Quality standard
Quality statement 3: Intensive insulin therapy and level 3 carbohydrate-counting education for type 1 diabetes
Quality statement 3: Intensive insulin therapy and level 3 carbohydrate-counting education for type 1 diabetes
Quality statement
Children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis.
Rationale
The aim of intensive insulin therapy is to reach near normal blood glucose levels, to reduce the risk of long-term complications and improve quality of life. Dietary management can also improve control of blood glucose and HbA1c levels. When using intensive insulin therapy, it is important to match the insulin dose to carbohydrate intake, in line with individualised insulin-to-carbohydrate ratios (level 3 carbohydrate-counting). Children and young people and their family members or carers (as appropriate) should be taught how to do this at diagnosis.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements and written clinical protocols to ensure that children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by provider organisations, for example from clinical protocols.
Process
Proportion of children and young people with type 1 diabetes who are offered intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.
Numerator – the number in the denominator who receive intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.
Denominator – the number of children and young people with type 1 diabetes.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
a) HbA1c level of 48 mmol/mol or lower.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. Included in the Royal College of Paediatrics and Child Health National Paediatric Diabetes Audit.
b) Quality of life of children and young people with type 1 diabetes.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient satisfaction surveys.
What the quality statement means for different audiences
Service providers (secondary care diabetes services for children and young people) ensure that systems are in place to offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.
Healthcare professionals (those providing diabetes services for children and young people) offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.
Commissioners commission services that offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.
Children and young people with type 1 diabetes are offered intensive insulin therapy (either multiple daily injections or an insulin pump) and level 3 carbohydrate‑counting education at diagnosis.
'Multiple daily injections' means injecting a long-acting (slow) insulin once or twice a day, and a rapid-acting (fast) insulin before eating. An insulin pump is a small machine connected to your body that gives you insulin throughout the day, so you don't need to inject yourself.
'Level 3 carbohydrate counting' means counting the carbohydrates in your food and drink, so you can make sure you are injecting the right amount of insulin.
Source guidance
Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NICE guideline NG18 (2015, updated 2023), recommendations 1.2.18, 1.2.19 and 1.2.38
Definitions of terms used in this quality statement
Intensive insulin therapy
Insulin therapy is aimed at reaching near-normal blood glucose levels. There are 2 types of intensive insulin therapy:
Multiple daily injection basal–bolus insulin regimens
An intermediate or long‑acting insulin that is usually injected once or twice a day (basal), and a rapid‑acting insulin that is injected as needed before each meal and snack. [Adapted from NICE's 2015 full guideline on diabetes (type 1 and type 2) in children and young people and expert opinion]
Continuous subcutaneous insulin infusion (insulin pump therapy)
A programmable pump and insulin storage device that delivers a background or basal supply of insulin (either a rapid‑acting analogue or a short‑acting insulin) and boluses of insulin as needed, through a subcutaneous needle or cannula. [Adapted from NICE's 2015 full guideline on diabetes (type 1 and type 2) in children and young people and expert opinion]
Level 3 carbohydrate counting
Carbohydrate counting for people with type 1 diabetes who are using intensive insulin regimens (multiple daily injections or insulin pump) involves calculating insulin‑to‑carbohydrate ratios that are individualised according to age, sex, pubertal status, duration of diabetes, time of day and activity. Pre‑meal insulin is adjusted according to the estimated carbohydrate content of meals and snacks using the specified insulin‑to‑carbohydrate ratios. [Adapted from NICE's 2015 full guideline on diabetes (type 1 and type 2) in children and young people and expert opinion]
Equality and diversity considerations
Children and young people with type 1 diabetes and their family members or carers (as appropriate) should be provided with information on intensive insulin therapy and level 3 carbohydrate counting that they can easily read and understand themselves, or with support, so they can communicate effectively with health and social care services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. People should have access to an interpreter or advocate if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.