INTRODUCTION
Diabetes, a disease where the blood sugar content is supposed to increase above the normal range. The disease has become quite prevalent in the world today. Almost every third adult we meet is diabetic. Not just adults, nowadays diabetes has caught hold of the children too. It is a common finding to get a diabetic child almost in every school.
Nowadays even adolescents and young children are exhibiting the occurrence of the disease. More commonly, it is the obese children who run a high risk of the disease, children with a positive family history of diabetes are also at an increased risk (CDC.gov, 2014). Thus creating a separate group of diabetes affected individuals, also called as MODY (Maturity Onset Diabetes of the Young) (Diabetes.org.uk, 2014). The symptoms although are quite similar, that are, polydypsia, polyuria or polyphagia(Mayoclinic.org, 2014).
According to International Diabetes Federation, approximately 387 million people in the world are diabetic, with 46.3% undiagnosed cases. The prevalence rate is as high as 8.3% worldwide (International Diabetes Federation, 2014). North America and the Carribean region show the highest percentage of diabetic individuals, followed by Middle East and Africa. In 2013, the country which showed the maximum prevalence of diabetes was Tokelau (37.5%) (Healthintelligence.drupalgardens.com, 2013).
Although random and fasting blood glucose tests are considered the gold standards for the diagnosis of the type 2 diabetes, still another big achievement has been brought about in the field of interventions of diabetes that is the HbA1c test. The use of this test can help the patient and the health care professionals to keep a check on the effectiveness of the provided treatment (American Diabetes Association, 2014), if the patient is abiding by the cautions he was asked to or if there is a chance of any complications related to diabetes, foreseen in the patient (Bonora and Tuomilehto, 2011)
HbA1c
Haemoglobin is a protein structure responsible for carrying oxygen to different parts of the body. It is divided into different types, for example, in adults it is called as HbA or adult haemoglobin, in the fetus it is called as fetal haemoglobin or HbF(Wikipedia, 2014). The adult haemoglobin is again divided into different categories, among which the 1c form is taken into consideration while monitoring diabetes (Stoppler, 2014). The HbA1c has an affinity to combine with glucose molecules present in the blood and thus forms glycated or glycosylated haemoglobin(Diabetes.co.uk, 2014). The higher is the blood glucose level, more is the presence of HbA1c in the blood. The test was recommended by WHO in 2011( Diabetes.org.uk., 2014). It is used not as a diagnostic tool, but as a prognostic marker. HbA1c levels can also indicate the risk of possible diabetes in patients with potential chances of diabetes (Rohlfing et al., 2000), like in patients with pre existing pancreatic or hepatic disorders or patients with a positive family history of diabetes, in obese individuals or persons with sedentary lifestyle habits.
HbA1c levels are not indicative of the blood sugar level at a particular point of time but of a time period corresponding to 2-3 months prior to the performance of the test (Science Daily, 2014). Ideally the level of HbA1c should be lower than 6% or 48mmol/mol. Level higher than 7% is considered to run a high risk of diabetes related complications in the patients(Medindia,2014). The levels above 7% do indicate a chance of diabetes in an undiagnosed patient, although it is not a confirmatory test for the diagnosis of diabetes. Any patient exceeding the normal levels of HbA1c but not having any symptoms of diabetes must be repeatedly tested to confirm or refute the diagnosis. If found high repeatedly, the patient should be labelled as a high risk patient and tested again after six months to reassess the levels of HbA1c. A false positive or false negative result can be misleading. Conditions where a false positive level may be obtained are excessive alcohol consumption or renal failure. A false negative result would be present in anaemic patients, as the haemoglobin level is below normal thus the HbA1c level would also remain low( Webmd.boots.com, 2014). The advantage of HbA1c test over blood glucose test is that it does not require an overnight fasting (Tidy, 2012). It can be done at any time of the day irrespective of the intake of meal.
Patients should take adequate measures to keep their HbA1c levels below normal, but it should be borne in mind that the control measures should not make the patient hypoglycaemic(, a large number of patients have been found to become hypoglycemic in an attempt to keep the HbA1c levels under check (Lipska et al., 2014). If taken proper care, a correct monitoring of the blood glucose levels may eliminate the risk of any probable diabetic complications.
ROLE OF COMMUNITY NURSE
The community nurses can help by identifying the warning signs in patients who are prone to become diabetic. They can educate the patients about the disease and encourage them to undergo screening test and other intervention programmes. By increasing awareness among the patients they can reduce the chances of life threatening complications in diabetic patients (Perry, 2001). They will be responsible for educating the patient about diabetes, its complications and the relevance of HbA1c test. By keeping a thorough check on the records of the patient they can guide the patients to undergo the test at regular intervals and make sure that they get the test done after every 3 months in case of patients with uncontrolled sugar levels or every 6 months in patients who are at a potential risk of developing diabetes. The nurses can regularly examine the patients to see if there is any development of signs and symptoms pointing towards complications of diabetes. They can insist people in the high risk category to undergo the screening test to eradicate the chances of occurrence of diabetes later on.
AUDIT
According to Merriam-Webster dictionary, the meaning of Audit is “a careful check or review of something” (Anon, 2014). Audit gives a clear picture of the ongoing activities being carried out at different levels in an organisation in one go. It sums up the data and forms a collective presentation of the facts in order to give a better understanding and a clear picture of the underlying events.
Auditing in the field of nursing is equally important. Nursing audit is defined as “a review of the patient record designed to identify, examine, or verify the performance of certainspecified aspects of nursing care by using established criteria”(Anon, 2014).It is done by the nurses and other health care professionals. It helps in assessing the quality and efficacy of the nursing care provided in the hospital set up. The nurses study the reports and the documentary evidences of the patients and form an audit depending on which the quality of the nursing care is assessed. The data collected from the patients’ hospital records are taken into consideration for the synthesis of the audit report. The nursing audit can be conducted in two ways, one is the retrospective study and the other is concurrent study ( Jairus and Walia, 2011). In retrospective study the data is studied after the patient has been discharged from the hospital. His reports and progress is observed, if he received proper care, if his medical history was taken appropriately, if the care provided to him was of utmost standard etc., are studied. On the other hand, in concurrent study the data is studied when the patient is still under the hospital set up or is admitted in the hospital during the study period. In this the patient and the staff responsible for providing care are interrogated and a report is formed on that basis about the progress in the condition of the patient and the adequacy of the treatment plan and methods prescribed. The auditing ensures that the quality of care that was required to be provided was actually given. It also helps in keeping a check on the functioning of the staff at all the levels (Currentnursing.com, 2014). In their studies Pinto and Melo took the nurses of a hospital administration as a sample for research. They concluded their role in the auditing as one of the most critical job. The constant efforts put by them into maintenance of the records, knowledge of prescribed medications and correct analysis and interpretation of data were appreciated by them. They interviewed professionals at different strata of the administration and came to a conclusion about the intricate nursing role (Pinto and Melo, 2010).
Similarly, auditing is a necessity for the treatment of diabetic patients as it is a disease with lifelong effects. A thorough check on the patients can help in controlling the probability of future complications, if any. The data collected will be helpful in assessing the efficacy of the medications prescribed, recommended dietary changes, lifestyle changes and also if the patient has been following the prescribed guidelines or not can also be determined. The ever increasing number of diabetic individuals in the world is leading to an alarming situation. The need to control the disease has been increasing substantially. According to the data, in 2010 almost 285 million all over the world were found to be diabetic with a percentage of people with type 2 diabetes or diabetes mellitus as high as 90%. The number increased almost up to 100 million within three years span. In 2013, the International Diabetes Federation estimated the number of diabetics as 381 million. Although found all over the world, the prevalence of diabetes is higher in developed countries (Wikipedia, 2014).The cause could be an affluent standard of living, hectic lifestyles with no time for exercises, food habits and sedentary lifestyle. In short it can be said that diabetes and other lifestyle diseases are the price the people are paying for modernisation. Studies reveal that by 2030 a huge population of the western countries will be diabetic individuals, including both adults and adolescents. The tendency to obesity increases the chances of diabetes manifolds. The dietary habits of the western culture play a very important role in that. The increasing dependence of the people on fast foods and processed foods is creating havoc on the health of the people.
AUDIT REPORT
The aim of the following audit is to observe the number of diabetic patients in a clinical set up, to determine the number of patients undergoing HbA1c test and their outcomes. We will take a sample group of 15 diabetic patients and study the pattern in them. Ideally the patients who are already diagnosed cases of diabetes should undergo the HbA1c test at least once annually. Those with uncontrolled diabetes should take the test every six months to keep an eye over any possible health hazards as a complication of diabetes. The patients were observed for a period of one year, the information was collected from the patients’ records. The nurses were informed about the conduction of the audit and permissions were taken from the concerned authorities and officials.
Out of the 15 patients, 9 patients had good glycemic control whereas 6 had a poor glycemic control. All these 15 patients were asked to undergo the HbA1c test. Among the 9 patients who were considered to have a good glycemic control on the basis of random blood sugar test, 6 patients got the test done, rest 3 did not turn up for the test. 2 of the patients who have undergone the test have shown an increased level of HbA1c which puts them in the risk group. The other 4 showed good results. Out of the high random blood sugar patients group, 4 people came for the test, rest were not available. All of the 4 showed high HbA1c levels, thus requiring an immediate action to be taken. The patient turnover for the recommended test is not satisfactory; the reasons could be lack of awareness among the patients about the importance of the test. It thus becomes the responsibility of the health care professionals to inform the patients about the values of the test and their significance as prognostic markers.
DISCUSSION
The HbA1c test can be used as a screening test for high risk individuals, in their study conducted by Rohlfing et al, they showed that levels above the normal values are indicative of risk for development of diabetes. A routine blood sugar test may not be that specific and sensitive but HbA1c levels almost confirm the future chances of diabetes. The study was conducted by them on a sample population who were made to undergo both fasting blood sugar test and HbA1c test. The reports were studied and it was found that the patients who showed a standard deviation of 2 above the normal HbA1c level were at a higher risk of developing diabetes than others. HbA1c levels were more specific and the test was more convenient than fasting blood sugar test (Rohlfing et al., 2000). The nursing professionals can prove to be a great help in spreading awareness among the patients about diabetes and its association with the HbA1c levels. Research conducted by Sanjay et al., depicted that a large number of patients who were diabetic had no knowledge of the test. Thus the lack of knowledge among the patients is making it difficult to fully enforce the utility of the test (Sanjay et al., 2012). They can instill among the patients the need to undergo the test repeatedly for their own well being. A good control over the blood sugar level over a period of 2-3 months will be reflected in the HbA1c values, thus giving a clear prognostic picture of the disease. A good hospital care taken by the nurses and other healthcare professionals can inculcate similar habits in the patients that they will follow after being discharged, thus helping in proper care taking. A proper dietary plan and a physical exercise schedule will help in achieving proper glycemic control. For patients with uncontrolled sugar levels or high HbA1c levels regular physical examinations will be required to be carried out to eliminate the occurrence of any complications like diabetic retinopathy, diabetic ulcers, cardiovascular diseases, renal failure and so on (International Diabetes Federation, 2014). Not just the nursing professionals, personnel at all the levels of the health care departments need to put in their best to reduce the chances of occurrence of the complications in diagnosed patients, to screen the high risk group individuals, and to combat the occurrence of diabetes at the very initial level (Barclay, 2010). The occurrence of diabetes can be reduced by creating awareness among the people about healthy eating habits, encouraging the people for physical activities and working towards reduction of obese individuals all over the world (Ndep.nih.gov., 2014). A frequent screening test should be carried out at the health centers, repeated HbA1c testing would be helpful in analyzing not only the complications in diagnosed diabetic individuals, but will also reflect the status of the patients who are at a risk of developing diabetes or in other words, the potential diabetics (Nhs.uk., 2014). Lack of awareness among the patients regarding the test is causing hindrance to its success, a thorough knowledge needs to be provided to the patients so that they will appreciate its importance and take the test when required. It should be made a mandatory practice in health care set ups for diabetes to make the patient undergo the test at least once in every 3 months, especially in the patients who showed an HbA1c level higher than 7 during the initial test (Driskell et al., 2014). In patients with a controlled blood sugar the test can be repeated every 6 months (Diabetes.niddk.nih.gov, 2014). In a study conducted by Higgins et al., they showed that alone HbA1c values cannot confirm the diagnosis of diabetes. Even after obtaining a value of less than 7%, around 12% patients tested positive for diabetes, thus suggesting that the HbA1c levels alone cannot confirm the diagnosis (Higgins et al., 2011).
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