Most important recommendations
• Contemporary comprehensive diabetes care requires an input of adequately competent physicians, nurses en-gaged in diabetic education or diabetes educators, and dietitians. Care should be patient-centered, taking into account individual patient situation, needs, and preferences. Due to multidisciplinary nature of late diabetic complications and concomitant conditions, cooperation with other specialists is also necessary. [B]
I. Outpatient care
Modern diabetes treatment requires competencies regarding treatment, monitoring, and patient education to convey appropriate knowledge and motivation to comply with treatment recommendations. Cooperation between primary care physicians and specialists is also required.
II. Goals of primary care
Health promotion, identification of risk factors, vention of carbohydrate disorders, education about pre--diabetes and type 2 diabetes.
1. Diagnosing carbohydrate metabolism disorders.
2. Referring patients to a diabetes clinic for chronic treat-ment in case of:
Type 1 diabetes;
Other specific types of diabetes;
Difficulties in determining the type of diabetes;
Any type of diabetes in children and adolescents, and in women who are pregnant or planning to become pregnant.
3. Treatment of pre-diabetes.
4. Treatment of type 2 diabetes, including simple insulin therapy.
5. Referring patients for diabetologist consultations (less frequently for chronic treatment) in case of:
— Failure to achieve therapeutic goals; patients should be referred primarily to intensify insulin therapy;
— Comorbidities that interfere with treatment;
— Complications of diabetes;
— Complications of pharmacotherapy;
— Other special situations.
III. Goals of specialist care (Table 5.1)
Evaluation of treatment effects and setting thera-peutic targets during annual check-ups in diabetic patients managed in the primary care setting;
Managing diabetic patients treated with injected agents [insulin, glucagon-like peptide 1 (GLP-1) receptor agonists];
Managing diabetic patients treated with continu-ous subcutanecontinu-ous insulin infusion (CSII);
Performing the differential diagnosis of diabetes types, including monogenic diabetes and diabetes combined with other diseases;
Diagnosing, preventing and treating long-term complications;
Diabetes education;
Investigating and managing diabetes in pregnant women;
Investigating and managing concomitant condi-tions;
Performing annual check-ups according to the cur-rent Diabetes Poland guidelines.
IV. Goals of specialist inpatient care
Cases of newly detected diabetes type 1 and di-abetes type 2 with symptomatic hyperglycemia, when appropriate treatment cannot be provided on an outpatient basis;
Acute diabetic complications (hypo- and hyperg-lycemia, diabetic ketosis and coma);
Exacerbation of chronic complications;
Modifications of the treatment regimen in pa-tients in whom therapeutic targets cannot be met during outpatient therapy;
Initiation of intensive insulin therapy using a per-sonal insulin pump and/or continuous glucose monitoring system (CGM), when appropriate treatment cannot be provided on an outpatient basis;
Initiation of insulin therapy in gestational dia-betes and preexisting diadia-betes previously not treated with insulin, when appropriate treat-ment cannot be provided on an outpatient basis;
Difficulties with obtaining normoglycemia in pregnant patients with preexisting diabetes, when appropriate treatment cannot be provided on an outpatient basis.
V. Organizational requirements Specialist diabetes hospital units 1. Physician personnel
— two full-time diabetologists, alternatively, in addi-tion to one diabetologist, an internist with a mi-Table 5.1. Recommendations regarding monitoring in adult diabetic patients
Parameter Comments
Nutritional and therapeutic education At each visit
HbA1c level Once a year, more frequently if doubts regarding maintenance
of normoglycemia or need to verify treatment effectiveness fol-lowing its modifications
Serum total cholesterol, HDL cholesterol, LDL cholesterol,
tri-glycerides Once a year, more frequently if dyslipidemia
Albuminuria Once a year in patients not receiving an angiotensin-converting
enzyme inhibitor or an angiotensin receptor blocker (beginning at 5 years after the diagnosis in diabetes type 1)
Urinalysis (with urine sediment) Once a year
Serum creatinine + calculation of eGFR Once a year (beginning at 5 years after the diagnosis in diabetes type 1)
Serum creatinine, Na+, K+, Ca2+, PO43– Every six months in patients with elevated serum creatinine Fundoscopy (with mydriasis) At 5 years after the diagnosis in diabetes type 1, at the time of
the diagnosis in diabetes type 2 (details see Chapter 20) eGFR — estimated glomerular filtration rate; HbA1c — hemoglobin A1c; HDL — high-density lipoprotein; LDL — low-density lipoprotein
2. Equipment in specialist diabetes clinics:
— Doctors’ offices;
— A treatment room with a separate part for sampling and performing tests;
— A nurse’s office also intended for patient education, with a dietary education section;
— Computer equipment that allows retrieval and ana-lysis of data from insulin pumps and continuous glucose monitoring systems;
— Instruments to screen for diabetic foot syndrome (thermos-tip, 128 Hz tuning fork, 10 g monofila-ments, reflex hammer);
— A Doppler ultrasound device for the assessment of vascular flow.
In addition, access to specialist consultations should be provided to periodically assess the diabetes complica-tion status.
VI. Organization of care for patients with diabetic foot syndrome
Referral diabetes foot outpatients clinics 1. Personnel requirements:
Physicians: equivalent of at least 2 full-time posi-tions — diabetes specialist with at least one year of documented experience in the management of patients with diabetic foot syndrome;
Nurses: equivalent of at least 2 full-time posi-tions — at least one year of documented expe-rience in the management and care of patients with diabetic foot syndrome or chronic wounds.
2. An established organizational pathway allowing pa-tient hospitalizations in a unit within the same facility (medical center) that has a contract for diabetology or internal medicine services signed with the Polish Na-tional Health Fund (NFZ, Narodowy Fundusz Zdrowia).
3. Access to multidisciplinary care, including surgeon, vas-cular surgeon, or angiology specialist consultations.
4. Ability to provide intravenous antibiotic therapy.
5. Access to basic imaging modalities, i.e., X-ray, ultra-sound (including Doppler studies) and CT and/or MRI.
6. Access to laboratory and microbiologic testing performed in a medical diagnostic laboratory listed in the register of the National Chamber of Laboratory Diagnosticians (KRDL, Krajowa Rada Diagnostów Laboratoryjnych).
Basic care outpatient clinics
1. The responsibility of these clinics should include the diagnosis and management of diabetes foot syndrome along with prevention of ulcerations, infections, and Charcot neuro-osteoarthropathy complicating the di-abetes foot syndrome. These clinics should cooperate with referral clinics where more severe cases are con-sulted and offered further treatment.
nimum one-year experience in a diabetes ward or clinic, or a 2nd year fellow in diabetology.
2. Nursing staff:
— a nurse specialized in diabetes care or internal medici-ne or who completed a “Diabetes Educator” course or a qualification course for diabetes nurses or with a mi-nimum 2-year experience in a diabetes ward/clinic;
— one nurse per 10 diabetic beds with duties limited to education and care for diabetic patients.
3. Dietician — a full-time dietician, with duties limited to diabetes care.
4. Access to psychologist consultations.
5. Access to specialist consultations.
6. Equipment:
— At least two beds for patients with acute metabolic conditions equipped with an ECG monitor, a blood pressure monitor, a pulse oximeter, an infusion pump, and access to oxygen therapy;
— Education room;
— Intravenous infusion pumps;
— Equipment for the diagnosis and treatment of dia-betic foot syndrome;
— Access to cardiac [exercise testing, electrocardio-graphy (ECG), echocardioelectrocardio-graphy, ECG Holter mo-nitoring, ambulatory blood pressure monitoring]
and vascular (Doppler ultrasonography) investi-gations.
Specialist diabetes clinics
1. The team providing Outpatient Specialist Care to diabetic patients includes:
— A diabetologist or an internist with a minimum two-year experience in a diabetes ward or clinic, or a 2nd year fellow in diabetology;
— In pediatric diabetology clinic — a diabetologist, or pediatric endocrinologist and diabetologist, or a pediatrician with a minimum two-year experience in a pediatric diabetes ward or clinic, or a 2nd year fellow in diabetology or pediatric endocrinology and diabetology;
— A nurse specialized in diabetes care or who com-pleted a “Diabetes Educator” course, or a nurse specialized in internal medicine or who completed a qualification course for diabetes nurses or with a minimum 2-year experience in a hospital diabetes ward or a specialist diabetes clinic.
— A full-time dietician with duties limited to diabetes education.
— Access to psychological care as warranted in indivi-dual clinical cases.
Children and adolescents, pregnant women — see relevant chapters.
VII. Telemedicine visits as part of diabetes care Each diabetes clinic should be able to provide ef-fective telemedicine visits. For this purpose, diabetes clinics should be equipped with appropriate equipe-ment (computers with dedicated software), and the personnel should have appropriate knowledge and skills. Individuals with diabetes should be encouraged to use technologies and apps facilitating telemedicine visits. It should be noted that telemedicine visits are more effective if more patient treatment data (e.g., data from glucose meter memory, CGM system, or personal insulin pump) are available to the physician performing the telemedicine visit.
Telemedicine visits in individuals with diabetes may be either a part of regular diabetes care or may be used in the epidemic settings.
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