Marika Lo Monaco2,3,4, RaffaellaMallaci Bocchio2,3, Giuseppe Natoli2,3, Salvatore Corrao1,2,3,4*
Received: June 01, 2018; Published: June 12, 2018
*Corresponding author: Salvatore Corrao,Internal Medicine Department, Italy
Keywords: Nursing Assessment, Diabetes Mellitus, Comorbidity, Outpatients, Clinical pathway, Patient Care Management, Chronic Disease, Needs Assessment, Clinical Complexity, Therapeutic Reconciliation,Diabetes Quality of life
Abbreviations: DDI: Drug-Drug Interactions, CIRS: Cumulative IllnessRating Scale,DQOL:Diabetes Quality of life, ABI: AnklebrachialIndex, MMSE:Mini-Mental StateExamination,SBT:ShortBlessed Test,GDS : Geriatric Depression Scale,MNA: Mini Nutritional AssessmentTest
Diabetes is a significant chronic disease, 424.9 million people worldwide are estimated to have diabetes in 2017,and this number is expected to increase to 628.6 million by 2045. More and more patients with diabetes areaffected by other comorbidities, in fact, more than 40% of diabetic people have 3 or more comorbidities . Another important aspect is that, as population ageing, health needs tend to become more complex,multimorbidity, the co-occurrence of multiple diseases in the same patient, represents the mostrelevant featureamong older adults, with a prevalence from 55% to 98% . Inevitably, the coexistence of chronic diseases isoften accompanied by polypharmacy (daily intake of five or more drugs), that could createa frailty condition,poor adherence to therapies, unknown Diabetes Quality of life (DDI) and inappropriatehospital admission, withsignificant implications on economic resources [4,5].In light of these reasons themanagement of complex diabetic outpatients should be reviewed,and nurses might play a central role to improve quality of care and patient quality of life.
Thispaper aims to describe our new model to assess complex outpatients affected by diabetesmellitus. In an internal medicine outpatient clinic at the NationalRelevance and HighSpecialization Hospital Trust ARNAS Civico in Palermo (Italy), a specific path way to managecomplex diabetic outpatients based on themultidimensional assessment with strong nursecoordination was set up in 2016 and is described as follow. According to the model a nursemanage the entireprocess and each outpatient is evaluated for specific personal, anamnesticand clinical data and receiveeducational advice by a multi-professional team made ofspecialised physicians, a coordinating nurse, a nutritionist, a podiatrist and a clinicalpharmacologist.At admission, each outpatient does the first clinical evaluation with the specialised physicianwho collects the clinical history also using the Cumulative IllnessRating Scale (CIRS) and doesthe physical examination. Each patient receives a complete cardiovascular, respiratory andmetabolic assessment. The nurse assesses patients’ vital signs, quality-of-life using theDiabetes Quality of life (DQOL) and potential peripheral artery disease through the Anklebrachialindex (ABI). Moreover, the nurse assesses cognitive function by the Mini-Mental StateExamination (MMSE) or the ShortBlessed Test (SBT), this last in the elderly patients. In thesame way, the nurse uses Geriatric depression scale(GDS) and the Hamilton rating scale fordepression. Finally, patient autonomy is evaluated with the BarthelIndex.
The nutritionalassessment includes Body mass index calculation, Waist circumference evaluation andthenurse’s role in the management of complex diabetic outpatients. Mini nutritional assessmenttest( MNA), body composition analysis by bioelectrical impedance, and heel ultrasound scan. All ouroutpatients with diabetes receive nurse education aboutlifestyles and the use of diabetic devices , specificnutritional advises, and podiatristeducation on foot care.The coordinating physician provides diagnostic andtherapeutic reconciliation . Thecoordinating nurse takes care of the entire patient pathway and evaluatespatient needs andcaregiver support. Moreover, the clinical pharmacologist evaluates in every phase of drugprescription the appropriatetreatments (through the use of the Beers criteria, START and STOPP ones) andearly identifiesdrug- drug interactions (through the use of specific databases, e.g., Micromedex).At discharge, a detailed medical and nurse report is sent to the general practitioner for thebest patient followup. However, the hospital nurse coordinates early admissions of eachpatient in the case of clinical instabilityby direct links with the general practitioner networkand periodic telephone calls to, particularly complexpatients.
The implementation of the multidimensional assessment of patients with diabetes coordinated by the nurse improves diabetes’ management and allows clinicians to have a whole vision of the complexity to better assesspatients affected by multiple chronic conditions. That complex pathway could represent in the future a newprerogative to improve patients’ self-management and therapeutic adherence for all their comorbidities reducing inappropriate hospital admissions and healthcare costs .