Implementing multiple daily injection insulin regimens (MDI) with carbohydrate counting for children and young people at diagnosis of type 1 diabetes: education provided by the Children’s Diabetes Service for patients, families and staff

• To support and enable children and young people to aim for the NICE recommended HbA1c target of 48mmol/mol (6.5%) or lower by 3 months post diagnosis.
• To provide the education and support required to enable children and young people and their families/carers to achieve their individualised lowest HbA1c target.
• To reduce average blood glucose levels while minimising incidences of severe hypoglycaemia.

In order to support children and young people to achieve the recommended HbA1c target as recommended by NICE, we knew we needed to achieve tighter blood glucose (BG) control earlier in diagnosis.  Prior to January 2015 our practice was to commence all children and young people with newly diagnosed Type 1 DM on MDI insulin therapy with fixed doses of rapid acting insulin.  Doses were based on a division of total daily insulin doses calculated on body weight.  Correction doses were not used at this stage.  Patients and families were provided basic education at this time about Type 1 Diabetes, the relationship between carbohydrate intake, blood glucose levels and the action of insulin.  They were then discharged home and one week post diagnosis the Dietitian would visit to provide further education about carbohydrate counting and insulin dose adjustment.

We identified that in this week after diagnosis, BG control was not optimal and levels remained above the target range. 

It was agreed within the team to improve glycaemic control in this first week of diagnosis we needed to start using carbohydrate counting and insulin correction doses at diagnosis. Therefore, in January 2015, in all newly-diagnosed children and teenagers, we started MDI with carbohydrate counting education, and insulin correction doses from the first time insulin is given.

Starting doses for rapid acting insulin were calculated by the Advanced Paediatric Dietitian and Lead Consultant.  An insulin-to-carbohydrate ratio (ICR) and insulin sensitivity factor (ISF) based on age at diagnosis was established.  From these we generated insulin dose calculation tables that convert a pre-meal BG reading and carb content into a calculated insulin dose for each meal or snack.  This is now a printed tool that we use both on the ward and provide to patients and families to use on discharge.

The Lead Consultant also developed age-dependent protocols for medical staff to follow which include initial insulin dose calculations and a guide on how to prescribe this using the electronic system we use in the Trust.

A Specialist Dietitian sees all new patients at diagnosis on the ward (within 24 hours of admission on weekdays or 48 hours at weekends).  During this consultation families receive education which includes what diabetes is, what insulin does, the profile and action of basal and bolus insulins, mealtime routine and timing of injections, carb counting and insulin dosing including correction doses.  Written and diagrammatic information and tools in our comprehensive Patient Information Pack supports all teaching.  This information includes graphs to explain insulin action, lists of carb foods to aid identification, a carb calculator to use when weighing foods and insulin dose calculation tables.  We also provide a set of digital scales for all newly diagnosed families which are funded by our Education fund.

The initial session takes 1.5-2 hours and if the patient stays in hospital a further night, further education may be provided the next day.

Education delivered while children are inpatients is supported by ward nurses who have attended training. The dietitians have developed a Ward Manual for the nurses to use which provides step-by-step information on how to calculate the carb content of hospital foods. As part of this all hospital menu items have been carb counted and this itemised list is included in the Ward Manual by day and week.

Within the first week of discharge, the Specialist Dietitian aims to complete a home visit where difficulties are discussed, knowledge gaps corrected and further education gaps about using ICRs and ISFs independently of the calculation sheets is delivered. We also review BG levels and adjust insulin ratios as indicated, educating families how to use these new ratios.

Because we undertook coordinated and informed planning we did not encounter any barriers throughout the implementation process.  Our key learning points listed below give essential points for other Children’s Diabetes Teams to assist in changing practice.

An audit of 20 patients on the new doses compared to  19 patients on the older regimen showed  :

Mean blood glucose levels were significantly lower:

• Day 5 (mean 8.8 vs 10.8 mmol/l)
• 2 weeks (6.6 vs 7.5)
• 1 month (5.7 vs 6.8)
• 3 months (6.2 vs 7.6)  

HbA1c at 3 months is lower:

–      43 vs 47mmmol/mol. 

Hypoglycaemia was no different and there was no severe hypoglycaemia.

However it should be noted that this audit did not include substantial numbers of patients to consider the results statistically significant.  We will aim to repeat it after one year.

A patient and parent survey completed 6 months after diagnosis provided very positive feedback about the education they received at the beginning.  Although they were feeling overwhelmed by the diagnosis, they felt that the education about carbohydrate counting and insulin dose adjustment was comprehensive, appropriately delivered and left them feeling empowered to manage their child’s diabetes.

• To ensure all team members have been trained and are all delivering consistent and clear messages.
• To provide adequate training for ward staff and junior doctors outside of the Specialist Paediatric Diabetes Team. This will need to include how to calculate and prescribe insulin based on an ICR and ISF.
• To develop written protocols and calculation tables that can be easily used by ward staff. We would encourage trusts to develop their own calculation tables based on their own population.
• Develop a comprehensive set of written information and tools to support patients.  Feedback from parents highlights how much they value this.
• Take the time to prepare and have everything set up before you go live with delivery of the new strategies for insulin dose adjustment from diagnosis.
• We have fully carbohydrate counted menus in the trust which has really helped embed the education. A dietetic assistant carried out this task.
• Although Specialist Paediatric Diabetes Dietitians are not available at weekends, the training of Ward Staff and provision of clear guidelines has enabled newly diagnosed patients to be managed safely and effectively during their admission, and even start their education before they are able to receive the full education programme.
• Once ICRs have been stabilised, generally between two and three weeks from diagnosis, a smart meter is offered to families to allow easier calculation of insulin doses in their daily lives.
• We plan to evaluate doses in the spring of 2016 to determine whether any changes need to be made to the protocols.