020) recommends the use of twice daily basal insulin for adults with T1DM initially, and a rapid-acting analogue injected before meals. This can, therefore, mean five or more injections to be delivered daily. It also advises that to manage diabetes, blood glucose testing should be performed up to 8-10 times a day. The key learning point initially is to get the person feeling confident in the mechanical process of administering insulin and monitoring their blood glucose levels independently so that they are safe.
It is about taking small steps and for the person with diabetes to be aware that they will be supported throughout their journey. Often, getting the person back into their own environment will enable them to learn quickly how to live their new life at home. It will also help them create a routine, which is difficult to do if the person has to be admitted to hospital on diagnosis and remains an inpatient. Furthermore, it enables the person with diabetes to develop their independence with support; ideally this should be available 7 days a week, although currently this service is not available in all centres. Over time, more information will be provided gradually to develop the person with diabetes' skills and confidence, helping them become more independent in their management.
NICE (2020) recommends structured education in the first 6-12 months following diagnosis, which would give the person with diabetes access to carbohydrate counting training. This is essential in order to develop self-management skills. It is estimated that a person with diabetes will spend, at most, 2-3 hours a year with their health professional; the remaining 8757 hours of the year, they will have to manage their diabetes independently (Diabetes UK, 2015).
Language
The language and how it is used by health professionals has a fundamental impact on people living with diabetes, and so it is vital that from the beginning positive language both verbal and non-verbal communication, that is non-judgemental, and patient-centred is used. It is essential at this stage to be aware of the language that is used regarding diabetes to help build these relationships. A document called Language Matters produced by NHS England (2018) is available to guide health professionals in achieving effective conversations in diabetes.
A positive approach to the language that is used can lower anxiety and build confidence to help improve self-care. Many people with diabetes feel that their diagnosis is the result of something they have done wrong and develop guilt because of this.
Many diabetes teams now include psychology as part of the MDT. Diagnosis is an opportune time to be introduced to psychological support as the emotional needs of the person with diabetes may be greater at this time. The reality of need at any one time will always be shaped by the demands of the condition and life, and the interaction between the two. Any intensification of emotional or psychological need is likely to make everyday self-management, the core of diabetes care, harder to achieve. Every time the person eats it is a constant reminder that their life has changed and what was once a simple daily task becomes a planning process. Before each meal people with diabetes will need to consider their blood glucose levels. It involves working out the correct insulin dose given the person's current blood glucose levels and what they plan to eat. Exercise and everyday stress will also have an impact on these levels, in some cases quite significantly.
Importantly, following diagnosis, care should continue within the correct setting by following the minimum requirements set out by the NHS RightCare programme (2018) pathway. The person with T1DM should have access to a consultant-led MDT, with all staff trained in DAFNE (Dose Adjustment for Normal Eating) (2021) or a NICE (2020) compliant alternative. Being part of a specialist team enables the person with T1DM to feel that the management of their diabetes is collaborative with a person-centred focus. Providing the person with diabetes with the knowledge to self-care allows them to make informed decisions, empowering them to manage all aspects of their diabetes (Davies and Davis, 1998)
Ideal diagnosis pathway: case study
During the first wave of the COVID-19 pandemic, having quick access to our diabetes team showed how advantageous this was when a 21-year-old male presented to the emergency department. He had an acute onset of lethargy, weight loss, thirst and polyuria at a time when the emergency department was overwhelmed with COVID-19 patients. The attending doctor was able to contact the diabetes team and transfer this patient directly to the diabetes unit for immediate assessment, treatment and education. This provided the team with an opportunity to deliver his diagnosis in an empathetic way and answer any questions to try and alleviate any immediate anxiety. Busy emergency departments do not generally allow enough time for clinicians to deliver the diagnosis in a timely manner; it often has to be rushed between seeing other patients.
His diagnosis was given in a controlled, quiet environment, having structured time with a specialist clinician without being interrupted. Attention could also be given to the language used without labelling the person or being judgemental. Not only did he get to see the specialist team immediately, he was able to be seen, treated and discharged within 2 hours of his arrival at the emergency department. This allowed the experience, albeit one with a life-changing implication, to be a far more positive one. Additionally, the team were there at diagnosis and helped establish a relationship immediately and one that progressed as he was able to call the unit on a daily basis for support and guidance, knowing who he was talking to.
Conclusion
If health professionals can get the experience right at diagnosis, it paves the way to make the journey of their long-term condition a more positive one.