Table 1: Tertiary Care level (outpatient and inpatient)
| Qualification and specialties | Staff | Structure |
| Physician based service (outpatient and inpatient) | At least one Endocrinology | Endocrinology board and certified in Diabetes Training program (SCHS accredited) |
| Health educator clinic | Health educator specialist /Health coach. | Bachelor in health education from medical science applied college with accredited diabetes training (SCHS accredited) |
| Clinical dietician clinic | Clinical dietician specialist / Health coach. | Bachelor in clinical dietitian from medical science applied college (SCHS accredited) |
| Nursing | Nurse | Diploma/bachelor (SCHS accredited) |
| Retinal fundoscopy camera. | Ophthalmology technician /Optometrists /Trained Nurse | Optometrist certification/ Diploma/bachelor (SCHS accredited) with established system of referral to ophthalmology service |
| Ophthalmology Clinic (in-hospital referral) | Ophthalmology specialist | Saudi Board in ophthalmology (SCHS accredited) |
| Laboratory service. | Lab technician / Trained Nurse. | Allies with central lab CAP CIBAHI |
| Pharmacy (in-hospital) | Pharmacist | Bachelor's in pharmacy |
| Social service | Social worker | Bachelor's in social science |
| Accessible medical service (in-hospital referral) | Neurology Nephrology Cardiology and psychiatry | Saudi Board (SCHS accredited) |
| Coordinator, Reception and Electronic appointment system | Secretary | Diploma in secretary (bilingual) |
Foot care clinic Inside the center | Podiatrist/orthopedics/ Vascular/ General surgery specialty | Saudi Board in specialty (SCHS accredited) |
| Specialized retina clinic (in hospital referral) | Retina specialist | Saudi Board in subspecialty (SCHS accredited) |
| Dental clinic (in hospital referral) | Dentist | Saudi Board in specialty (SCHS accredited) |
| Insulin Pump service | Endocrinologist, diabetic educator and clinical dietician specialized in pump | Endocrinologist, educator and clinical dietician with accredited pump training (SCHS accredited) |
Table 2 Diabetes clinic KPI's
| Quality measure | ADA benchmark | SNDC benchmark |
| Percentage of patients received an A1C in last 6 months | >93% | 70<% |
| Percentage of patients who had lipid profile tested in a year time | >80% | 80<% |
| Percentage of diabetes patients how had retinopathy screening * | >61% | 60<% |
| percentage of new diabetes cases referred for diabetes education within (≤) 8 weeks from first visit | >70% | 70<% |
| Percentage of diabetes patients tested for microalbuminuria within 12month | >73% | 70<% |
| Percentage of patients received visual foot exam or monofilament testing | 80<% | 80<%
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Assessment:
This should be achieved within 5 years, after 1year, we are going to reassess benchmark locally and international and then you put a plan to reach ADA target.
**KPI well be 60% first year and then 5% annually increase.
*Although ADA recommend dilated eye exam but due to deficiency in personal providing the service we would indorse person with fundus camera service initially instead of dilated eye exam.
Table 3: autoimmune disease screening
| Condition | Indications for screening | Screening test | Frequency |
| Autoimmune thyroid disease | All children with type 1 diabetes | Serum TSH level + thyroid peroxidase antibodies | At diagnosis and every 2 years thereafter; thyroperoxidase antibodies do not need to be repeated if previously positive |
| Positive thyroid antibodies, symptoms of thyroid disease or goiter | Serum TSH level (+thyroid peroxidase antibodies if previously negative) | Every 6–12 months | |
| Primary adrenal insufficiency | Unexplained recurrent hypoglycemia and decreasing insulin requirements | 8 AM serum cortisol and serum sodium and potassium | As clinically indicated |
| Celiac disease | Recurrent gastrointestinal symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic control | Tissue transglutaminase + immunoglobulin A levels | As clinically indicated |
| TSH, thyroid-stimulating hormone. | | |
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Table 4: Long-term complication screening:
| Complication/ Comorbidity | Indications and intervals for screening | Screening method |
| Nephropathy | - Yearly screening commencing at 12 years of age in those with duration of type 1 diabetes >5 years
| - First morning (preferred) or random urine ACR
- Abnormal ACR requires confirmation at least 1 month later with a first morning ACR and, if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate
- Repeated sampling should be done every 3–4 months over a 6- to 12-month period to demonstrate persistence
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| Retinopathy | - Yearly screening commencing at 15 years of age with duration of type 1 diabetes >5 years
- Screening interval can increase to 2 years if good glycemic control, duration of diabetes <10 years and no retinopathy at initial assessment
| - 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard); or
- Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil; or
- Digital fundus photography
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| Neuropathy | - Children ≥15 years with poor metabolic control should be screened yearly after 5 years of type 1 diabetes
| - Question and examine for symptoms of numbness, pain, cramps and paresthesia, as well as skin sensation, vibration sense, light touch and ankle reflexes
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| Dyslipidemia | - Delay screening post-diabetes diagnosis until metabolic control has stabilized
- Screen at 12 and 17 years of age
- <12 years of age: screen only those with BMI >97th percentile, family history of hyperlipidemia or premature CVD
| - Fasting or non-fasting TC, HDL-C, TG, calculated LDL-C. Measurement of non-fasting lipids may be considered if TG are not elevated.
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| Hypertension | - Screen all children with type 1 diabetes at least twice a year
| - Use appropriate cuff size
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| ACR, albumin to creatinine ratio; BMI, body mass index; CVD, cardiovascular disease; HDL-C; high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triglycerides. | |
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