NHS Standards of Clinical Practice
An overview of the standards of clinical practice with regard to diabetes care shows that a strict focus on improving clinical services by providing comprehensive health-care to patients could help in effective implementation of health-care objectives. The standards of clinical practice with regard to diabetes care state that following protocols for diabetes management would be very important for the NHS services and effective implementation of insulin as a treatment method would also form a crucial aspect of these protocols.
The standards are based on the considerations that the NHS will develop, implement and monitor strategies to reduce risks of diabetes and would also seek to identify people who are not aware that they have diabetes. The NHS aims to empower people with diabetes and to provide a service for young people and adults with diabetes that would help them to adopt and maintain a healthy lifestyle. The NHS also states that all adults with diabetes should receive high-quality care including enough support to optimise control of their blood glucose and blood pressure (DH; 2001). Children and young people with diabetes are also given high-quality care and support to optimise their physical; psychological; intellectual and educational development. The NHS emphasises that all young people with diabetes should experience a smooth transition of care from paediatric diabetes services to adult diabetes services during the most appropriate time. The management of diabetes emergencies is also one of the clinical standards laid out and the NHS has to develop, implement and monitor on agreed protocols for effective treatment of diabetic emergencies by trained health-care professionals (DH; 2001; DH 2003). The management of acute diabetic complications and minimising risks of recurrence are some of the major aspects of clinical care in diabetes. One of the clinical standards also suggest that all children and young people with diabetes and admitted to hospitals should receive effective care for their diabetes and they should also be involved in the decision-making process that deals with the overall management of the condition. The standard 9 on the clinical care of diabetes during pregnancy suggests that the NHS will develop and monitor policies seeking to empower and support women with diabetic conditions present before or during pregnancy (DH; 2001). To avoid long-term complications; all young people should receive regular surveillance provided by the NHS. The NHS also seeks to develop and monitor agreed protocols and systems of care to ensure that all people with long-term diabetic complications receive timely and appropriate treatment to reduce risks of disability and even premature death. The Department of Health also emphasises that all people with diabetes and requiring multi-agency support should receive integrated social- and health-care (DH; 2003).
Considering the standards of clinical care; it would be important to understand the difference between clinical standards as should be followed and clinical standards that are followed in NHS trusts and hospital units. Audits done in hospital settings and clinical assessment of standards followed in the hospitals show the gap between principles and practice. Methods of change in clinical standards and practice in diabetes management could be suggested on the basis of failures noted in implementation of these standards or general flaws in actual practice of the standards set. One of the main aspects of clinical standards is related to the effectiveness of the applications of insulin therapy. Newer methods of therapy could be recommended for effective diabetes management.
As Korytkowski et al. (2005) have suggested diabetes management is largely affected by poor adherence or adaptation to insulin therapy. The reasons of poor adherence to insulin therapy may not always be clinical causes and can be associated with social embarrassment; fear of injection; intolerance to pain; needle anxiety, and social and physical inconvenience. To overcome these difficulties of administration and application and to ease patient anxiety or pain, other newer techniques of delivery and additional choices and features of insulin delivery devices are being investigated. Korytkowski et al. (2005) describe the features, efficacy, advantages and disadvantages of insulin pen devices or Flex Pen which is a disposable pen device used for insulin therapy. The results of their study indicated that as many as 65% of patients with diabetes were not confident in their ability to manage the disease by themselves and indicated that they do require professional clinical advice although only 23% indicated that insulin therapy would be effective for management of their disease. Methods of injection used for insulin administration were found to create anxiety in 25% of patients and most other problems associated with insulin administration have been related to fear of injection, fear of pain, weight gain, hypoglycaemia, feelings of failure and lack of motivation. The study reported that insulin pen devices are convenient and flexible for therapy and help patients to overcome needle anxiety and social embarrassment associated with more regular methods of insulin injection. Korytkowski et al. suggest that using pen devices may help improve adherence to insulin dosing schedules as this can overcome the major obstacles associated with compliance to multiple injection schedules.
Insulin Injection and Clinical Practice
Within the context of the standards of clinical practice for diabetes management; the changes in practice could be recognised and implementation methods could be evaluated with the help of research studies.
Gelling et al. (2006) investigated the role of insulin action in the brain during the treatment processes of diabetes and determined whether the brain requires the neuronal signalling for lowering glucose content when insulin treatment is given for diabetes. For uncontrolled diabetes, the results showed that hypothalamic signalling was reduced. In the acute and chronic infection treatment paradigm, the rate of insulin-induced glucose lowering was 35%-40%. The results showed that hypothalamic insulin signalling would be a key factor in determining the response of an individual to insulin and in the overall successful management of uncontrolled diabetes. This would provide us with key insights into the insulin injection process and would help us to understand the brain mechanisms responsible for diabetes control. Understanding brain mechanisms and insulin action triggered by brain changes is an important aspect of diabetes care. Considering the NHS standards of care specified for diabetes, we could suggest that appropriate insulin administration would be an important part of agreed protocols that should be followed in diabetes care. Certain changes within clinical practice would relate to introducing newer techniques of insulin therapy.
Plum et al. (2003) describe newer insulin therapies for management of both type 1 and type 2 diabetes. Their study provides an overview of the two types of diabetes and also reviews and evaluates the newer types of insulin therapies that are used for treatment of such patients. The newer insulin products such as insulin glargine and insulin aspart; and other novel insulin therapies were studied in terms of formulations; dosing and administration and adverse effects; storage; applications and costs. Plum et al. highlighted the fact that although diabetes patients are largely dependent on insulin products, there are no products that can lead to natural endogenous insulin secretion in patients and insulin has to be administered externally. Administration of insulin has shown problems of variable or selective absorption, hypoglycemic events, inadequate duration of response and timing difficulties. Although insulin analogues used help in overcoming such problems, novel insulin formulations which can be taken orally or even inhaled are being investigated to help make the process easier for patients. As of now; insulin glargine and insulin aspart are the latest clinically approved products for managing diabetes and tend to offer clinical benefits to the patients. However there are certain advantages in these newer types of insulin which may have to be evaluated against increased costs of these newer therapies. Changes to traditional forms of insulin therapy are necessary considering medical complications in patients who react adversely to insulin injections. Newer more sophisticated products that could be easily absorbed and also easily administered would be necessary for successful insulin therapy of diabetic conditions. One of the major focuses for changes in clinical practice would be on updating and improving insulin therapy techniques with emphasis on introducing simpler and more effective techniques.
Heinemann and Anderson (2004) point out that it would be important to understand the course of action of therapeutically used short- and long-acting insulin to determine the factors related to the successful outcomes of the therapy. The euglycemic glucose clamp technique has been used to determine the pharmacokinetic and glucodynamic properties of insulin and the study highlights that new insulin formulation and applications techniques should be tested rigorously for their effectiveness. Heinemann and Anderson suggest that investigational approaches limited to determining the pharmacokinetic properties of insulin preparations using blood glucose level decrease measures may not produce valid results. The new glucose clamp technique as suggested is effective for a quantitative study of pharmacokinetic and pharmacodynamic properties of insulin preparations under comparative conditions (also in Cernea et al.; 2004).
Considering the changes necessary for better and more effective management in clinical care of diabetes, Venekamp et al. (2006) suggest the use of a new reusable insulin injection pen known as HumaPen Memoir (HPM) , similar to Korytkowski et als study on the Flex Pen. The electronic feature helps to store 16 insulin doses in its memory card. Venekamp et al. studied the functionality and acceptance of this device as a new method for insulin therapy and their study indicated that there were no reports of adverse effects and no hypoglycaemic or hyperglycaemic episodes were reported. This new insulin pen was rated higher than the other techniques used for diabetes suggesting possible benefits to its extended use.
Conclusions and Recommendations:
Considering the reports and studies on the changing effectiveness of diabetes management, it is important to highlight the uses of the new devices that could be used for meeting clinical standards and objectives. The focus of clinical care is effective patient service and management and using new technologies to overcome the general obstacles of needle anxiety, apprehension and pain could be a recommended strategy for improvement of health-care services.
The recommendations for improving health-care and maintaining clinical standards in the management of diabetes could be given as:
1. use of technologically advanced and superior devices to make the insulin injection process simpler and effective;
2. use of better and newer methods for advanced insulin therapy;
3. effective support and counselling to patients who show aversion for insulin treatment; and
4. focusing on long-term care and support to help reduce long-term effects of diabetes to encourage a full, healthy and socially productive lifestyle.
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Department of Health; 2003. National Service Framework for Diabetes: Delivery Strategy, Crown Copyright
Department of Health; 2001. NSF Diabetes, Crown Copyright