Outpatient clinics carry out check-ups for people with diabetes and other endocrine metabolic disorders. Approximately 10000 patients attend these outpatient check-ups, on average four times a year. Endocrinologists Diabetologists, physicians, ophthalmologists, diabetes specialist counselors, clinical dieticians, specialist nurses, medical secretaries, podiatrists, and social counsellors serve in the outpatient clinics.
The main functions of the outpatient clinics
• To start up insulin treatment in persons with newly diagnosed type 1 diabetes
• To maintain lifelong contact with persons with type 1 diabetes
- To start up nutrition, exercise and medication treatment in persons with newly diagnosed type 2 diabetes
• To establish and maintain lifelong contact with persons with type 2 diabetes with the objective of preventing and managing complications
• To diagnose and treat patients with diverse endocrine metabolic disorders, most of which need life long treatment.
All patients who attend the outpatient clinics at Samatvam are attached to a diabetes care team. Each care team is made up of two physicians (a chief endocrinologist diabetologist and a senior house officer or specialist registrar / fellow), 2 -4 diabetes specialist counselors / physician assistants, a clinical dietician, a clinical assistant, and a medical secretary.
The purposes of the diabetes care team
- To ensure each patient is attached to a care team
• To provide continuity of care – ideally, patients should always be examined by the same person; if this is not possible, another member of the same team will carry out the examination
• To make team decisions concerning the management of the patient’s diabetes
The main outpatient clinics also have a number of smaller specialist clinics. These clinics have their own specified timings, within the main clinic working hours. In addition to the various clinics and departments for examinations and treatment, the outpatient clinics offer counseling, and dietary advice and support.
The pregnancy clinic
The pump clinic
The type 2 clilnic
The children and youth clinic
Counselling, advice and support
Diabetes specialist counsellor
Clinics for examination and treatment
The foot clinic
The eye clinic
Endocrine metabolic laboratory
The pump clinic
Presentation coming soon.
The pregnancy clinic
The pregnancy clinic runs once a week, on Saturday mornings. Here, women with diabetes who are pregnant, or planning a pregnancy, can seek the advice of a care team made up of a chief endocrinologist diabetologist, a diabetes specialist counsellor and a clinical dietician. The care covers both type 1 and type 2 diabetes. The care team manages the treatment of the diabetes during the pregnancy, while the other routine examinations are carried out at the antenatal clinic.
Right at the start of planning a pregnancy, in the pre-conception stage, doctors and nurses are available to advise woman on what being pregnant and having diabetes involves, in particular, what the HbA1c, the blood glucose level, should be around the time of conception. The aim of pregnancy planning is to avoid unplanned pregnancies where diabetes management has not been considered. For women with type 2 diabetes who are planning a pregnancy, tablet treatment may be replaced by insulin injections. Other medication is checked and changed if necessary.
Women with diabetes have a higher risk of developing pre-eclampsia, giving birth prematurely and giving birth to very large infants. In rare case, fetal malformations occur. The risk of complications can be decreased by careful regulation of blood glucose (e.g. by monitoring levels at least four times a day) and by maintaining normal blood pressure.
Check-ups in the pregnancy clinic
Women are referred to the pregnancy care clinic once the pregnancy has been confirmed. They are offered an eye examination (retinal examination) and a urine- and blood test. These examinations are repeated in the 26th week of pregnancy and again two months after the woman has given birth. From the very start of the pregnancy, women are encouraged to keep a pregnancy diary and to monitor their blood glucose four times a day.
A typical visit
At every visit the woman’s blood pressure and blood glucose (Hba1c) are measured and an assessment is made of albuminuria (protein in urine). The woman’s self-monitored blood glucose levels are checked by either a physician or nurse, and treatment is adjusted accordingly. The diabetes team give any necessary information and advice related to the pregnancy, in particular concerning how reactions to and the need for insulin change during the course of a pregnancy. Women are shown how to adjust their insulin dose in line with their blood glucose reading, and are encouraged to discuss any care or dietary concerns they may have.
Two months after giving birth, they have a last check-up at the pregnancy clinic before being signed off. The forthcoming check-ups are done in the general outpatient clinics.
The children and youth clinic
The children and youth clinic, for young people upto 25 years of age with diabetes, is part of the outpatient clinics. It runs once a month on the first Sunday from 9.00 am to 12.00 noon. people meet to share experiences and make new friends.
Childern with diabetes
Infancy and childhood present special difficulties to the patients and their parents. Intensive insulin therapy may not be feasible and certain targets need to be relaxed. Adjustments at school and play need special attention. Self care responsibilities needs to be slowly transferred to the child based on its capabilities and accomplishements. Most day to day treatment decisions may still lie with the parents. The team includes a pediatrician for general health care.
Young people with diabetes
Puberty can present particular difficulties for young people with diabetes. The need for insulin increases and the physical and psychosocial changes in the youngsters’ lives mean that the diabetes treatment needs to be frequently adjusted. The clinic was set up to help adolescents and their parents with the problems specifically related to diabetes during puberty. It has a team of specialist practitioners, and each young person has his or her personal practitioner.
Taking responsibility for their own treatment
The practitioners in the multidisciplinary team work towards getting the young people to accept they do have an illness, but that it can be treated. They aim to gain the youngsters’ confidence and to motivate them to take responsibility for their lives, especially in relation to diabetes. Education in diabetes, its symptoms and treatment; and instruction in how to inject themselves and monitor blood glucose is aimed at empowering the youngsters to take responsibility and make informed decisions about their treatment.
During the opening hours of the clinic, usually around 11.00 am, the practitioners put on an “event”. The event deals with topics relevant to youngsters with diabetes, for example, hypoglycaemia, parties, achievements in school and sports, and subsidies for blood glucose monitoring apparatus. Often, sweets and potato crisps are handed round; this paves the way for a discussion about confectionery and other snacks.
Consultations and other arrangements
Parents attend the consultation when considered necessary, usually only the first few times. The clinic arranges an annual meeting for adult relatives; this begins with a diabetes-related talk, which is followed by a discussion.
The type 2 clinic
The type 2 clinic is part of the outpatient clinics, and its team, consists of an endocrinologist diabetologist, a senior house officer, registrar or fellow, 2 – 4 diabetes specialist counsellors, a clinical dietician and a medical secretary. The responsibilities of the type 2 clinic cover education, developing treatment management plans and carrying out status investigations in patients with newly diagnosed type 2 diabetes who have been referred to the clinic by their own general practitioner.
The overall purpose of the clinic
To contribute to improving the quality of life and extending the life expectancy of persons with type 2 diabetes through prevention of acute and chronic diabetic complications.
The primary functions of the type 2 clinic:
• To provide education, treatment and status on possible diabetic complications
• To provide education and practical instruction on insulin treatment.
• To provide intensive care management for persons with type 2 diabetes with severe diabetic complications
The clinic’s focus areas:
• Lifestyle changes: increased physical activity, smoking cessation, weight loss
• Dietary changes
• Setting personal diabetes-management goals
• Involvement in working with problem areas
Treatment in the type 2 clinic
The treatment course
Treatment spans approximately 8 months and is split into A, B, C and D visits, see below. A specialist diabetes nurse coordinates and supervises the visits. After the treatment has ended, all further check-ups are carried out in coordination with the patient’s own general practitioner
- A-visits – Initial consultation with the diabetes specialist counselor and diabetes registrar or fellow..
- B-visits – Consultation with the endocrinologist diabetologist to establish the patient’s medical record, repeat consultation with the diabetes specialist counselor and the clinical dietician.
- C-visits – A half day education course with group-based teaching, with special emphasis on diabetes, late diabetic complications and medical treatment. Blood glucose is monitored and a urine test is taken. Retinal photography at the eye clinic is conducted. In addition, information is given concerning the principles of a healthy diet, alcohol, smoking, physical exercise and preventive footcare. The legal rights of persons with diabetes and available support are discussed. A follow-up consultation with the diabetes specialist counsellor also takes place
- D-visits – End of treatment and status
The half day course days are a month apart (2nd or 4th Saturday of the month). Each course has about 20 participants. Participants are encouraged to share their experiences of living with diabetes, ask questions and explore areas where they feel they lack information. Early on in the proceedings, each participant is asked to consider his or her lifestyle and to create personal diabetes-management goals for the changes he or she needs to work towards.
The course facilitators
A diabetes specialist counselor is responsible for the teaching concerning the diabetes illness, its complications and the medical treatment. They also give instruction on blood glucose monitoring and urine testing for glucose levels.
• A clinical dietician teaches the principles of a healthy diabetic diet and provides information about alcohol, smoking and physical exercise
• A podiatrist teaches about the importance preventive footcare
• A social counsellor informs participants about their legal rights and about available subsidies and support.
Focus of the education
All course facilitators put special emphasis on the need to make lifestyle changes and revise habits.
The concluding visit entails a consultation with the endocrinologist diabetologist, a diabetes specialist counsellor and a clinical dietician, and a status is made. The effect of the treatment is assessed and the lifestyle scheme adjusted to allow the person with diabetes to clearly see what has been achieved and what must be worked towards. Few people need further monitoring in the outpatient clinics.
Course in outpatient insulin treatment start-up
If lifestyle changes and treatment with tablets do not provide satisfactory regulation of the blood glucose (HbA1c remaining over 6.5%), the treatment may be supplemented with insulin injections. Depending on the blood glucose profile, insulin is administered with meals or before bedtime. Courses are frequently run to teach patients how to inject themselves with insulin; theoretical and practical instruction is given by a diabetes specialist counselor and a clinical dietician. Courses are for 4 to 6 participants, and relatives may attend if the patient wishes.
The course content
The 4-hour course starts with a clinical dietician giving participants information about the principles of a healthy diabetic diet, and this is followed by a nurse teaching:
• The construction and function of the insulin pen
• Injection technique
• Storage and destruction of the pen and needles/syringes
• Hypoglycaemia – its symptoms and management
• Hyperglycaemia – its symptoms and management
• Monitoring blood glucose
• Precautions – travelling, social events, alcohol and illness
The nurse provides explanations and instructions about taking insulin backed up by detailed handouts. On this course, participants have the opportunity to practise injecting themselves.
After the course, the patient and nurse keep in close telephone contact during the next few days, and the patient is given a new appointment at the outpatient clinic. This arrangement allows any problems experienced by the patient to be dealt with, and the effect of the insulin treatment can be assessed and adjusted. If problems arise outside the clinic’s opening hours, telephone calls are redirected to a round-the-clock telephone service answered by a diabetes specialist counselor.
Members of the various professional groups offer counselling within their specialist area. Appointments must be made. See the list of health professionals in the menu on the left.
Counsellors take the responsibility to test the quality of devices used to monitor blood glucose levels and to teach persons with diabetes how to use them. A wide range of commercially available blood glucose monitoring devices are available.
Trying out blood glucose monitoring devices
The Counsellors have detailed knowledge about the range of available blood glucose monitoring devices. Patients receive advice tailored to their specific needs about which device to buy and under the guidance of a counselor , have the opportunity of trying out the various apparatus.
Checking blood glucose monitoring devices
The laboratory recommends that all blood glucose monitoring devices are checked once a year, or more often if faulty measurements are suspected. When the devices are checked, a counselor takes a blood sample for analysis and checks how the person with diabetes does his or her self-monitoring. The results of the two samples are compared and if a significant difference is apparent, the device is returned to the producer to be examined for defects.
Every new, commercially available, blood glucose monitoring device is tested to assess its quality and to determine whether its functionality and instructions for use are user friendly. Quality is assessed by comparing the results of samples taken using the new device with those of samples taken by the clinical biochemistry department. The counselors test the new device and assess the likelihood of errors.
The loan of blood glucose monitoring devices
Blood glucose monitoring devices can be borrowed for short periods from the counselors, and following authorisation from a member of the care team devices are also available for home use. Patients are shown how to use the device and are given forms on which to register the readings.
Samatvam has the services of several clinical dieticians; they are attached to the multidisciplinary care team. Their job is to give advice and education about lifestyle changes: diet, physical exercise, alcohol and tobacco are just some of the areas covered. The dieticians work in the outpatient clinics, the type 2 clinic, the pregnancy clinic, the children and youth clinic, and the diabetes units of affiliated hospitals.
Diet and diabetes
Diet is a central component in treating diabetes, and the clinical dieticians are there to explain about the nutritional and chemical composition of different foods and the importance of knowing how to combine these foods. Information is also given on alcohol. Both the composition and the amount of food are key factors in a diabetic diet; the dieticians help patients come to terms with this by providing menu ideas and tips.
The goals of dietary advice
To ensure the person with diabetes
• Maintains a blood glucose level as close as possible to normal
• Reaches and maintains an acceptable weight
• Can prevent or delay the development of complications
All dietary advice and support takes the individual’s lifestyle and eating habits into consideration.
Dietary advice may cover:
• Cholesterol count
• Fluctuating blood glucose levels
• Weight loss
• Weight gain
• Renal function
• Digestion problems
• Food and physical exercise
• Smoking cessation
The clinical dieticians hold courses in the type 2 clinic and on the outpatient ward; teaching is based on the participants’ needs. Courses are also run outside Samatvam for patient groups and other healthcare professionals.
Diabetes is a chronic illness that may lead to social problems for some patients. Coping with these problems and their consequences can be difficult. Counsellors are there to help patients get an overview of the situation and to find ways of dealing with the difficulties, perhaps with the help of social legislation.
The duties of the social counsellor
Samatvam has several social counsellors and all patients connected to the centre are entitled to seek help from him or her. The social counsellor’s work lies primarily in giving information and counselling and, to a lesser extent, in teaching on the outpatient ward and in the clinic.
Most appointments with the social counsellor are made over the telephone or following referral from a practitioner, but sometimes people just drop by after a consultation with one of the practitioners.
The meeting with the social counsellor
Some people contact the counsellor for advice on a specific problem; others come with situations they feel unable to cope with. Mutual trust is an important element of these meetings and the counsellor works hard to establish this.
The counsellor listens to a person’s concerns and helps put the situation in perspective, and, if required, offers supportive advice to ease the predicament. However, emphasis is on empowering the persons to solve the problems themselves. Often, problems cannot be solved by a single meeting and counsellor and client meet several times; between meetings both parties work towards finding possible solutions.
Typical problem areas
The majority of questions put to the counsellor are about employment conditions, legislation regarding subsidies and social problems.
The foot clinic
The foot clinic is staffed by one podiatrist, a physician foot specialist, and two general surgeons with experience in diabetes foot surgery, who have a weekly consultation. The surgeons examine and treat people with special diabetes-related foot problems. Vascular surgery referrals are obtained as per need.
Diabetes and the feet
People with diabetes may experience complications in the form of nerve damage (neuropathy), reduced circulation to the feet or a combination of both. Changes in the skin’s elasticity and moisture content may occur as well as changes in the muscular function. These conditions require preventive footcare and regular examination of both feet and footwear to avoid problems. Proper guidance and education in footcare is therefore crucial to understanding and preventing complications.
In addition to improving the overall quality of life of people with diabetes, the foot clinic aims:
– to detect neuropathy and changes in the blood vessels sufficiently early to prevent foot ulcers
– to reduce the number of major amputations
– to reduce the number of new amputations in those patients who have already had an amputation
Check-ups in the foot clinic
All patients with current or potential foot problems and/or symptoms of complications such as neuropathy or circulatory problems are referred to the foot clinic.
Patients are examined to assess the extent of the problem: blood samples, x-rays of the feet and swabs of wounds are taken, and the blood flow in the legs and feet is checked. Those who are not at risk of developing complications are referred to a local podiatrist.
What the podiatrist looks for
The podiatrist examines the condition of the feet. This includes an examination of the blood flow to the feet, the sense of feeling in the feet and whether the patient has any skin problems. Based on these observations, the podiatrist advises on prevention, relief and treatment.
In a typical examination:
• the feet are examined for pressure sores, hard skin and cracks
• the shape and appearance of the toenails are examined
• the feet and toes are examined for incorrect positioning
• foot pulses are checked
• the sensitivity of the feet is checked
• the patient’s gait is observed
• the patient’s footwear is checked
Prevention and treatment
• initiates and follows up treatment
• advises on proper footcare management.
• tries to motivate a change towards more foot-friendly footwear
• alleviates discomfort by providing insoles for the patient’s own shoes, special footwear or custom-moulded shoes
• promotes mobility by fitting walking braces
• tries to prevent small wounds and infections from becoming ulcers
• in the case of loss of feeling, a template of the foot is made for use when buying new footwear
• in the case of foot ulcers, a wound-management plan is made
• in the case of complicated and infected foot ulcers admission to the outpatient ward may be necessary.
The patient’s diabetes management plan is checked and adjusted if the blood glucose level is too high. A high blood glucose level will slow down the speed at which wounds heal.
The eye clinic
The eye clinic screens for diabetes-related changes in the eye (diabetic retinopathy). These changes often occur without any symptoms. Early detection and diagnoses is important in order to begin treatment as soon as possible: early treatment may delay or even prevent some diabetes-related changes. Treatment is based on regulating high levels of blood glucose and blood pressure, but for some patients laser treatment is also necessary.
The eye-clinic staff
The clinic is staffed by ophthalmologists who are clinical specialists in eye diseases. An ophthalmologist visits the clinic twice a week to study the eye photographs and carry out clinical check-ups (following referral).
The eye consultation
The consultation with the ophthalmologist includes an eye test and examining / photographing of the retina in both eyes; the patient is also given information about how the eye can change as a result of diabetes. The patient’s vision is assessed in relation to the impact of diabetes and other eye diseases are discussed. Before the consultation the patient’s eyes are dripped with eye drops that act as a local anaesthetic and also enlarge the pupils. This is done to obtain the best possible picture quality. The assistant takes five pictures of each retina with a digital camera. These pictures are then assembled in one picture, and can be seen immediately.
The results of the eye pictures
Most people get the preliminary results of their eye pictures immediately after the photographs have been taken; however, the final results are given at a later consultation, after the assistant has made a thorough evaluation of the condition of the retina, sometimes in collaboration with the ophthalmologist.
Data on the condition of the retina are stored in a computer program along with all other data concerning the patient’s diabetes monitoring. Based on this information, the program calculates the date of the next check-up. The assistant then takes this date and relates it to the patient’s current level of vision, history of diabetes and the result of the pictures from the previous check-up before determining the actual date of the next check-up. Check-ups are carried out every 3 – 24 months, depending on the severity of any changes in the retina.
The clinical physiology department carries out examinations to either detect and manage diabetic complications, or to determine a diagnosis.
What happens in the department
Practitioners refer patients to the clinical physiology department. Patients receive the preliminary results directly after the examination and the final results at their next consultation.
Examinations for complications
Beat to beat: examination of the autonomic nervous system for signs of nerve disorders (the autonomic nervous system is an involuntary system). In this examination changes in the pulse are registered during deep breathing.
Orthostatic blood pressure measurement: examination of the autonomic nervous system for signs of nerve disorders. In this examination, changes in blood pressure are measured when the patient moves from a lying to a standing position.
Distal blood pressure measurement: assessment of the blood flow to the feet and toes. This measurement indicates the likelihood of a foot ulcer healing.
GFR examination of renal function, i.e., how efficiently the kidneys clean the blood of the toxins that are constantly being created in the body.
Glucagon test: examination of how much insulin the pancreas produces.
Oral Glucose Tolerance Test (OGGT): an examination that can confirm/reject the diagnosis of diabetes.
Synacthen test: measurement of the adrenal production.
The work of the department
The department’s work is very varied and ranges from analysis to teaching and quality control. For example, the work comprises:
• taking blood samples in the outpatient clinics and on the outpatient ward
• analysing blood, serum and plasma – hormone and urine analyses are also done
• analyses of material from other hospitals, after prior agreement
• working up and transfer of results to the IT system in the laboratory
• preparing production statistics and running quality assurance on analyses
• testing and data handling of results for research projects
Blood glucose and HbA1c are measured prior to almost all consultations in Samatvam; every year blood samples are taken for routine examination; blood samples are also taken when recommended by a practitioner. Urine samples are taken annually to check the protein content. The patient’s weight is measured at every visit to calculate body mass index (BMI). The care team uses the results of the blood samples and the ECG to determine a diagnosis, draw up a diabetes management plan and prevent further illnesses and/or complications.
The clinical biochemistry department uses a comprehensive program for analysis that ranges from stix and spectrophotometric methods to immunochemical and chromatographic techniques. Each year the laboratory analyses several thousand patient samples. In line with a mutual agreement, a few samples are sent for analyses at outside reference laboratories.