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Supporting patients outside the clinic: A secondary care experience of DSN telephone support to people with diabetes

Diabetes is a chronic, complex condition, which requires lifelong medical and nursing interventions to support individuals with self-management strategies and prevent associated complications. Good communication via a variety of media is advocated and the use of telephone support is identified as a communication method for people with diabetes (NICE, 2004; 2009). Various benefits have been associated with this method of support including improvements in glycaemic control and adherence to diet and blood glucose monitoring (Kim and Oh, 2003). Acute hospital care admissions may also be reduced through support and information offered by DSNs via telephone communication (Evans et al, 2012).

The project
At Clatterbridge Hospital, we offer a DSN telephone support service from Monday to Friday during office hours. This activity is an integral part of the DSN workload but is often under-recognised. In 2011, an audit of the workload generated by DSN calls to people with diabetes at the Clatterbridge Hospital site was undertaken (Leong et al, 2012). All planned and successful calls from the DSNs (0.67 whole time equivalent)  over a 1-month period were retrospectively reviewed and classified according to reason for contact. Two hundred and sixty-two calls were made in total; the majority of calls were for general support following a clinic visit (123 calls) and insulin titration (85 calls). Each call lasted between 5 and 15 minutes. The audit demonstrated that a significant amount of DSN time is taken supporting people outside of clinic settings and requires appropriate recognition and resources. 

In 2012, a further audit was undertaken at Clatterbridge Hospital to retrospectively evaluate the impact of DSN telephone support for people with suboptimal diabetes control (HbA1c >58 mmol/mol [7.5%]), (Joseph et al, 2013). These people were identified from weekly scheduled telephone call lists in December 2011 and January 2012. HbA1c levels were collected prior to the first call and at 6 months. In total, 107 people were contacted and 39 of these required support to improve glycaemic control (all were on insulin therapy). Over a 6-month period, 264 calls were made to these people.

On average, each person had 6.6 calls over 14.4 weeks. The majority of people did not require telephone support over the 6-month period and  only five people required intervention over the whole 6 months. Over the 6-month time period, HbA1c levels in the 39 people had significantly improved from 80.5 mmol/mol (9.5%) at baseline (prior to phone support) to 74.7 mmol/mol (9%) at 6 months (P<0.004). 

Conclusion
Our experience shows that DSN telephone support to patients improves HbA1c in the short-term, although longer follow-up is required to determine if this reduction is sustained. In the current economic climate, providers of healthcare services must demonstrate effectiveness of clinical care and interventions. The use of the local DSN telephone support service clearly demonstrates this and at the same time minimises disruption to patients’ lives. Telephone support to patients should be appropriately supported and resourced.

Diabetes is a chronic, complex condition, which requires lifelong medical and nursing interventions to support individuals with self-management strategies and prevent associated complications. Good communication via a variety of media is advocated and the use of telephone support is identified as a communication method for people with diabetes (NICE, 2004; 2009). Various benefits have been associated with this method of support including improvements in glycaemic control and adherence to diet and blood glucose monitoring (Kim and Oh, 2003). Acute hospital care admissions may also be reduced through support and information offered by DSNs via telephone communication (Evans et al, 2012).

The project
At Clatterbridge Hospital, we offer a DSN telephone support service from Monday to Friday during office hours. This activity is an integral part of the DSN workload but is often under-recognised. In 2011, an audit of the workload generated by DSN calls to people with diabetes at the Clatterbridge Hospital site was undertaken (Leong et al, 2012). All planned and successful calls from the DSNs (0.67 whole time equivalent)  over a 1-month period were retrospectively reviewed and classified according to reason for contact. Two hundred and sixty-two calls were made in total; the majority of calls were for general support following a clinic visit (123 calls) and insulin titration (85 calls). Each call lasted between 5 and 15 minutes. The audit demonstrated that a significant amount of DSN time is taken supporting people outside of clinic settings and requires appropriate recognition and resources. 

In 2012, a further audit was undertaken at Clatterbridge Hospital to retrospectively evaluate the impact of DSN telephone support for people with suboptimal diabetes control (HbA1c >58 mmol/mol [7.5%]), (Joseph et al, 2013). These people were identified from weekly scheduled telephone call lists in December 2011 and January 2012. HbA1c levels were collected prior to the first call and at 6 months. In total, 107 people were contacted and 39 of these required support to improve glycaemic control (all were on insulin therapy). Over a 6-month period, 264 calls were made to these people.

On average, each person had 6.6 calls over 14.4 weeks. The majority of people did not require telephone support over the 6-month period and  only five people required intervention over the whole 6 months. Over the 6-month time period, HbA1c levels in the 39 people had significantly improved from 80.5 mmol/mol (9.5%) at baseline (prior to phone support) to 74.7 mmol/mol (9%) at 6 months (P<0.004). 

Conclusion
Our experience shows that DSN telephone support to patients improves HbA1c in the short-term, although longer follow-up is required to determine if this reduction is sustained. In the current economic climate, providers of healthcare services must demonstrate effectiveness of clinical care and interventions. The use of the local DSN telephone support service clearly demonstrates this and at the same time minimises disruption to patients’ lives. Telephone support to patients should be appropriately supported and resourced.

Evans RE, Richardson LS, Dhatariya KK et al (2012) Diabetes specialist nurse telemedicine: admissions, avoidance, costs and casemix. Practical Diabetes 29: 25–8
Joseph P, Leong K, Leong KS (2013) Diabetes specialist nurse telephone support improves HbA1c at 6 months. Diabet Med 30: 243
Kim HS, Oh JA (2003) Adherence to diabetes control recommendations: Impact of nurse telephone calls. J Adv Nurs 44: 256–61
Leong K, Joseph P, Fenna I et al (2012) Diabetes specialist nurse calling: an audit of diabetes specialist nurse workload generated by patient phone contacts. Diabet Med 29: 194
NICE (2004) Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. CG15. NICE, London. Available at: www.nice.org.uk/cg15 (accessed 08.05.13)
NICE (2009) Type 2 diabetes: The management of type 2 diabetes. CG87. NICE, London. Available at: www.nice.org.uk/cg87 (accessed 08..05.13)

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