TYPE 1 DIABETES TOOLKIT ESSENTIAL EDUCATION REQUIRED ON DISCHARGE FROM HOSPITAL

TYPE 1 DIABETES TOOLKIT ESSENTIAL EDUCATION REQUIRED ON DISCHARGE FROM HOSPITAL Information Leaflet Your Health. Our Priority.

of 14 Introduction You have recently been diagnosed with Type 1 Diabetes. This leaflet is designed to offer you the immediate advice following your discharge from hospital. During your stay in the hospital, it is hoped that you have become confident in performing blood glucose testing and a meter should have been given to you to take home. A letter should also have been given stating which type of blood glucose and ketone strips you have been prescribed and it is essential that this is taken to your doctor s surgery as soon as possible so that the prescription can be dispensed. You will be given a supply of insulin on discharge and then your Doctor will be notified via the hospital discharge letter so that this can then be placed onto your repeat prescription. It is also hoped that you are now confident with giving injections but some people may need a little more support with this and if so, the Ward Nurses will organise the District Nurse to attend your home. She will inform you of this if needed. Following discharge, the Diabetes Specialist Nurses will be available for advice and will offer you an appointment within the clinic setting to obtain further education and advice in relation to your new diagnosis. The contact number for the DSN (Diabetes Specialist Nurse) is listed at the end of the document. Leaflet Index What is Type 1 Diabetes? Food and drink Hypoglycaemia Blood glucose and Ketone testing Safe use of insulin Safe disposal of sharps Driving regulation Frequently asked questions Glossary of useful words Contact details What is Type 1 Diabetes? Type 1 Diabetes accounts for 10 per cent of all adults with diabetes and is treated by daily insulin injections, a healthy diet and regular physical activity. Type 1 diabetes can develop at any age but usually appears before the age of 40, and especially in childhood. It is the most common type of diabetes found in childhood. Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin.

of 14 What is INSULIN? Insulin is a hormone. It works as a chemical messenger that helps your body use the glucose in your blood to give you energy. You can think of it as the key that unlocks the door to the body s cells. Once the door is unlocked, glucose can enter the cells where it is used as fuel. In Type 1 diabetes the body is unable to produce any insulin so there is no key to unlock the door, and the glucose builds up in the blood. The body can't use glucose to provide energy and tries to get it from elsewhere and starts to break down stores of fat and protein instead. This can cause weight loss. Because the body doesn t use the glucose it ends up passing into the urine. Nobody knows for sure why these insulin-producing cells have been destroyed, but the most likely cause is the body having an abnormal reaction to the cells. This may be triggered by a virus or other infection. INSULIN IS VITAL FOR LIFE IN TYPE 1 DIABETES AND SHOULD NEVER BE DISCONTINUED The insulin regimen that you have been prescribed is: Date Product Pre-breakfast dose Pre-lunch dose Pre-tea dose Bedtime dose

of 14 What should I do about food and drink? Initial Advice: The following advice is first aid for those at diagnosis. Longer term, the recommendations for you are no different to the rest of the population but you may wish to be more aware of how various foods affect you to help you manage your diabetes. We will go into this in more detail later. For now, because your glucose levels are already elevated it is recommended; 1. Stop sugary drinks, e.g. squash, fizzy drinks etc. If you like these, they can be replaced with sugar free/low calorie or diet varieties. 2. Stop adding sugar to drinks. If you still want a sweet taste try using an artificial sweetener instead. Artificial sweeteners made from aspartame, saccharin and acesulfame potassium are sugar free and will not cause a rise in blood glucose levels. There are lots to choose from here are a few examples:- Canderel, Trim spoon Sweetex, Sweetex plus Hermesetas, Hermesetas Gold Natrena Saccharin tablets Sweet n low, Sweet n low 2 Splenda 3. Stop any obvious sugary foods, sweets and biscuits etc. 4. Limit fruit juice to one glass per day with meals. 5. Otherwise, continue to eat as usual. What food affects blood glucose levels? Carbohydrates are the foods which will cause your blood glucose levels to rise. These can be complex what we commonly refer to as starchy foods or simple what we commonly refer to as sugary foods. Once carbohydrate is eaten then blood glucose levels will rise. The levels will remain elevated as there is a shortage of Insulin; insulin is needed to lower blood glucose levels by converting it to energy. The next step is to start matching insulin doses and carbohydrate intake. We will be giving you information and support to help with this as it is likely to be different for each individual. So You may wish to start blood glucose testing around meals to gain information regarding how your food is affecting your glucose levels. One way of doing this is to pick a common meal or food, test just before eating it and then again about 2 hours after. Repeat this on different days (e.g. weekdays or weekends) and then assess the patterns. There are other foods that may have an impact on your patterns of glucose levels or other aspects of your health. We will these in more detail later in this leaflet.

of 14 Hypoglycaemia guideline Importance of understanding what hypoglycaemia is and how it is best treated. What is a hypo? [short for hypoglycaemia] A hypo is when your blood glucose falls below 4mmols/L, with or without symptoms. How will I feel? The early common symptoms include: Trembling Faintness Sweating Headache Tingling of the lips Palpitations As the blood glucose falls lower, symptoms may change and you may experience: Trembling Unsteadiness Lack of concentration Irritability/confusion Blurring of vision What if I am not sure if I am hypo? Whenever possible, test your blood glucose to check it and confirm that you are hypo. If you do not have your machine with you, it is best to assume you are in fact hypo and treat yourself by following the plan below. What if my blood glucose level is under 4mmols/L? You are hypo; you must have fast acting carbohydrate, choose one of the following; 120mls of Lucozade ( not sport ) or 150mls of coke or lemonade ( not diet) or a 200mls of fresh fruit juice or 4 glucose tablets [e.g. Lucozade or Dextrose etc] or 2 large teaspoons of sugar in some warm water or 1.5 tubes of Glucogel Check your blood glucose after 15 minutes, if still below 4mmols/L repeat the treatment. Check blood glucose again after a further 15mins. Once above 4mmols/L: You must then have some longer-acting carbohydrate, such as half a sandwich, a piece of fruit or a biscuit. If you are due to have a meal then this step may not be required. Be mindful that hypoglycaemia usually means there is a little too much insulin in your body and if not treated properly it may reoccur.

of 14 What should I do if I am hypo just before I take my insulin injection? If the hypo happens immediately before you are due your insulin injection, treat as above remembering that your reading should be above 4mmols and then you may take your insulin immediately after your meal on this occasion. What should I do if I am going hypo whilst I am driving? Follow the instructions that appear later in this leaflet regarding Diabetes and Driving. Why do I feel hypo when my blood glucose level is higher than 4mmols/L? Sometimes, if you have had high very high blood glucose levels over a long period of time, as your control improves and the levels begin to reduce you may experience some of the symptoms associated with hypoglycaemia, but at a much higher level. In this instance, it is not necessary to treat the symptoms as you would for a hypoglycaemic event but to understand what is happening, maybe have a light snack. Inform your diabetes nurse and she will be able to help. Safe use of insulin Insulin is prescribed in vials, prefilled pens or cartridges It is essential that supplies of insulin are stored in the fridge on the top shelf but the insulin you are currently using is kept at room temperature. Insulin does have an expiry date on each cartridge. Spare insulin in the fridge will last until the documented expiry date on the cartridge but those in current use will have an expiry of 1month from being removed from the fridge. Any insulin left in the cartridge after the month should be discarded in the sharps guard/bin Ensure that all insulin pens or cartridges the insulin is free from debris, air bubbles and ensure that the cartridge or pen has no leakage. Ensure that a new needle is used for each individual injection and never left on the pen after the injection as this will lead to leakage of the pen. Ensure the correct insulin product is given at the right time if more than one insulin is being used Ensure that you have an insulin passport this should be given to you on discharge or by your GP or nurse looking after you and your diabetes. It is essential you carry this document on your person as it will offer any other health care professional the name of the insulin product prescribed for you. Ensure that any insulin collected from pharmacy is the correct product and if in doubt please seek advice Ensure that each product is given at the correct time.

of 14 Safe disposal of sharps It is vital that sharps are disposed of safely. This is to protect yourself and the environment. It is important that needles used with insulin pens are replaced before each injection Please do not re-sheath any needles Please do not fill the bin to the brim as this may lead to needle stick injuries. If you are treated with insulin, it is encouraged that you do use the provided yellow sharps guard. All Insulin pen needles syringe and needle and lancets from your blood glucose monitor may be disposed in the sharps guard. The full sharps guard should be taken back to the dispensing pharmacy for safe disposal. High Peak patients Sharps in Buxton are collected from home and a form must be completed by the GP surgery. Please seek further advice from Diabetes Specialist Nurse NB: Please read the instructions for closing your sharps box carefully to prevent locking it before it is full. When it is full to the specified line, then you must lock it. Once locked it cannot be opened again Appropriate blood glucose and Ketone monitoring You should have been offered a dual purpose meter. This specific type of meter is essential for those with T1 diabetes as it has two functions. Blood glucose measurement Blood Ketone measurement. It is essential that you have adequate amounts of test strips available and you may need to organise this, following discharge from hospital, with your GP. The hospital will inform the surgery of the type. Blood ketone strips are not usually used routinely and you will be informed of the appropriate time to test but in the meantime it is essential that you keep a supply for a time when they are needed. When and how often shall I test my blood glucose? When you are newly diagnosed the specialist team will be trying to help you to regulate your blood glucose. They will usually ask you to perform daily blood glucose testing and where possible they would ask that you perform the test before your meals and when you are going to bed. The results should then be recorded in a record diary which the team should provide you with.

of 14 When you attend your appointment the nurse or doctor will be able to advise you on the insulin doses if the readings are available and have been performed at those times. It is a huge commitment to perform such regular testing, and we appreciate that some may not be able to do so, but in the early weeks following diagnosis these readings will assist you and the nurse in ensuring your control settles. When do I test for Ketones? Ketones are formed in the body of someone with Type 1 diabetes when there is a lack of insulin in your system. They can lead to illness and further admission to hospital. Your diabetes nurse will spend more time with you but in the early days until you are seen by the team we would advise that you test for ketones if you experience: Hyperglycaemia with levels of blood glucose above 13mmols/L- however as you are newly diagnosed your blood glucose readings may currently be elevated and this is often usual in the early days. If however you notice a rapid unexplained rise then it may be the time to test for ketones. An explained rise for example, may be if you have eaten a little more carbohydrate than usual and this is the cause for the rise in the reading. Above 13mmols with illness, in particular abdominal discomfort, vomiting or breathlessness. If ketones are present then it is essential that you seek medical advice from either the diabetes team/gp or out of hours service and they will advise you on the next step. The basics of blood ketone testing Ensure all equipment is organised and that strips are in date. Ensure you have adequate supply. Wash and dry hands, do not use alcohol hand gel. Ensure that the procedure for the meter is followed as documented. Record the reading in your diary. Try and look at the result in relation to what you have eaten as this may start to give you an idea as to which foods may make your blood glucose levels rise. Driving and Diabetes Having diabetes does not mean that you need to give up driving, but it does mean that you need to plan in advance before you get behind the wheel. We have been campaigning for many years to ensure that you will be able to continue driving safely and without any unnecessary restrictions. This information can help you ensure that your driving is hazard-free. If you require further information, please see the Driver and Vehicle Licensing Agency (DVLA) website (or the DVA in Northern Ireland), or call our Careline.

of 14 Group 1 driver (cars and motorbikes) If you are on insulin, you must tell the DVLA (in the UK) or DVA (Northern Ireland). Your license will then be renewed every one, two, or three years. Any changes to your condition or treatment which occur between renewals (e.g. complications which might affect your ability to drive safely) should be reported when they happen. Drivers who are under medical supervision by a doctor do not need to notify if insulin is used temporary period only (less than 3 months or for gestational diabetes less than 3 months after delivery) unless they have problems with hypos/severe hypos/hypo unawareness Group 2 driver (bus or lorry) You must tell the DVLA if you have diabetes for which you take any type of medication. If you have insulin treatment you will undergo an independent medical assessment every year. This also applies to holders of C1 license which may previously have been included on your standard Car/motorbike license. You should monitor your blood glucose levels regularly and store results on a memory meter. You will need to provide three months of continuous meter readings at your assessment. Any changes to your condition or treatment (e.g. complications which might affect your ability to drive safely) should be reported. Hypos and driving The licensing agencies are trying to ensure you are safe on the road. They will be concerned if you are unable to recognise or self-treat your hypos. If you are on insulin, check your blood glucose within 2 hours before getting behind the wheel and every two hours whilst driving. ENSURE THAT BLOOD GLUCOSE IS CHECKED PRIOR TO DRIVING AND THAT THE READING IS ABOVE 5MMOLS Safe Driving Tips Avoid delaying or missing meals and snacks Take breaks on long journeys and recheck blood glucose levels every two hours if the journey is long. Always keep hypo treatments to hand in the car. Do not drink alcohol and drive. Many of the accidents caused by hypoglycemia are because drivers have continued to drive, ignoring their hypo warning signs (e.g. hunger, sweating, feeling faint). If you have a hypo whilst driving: Stop the vehicle as soon as possible Switch off the engine, remove the keys from the ignition and remove yourself from the driver s seat.

of 14 Ensure that you are then in a safe place as experiencing a hypo can alter your thought and reasoning ability. Take some fast-acting carbohydrate, such as glucose tablets or sweets, and some form of longer-acting carbohydrate. Follow the hypoglycemia guidelines. Do not start driving until 45 minutes after blood glucose has returned normal and we recommend above 7mmols. If you have poor warning signs, or have frequent hypos, you should probably not be driving because of the risk to yourself and others. Discuss this with your diabetes healthcare team. If your team advises you to notify the DVLA/DVA you must do so. If you fail to do this, your doctor has an obligation to do so on your behalf. Motor Insurance When applying for motor insurance you must declare you have diabetes even if you are not asked about this. You should also inform your insurance company of any changes to your condition or treatment. Failure to do so or failure to notify DVLA/DVA where required, could mean you are not covered. If you feel your premium is too high it is worth challenging your insurer. Insurers can only refuse cover, or charge more if they have evidence of increased risk. Frequently asked questions? What if I forget to take the insulin? The key is to be organised so that you try and prevent this situation from occurring as it is essential that insulin to help to regulate your blood glucose levels, however you are human and sometimes mistakes happen! If it does, then please do not panic. Consider If the insulin should have been given with a meal but forgotten, then it is quite safe to take the dose just after the meal but only 15 minutes maximum afterwards, otherwise your blood glucose levels could fall too low. If the insulin is a mixed insulin (usually taken twice per day, before breakfast and evening meal) and you have forgotten to take the morning dose and it is now dinnertime, then again do not panic but continue to take the next dose at the next prescribed time e.g. the tea time meal. If it is within 15minutes of the breakfast then it is ok to take the dose. It may be that your blood glucose level may be a little more elevated during the day but this will settle. If you have forgotten your background insulin it does depend upon what time you remembered. If it is within 2hours then administer as usual. If it is the morning following the evening administration then it may be safer to just continue with the usual dose in the evening. Some diabetes nurses may advise you to give a little more of the meal time insulin to correct the blood glucose until the usual dose can be given at the usual time.

of 14 It is important that you seek advice from your diabetes team if this happens and they can then advise you of what to do. What if I have forgotten to monitor my blood glucose? If you have forgotten to perform a test then continue as normal and monitor at the next meal. Always remember though the importance of performing a blood glucose retest if you have suffered a hypo event. Please see HYPO guideline. What do I do if I don t feel like eating a meal, do I take my insulin? If you are taking insulin with meals, then remember that the dose does come with the meal and the time of the meal is up to you. There are no fixed times to eat. So if you feel like skipping the meal then no insulin is needed. You MUST however always take the background insulin as this is not linked to meals and must be given at the same time each day. Unfortunately being treated with a mixed insulin does not allow the freedom to skip meals. If this is the case and your appetite is reduced it may be necessary to substitute the meal with an alternative carbohydrate source. e.g. fruit or milky drink. A mixed insulin will continue to be effective resulting in low blood glucose levels without the predicted meal being taken. What do I do if I feel shaky and jittery? This may be a symptom of being HYPO. ALWAYS check what your blood glucose level is if this happens and follow the hypo guidelines. What do I do if I have a blood glucose less than 4mmols/L This result is hypoglycaemia- please follow the hypo guidelines. If this occurs regularly it may be that the insulin doses are too high and you need to speak to your diabetes team What happens if when I perform an injection it bleeds slightly or becomes bruised? There is a tiny capillary network within the fat layer and occasionally the needle may penetrate them. It is nothing to worry about, just choose a slightly different place next time. Bruising can occur if you pinch the skin a little too vigorously whilst administering the injection or you press the pen device too hard into your flesh. My vision is blurred, is this normal? This is often normal in the time prior to diagnosis and immediately afterwards High blood glucose levels cause the lens of the eye to swell, which changes your ability to see. This may last for some weeks until the blood glucose levels stabilise. It is important that you keep your diabetes team informed of how your vision is affected and be mindful if driving or operating machinery if you have returned to work. This visual disturbance will resolve but there is no exact time limit for it to be resolved, we do however understand that it should be short term. Quick reference guide to our frequently used words Hyperglycaemia high blood glucose (above 13mmols) Hypoglycaemia - low blood glucose often termed hypo (below 4mmols)

of 14 Rapid acting insulin - Often termed the meal time insulin. This should be given just before, during or immediately after the meal. Background or Basal insulin. This is usually given once a day and always at the same time. Often termed night time insulin BG Blood glucose. This is what is measured when you prick your finger and indicates how the insulin dose is working for you Rapid acting carbohydrate these are what we encourage you to take if you experience hypoglycaemia as they work very quickly and are listed in the hypo treatment guidelines Units- insulin is measured in units and the dial on your insulin pen ensures the number dialled is the exact number of units to be given MMOLS/L - Blood glucose is measured in millimols per litre and this is the abbreviation used. Contact us Our team in Stockport comprises of many health care professionals including your Practice Nurse and GP Stockport Diabetes Specialist Nurses and Dietitians are based within the community setting at Kingsgate House, but work alongside the Diabetes Consultants, hospital Diabetes Specialist Nurse and Advanced Podiatrist who are based at Stepping Hill Hospital. Tameside and High Peak have Diabetes Specialist Nursing Services, please see contact numbers below. If you are in need of urgent advice following discharge outside of the working hours please contact your local out of hours provider- Master Call in Stockport. Diabetes Specialist Nurses Stockport Diabetes Service Tel: 0161 426 5408 9am-5pm Monday Fri Fax 0161 426 5413 Web site: www.stockportdiabetes.co.uk Email for snt-tr.diabetesteam@nhs.net this email is for patients currently being managed by the nurses and not for referrals Tameside Diabetes Specialist Nurses form part of the Tameside integrated Diabetes Service and their contact numbers are Hours of Service Monday-Friday 08.30-17.30 Wednesday 08.30-20.00 Saturday 10.00-13.00 How to Contact the Service at Tameside all calls and referrals Telephone 0161 366 2335 Fax 0161 366 2388 Email snt-tr.dvadmin@nhs.net Tameside only - Telephone support line-available to provide urgent Diabetes advice and telephone support to patients and health care professionals Monday-Friday 08.00-22.00

of 14 Weekend and Bank Holidays 09.00-13.00 Telephone advice line 0161 366 2354 Diabetes Specialist Nurses High Peak 9am-5pm Monday Fri 01629817878

of 14 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite, Stepping Hill Hospital. Tel: 0161 419 5678. Email: PCS@stockport.nhs.uk. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number MED92 Publication date February 2016 Review date February 2017 Department Diabetes Location Kingsgate House, Stockport