In accordance with NICE diabetes guidance NG17 and NG18, and in line with Quality Standard 140 on transition from children’s to adults services, it was recognised that achieving good glycaemic outcomes for young adults with diabetes remained a challenge at the Royal Liverpool University Hospital. Towards the end of 2015, patient engagement was poor with high non-attendance in clinics. A tiny proportion of the cohort was achieving the NICE recommended HbA1c <53mmol/mol and admission rates for diabetes-related emergencies remained high.
To make improvements, there was a desperate need for engagement and innovative working methods. Through a process of team briefings and service user feedback, a number of changes were made, which included a clinic restructure, addition of flexible drop-in sessions, following a structured care pathway, construction of a clinic spreadsheet for data analysis and establishment of the first peer-support group for type 1 diabetes in Liverpool, with a view to engage and support.
In December 2020, NICE reviewed the evidence and updated the recommendations on fluid therapy for children and young people with diabetic ketoacidosis in NG18. The updated recommendations should be referred to if replicating any aspect of this example.
This example was highly commended in the 2018 NICE Shared Learning Awards.
Aims and objectives
Using results of local audits and feedback from a subsequent multi-disciplinary team (MDT) and patient focus group meeting, the young adult diabetes clinic was re-designed with a vision to have a structured, patient-led, flexible clinic service with specific aims and objectives, to be achieved within 12 months (December 2016):
- Reduction of the DNA rate
- Increase in the percentage of patients with HbA1C <53mmol/mol
- Reduction in mean HbA1c of clinic cohort
- Reduction in admissions with DKA and SH
- Improving access to the clinic service to increase engagement
- Establishing a local peer-support platform to aid in patient empowerment and self-management.
This was in line with standards and guidance laid out in:
• NICE NG17: Type 1 diabetes in adults: diagnosis and management
• NICE NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management
• NICE Quality Standard 6: Diabetes in Adults
• NICE Quality Standard 140: Transition from children’s to adult’s services
Reasons for implementing your project
There are approximately 25000 people living with diabetes in Liverpool, with a significant proportion being young adults (19-25 years). The city is home to 3 universities, 2 world class football academies and a bustling social scene. The age of emerging adulthood is that of growing independence, increased experimentation, differing priorities and, unfortunately, frequent disengagement with the clinic service. It is also the age when worsening glycaemic control and frequent hospitalisation with diabetes-related emergencies are encountered.
Towards the end of 2015, the immediate challenges faced by the young adult diabetes service at the Royal Liverpool University Hospital were a high clinic ‘did-not-attend’ (DNA) rate (47%), rising admission rates of diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH) in this age group (15% and 6%), and a lack of data analysis to measure specific outcomes of this clinic cohort, as the National Diabetes Audit (NDA) measured outcomes of all people with type 1 (T1D) and type 2 (T2D) diabetes. In addition, there was no support for young adults outside the clinic setting for encouragement and empowerment.
The aim of LIVT1D was to create a platform for people with type 1 diabetes to be supported by peers, family members and healthcare professionals, outside the clinic set-up. It was established following a focus group meeting of the MDT and 10 people with type 1 diabetes, attending the young adult diabetes clinic, held at the University of Liverpool campus in September 2016. Feedback from the meeting included ideas for running the peer-support group and thoughts on ‘the ideal clinic service’.
A steering group was formed, which included 3 patients, a consultant diabetologist and a senior diabetes specialist nurse. In addition, a closed Facebook® group and a Twitter® handle were created and managed by people attending the young adult clinic, with an aim to reach out to anyone with type 1 diabetes for support and empowerment, whilst ensuring privacy and highlighting that this was not a substitute to clinical care at the hospital. Furthermore, it was decided that 3 monthly structured educational meetings would be held in an easily accessible location in Liverpool. Funding for these meetings would be arranged through various glucose measuring device companies.
How did you implement the project
Through a process of team briefings and service user feedback, a number of changes were made, which included a clinic restructure, addition of flexible drop-in sessions, following a structured care pathway, construction of a clinic spreadsheet for data analysis and establishment of the first peer-support group for type 1 diabetes in Liverpool, with a view to engage, support and empower young adults in managing their diabetes. The service redesign involved the implementation of the following:
- A weekly joint-multidisciplinary team (MDT) ‘Young Adult Diabetes Clinic’ with the consultant, diabetes specialist nurse and specialist dietitian, lasting at least 30 minutes per patient, with 4 monthly follow-up appointments. This was different from the individual appointments made earlier. The total number of appointments per year would be similar to previous years.
- Development of a clinic pathway, defining the young-adult cohort (19-25 years), services offered, follow-up arrangements and transfer to the >25 years adult clinic under the same consultant, to ensure continuity of care.
- Flexible drop-in sessions with diabetes specialist nurse and dietitian, in between planned clinic appointments, for structured education, self-management advice and carbohydrate counting revision.
- Team information leaflets with contact details (telephone and email) and guide to useful diabetes related on-line resources. Patients are encouraged to email data, questions and feedback regularly.
- Telephonic reminders to patients of the upcoming clinic appointment, in addition to texts already sent, by the clinic clerk and department secretary.
- Pre-clinic questionnaire for patients to fill prior to entering the consultation room, highlighting the most important lifestyle and diabetes-related topics to discuss, with an aim to make the consultation more focused.
- Use of DIASEND® for downloaded glucose data analysis during clinic appointments, uploaded upon patient arrival to the clinic by the outpatient clerk.
A clinic database spreadsheet, using information from various in-house online platforms (diabetes register, inpatient notes, laboratory system and GP records) for retrospective and prospective data analysis for audit and service development. Data would be fed in simultaneously during the clinic appointments by a member of the MDT. 9. LIVT1D-Liverpool’s first peer-support group for adults with T1D, established by people attending the young adult diabetes service.
Using the information from the clinic database spreadsheet, we analysed demographics and outcomes in a 24-month period, from January 2015 (12 months pre-clinic redesign) to December 2016 (12 months post-clinic redesign).
123 patients in total were identified in the clinic cohort. Diabetes diagnosis of all patients included type 1 diabetes (92%), type 2 diabetes (7%) and MODY (1%), with mean duration of diabetes of 13.7 ± 6.6 years. The majority of these patients (85%) were on a basal-bolus insulin regime. In 2016, 89 patients (versus 76 in 2015) attended the MDT clinic appointments, with the total number of attendances for the year being 192 (v. 129).
More significantly, 65% (v. 42%, p=0.001) of patients attended 2 or more clinic appointments and the DNA rate for the clinic was reduced to 32% (v. 47%, p=0.03). After adjusting for the number of appointments and DNA rate, financial gains made in 2016 were £3663. Mean HbA1c for the clinic was reduced at 74 ± 22mmol/mol (v. 76 ± 20mmol/mol, p=0.91).12.3% of patients (v. 2.6%, p=0.03) had an HbA1c at the NICE recommended target of <53mmol/mol and 25% (v. 14%, p=0.17) of patients had an HbA1c <58mmol/mol.
Reductions in admission rates for DKA and SH at the Royal Liverpool University Hospital for this patient cohort, in 2016, were seen with 8% (v. 15%, p=0.12) and 2% (v. 4%, p=0.40), respectively. 11 fewer admissions for DKA and SH were recorded in 2016, totalling a financial saving of £9336. 90 patients attending the clinic completed satisfaction forms regarding the service in April 2017. 80% of patients were ‘satisfied’ with the length of appointments, 80% with expertise of the team, 70% with appointments being productive and100% agreeing to recommend the service to those who do not attend in the region.
Analysis of the pre-clinic questionnaire has highlighted the differences in discussion topics between men and women and given an insight to most popular themes. It has, undoubtedly, made the consultation process more focussed.
Results of the analysis were presented at the Diabetes UK Annual Professional Conference, 2017 in Manchester. Results from LIVT1D have been equally encouraging; as of January 2018, the group has had 150 members on Facebook® and 158 followers on Twitter®, organised 4 structured educational meetings with over 60 members in attendance, held 3 monthly at a local hotel, on themes such as ‘Exercise and type 1 diabetes’ and ‘Alcohol and eating out with type 1 diabetes’, and numerous social meet-ups.
Key learning points
Improving the delivery of high quality of care will be possible by working through the following 3 areas:
- Systematic quality improvement through clinical outcomes:
This will also feed in data for complications and emergency admissions. In addition, audits of NICE recommended guidance will continue to be implemented, along with service evaluation studies and measurement of DNA rates. Quarterly analysis of this data will allow us to study trends in outcomes and benchmark our performance with national data.
Refining and updating the clinic database spreadsheet will allow us to measure completion and target achievement rates for the NICE recommended 8 care processes, specifically in the young adult cohort.
- Assessing expectation and satisfaction:
As satisfied patients and providers continue to demand higher expectations, a key area of sustainability and improvement will be arranging interactive opportunities, through questionnaires and focus group meetings, to engage and obtain constructive and candid feedback. This will allow us to reflect on the positive and negative aspects of the service with a view to continued improvement to achieve high satisfaction rates.
- Broadening the programme scope and reach:
The positivity generated by LIVT1D in a short space of time and its speculated impact on clinical outcomes will allow the team to share its experiences with a wider audience through partnerships with neighbouring Trusts, similar peer-support groups and local universities in the North West and nationally. Feedback from this group along with clinical outcomes will be presented as a business case for funding peer-support through the local CCG and potential transformational funds.