Experiences of a CentreFiona Hegarty

Diabetes Specialist DietitianLetterkenny General Hospital, Donegal, Ireland

DEN,10th June 2014

Background• Acute general hospital in North West of Ireland• Services population of 161,000• Diabetes population

– Total - 5165– Type two - 4414– Type one – 751, 145 under 18yrs

• Diabetes Team– Consultant Endocringolist – Paediatrician, interest in Diabetes– 2 WTE Diabetes Specialist Nurses– 0.8 Diabetes paediatric staff nurse– 0.7 Diabetes Specialist Dietitian– 0.1 Paediatric Dietitian

• Program commenced July 2011• CAWT funded project – European union funded

project, Northern Ireland and border counties• Designed locally by David Chaney, DSN’s,

Dietitian’s and Roche• To date-

– Completed 14 groups– Educated 114 children

• Project due for completion September 2014

• Hopefully will be mainstreamed in the future

Basics• Delivered by Diabetes Specialist Nurse

and Diabetes Specialist Dietitian

• Delivered locally within the community

• Children/young adults with type one diabetes 0-19 years, and their families

• Promoted as part of treatment but not compulsory

• Group sizes 6-12

Time line of group• Child/young adult and family opt into group

• 3 hour sessions run on 4 consecutive weeks

• Group follow up at 4 weeks, commenced on Accu-chek Expert Bolus Advisor – Correction mode– Bolus advice

• Consultant led clinic appointment

• Group follow up at 6 months

• Support via e-mail/phone throughout

Week OneRe-cap of Diabetes

Healthy eating and diabetes

Carbohydrate Counting

Blood Glucose Monitoring

Week Two

Insulin Action and Injection

Carbohydrate counting using food labels

Blood Glucose correction

Week Three

Eating out / takeaways

Hypoglycaemia

Insulin Adjustment

Pump Therapy

Week FourPhysical activity

Sick day rules

Travel

Lifestyle/long term health

Alcohol/drugs

Program• Follow up 4 weeks, 2-3 hour session

– Insulin to carbohydrate ratios and insulin sensitivity reviewed

– Topics reviewed at the groups request– Commenced on Accu-Chek Bolus Advisor

• Follow up at 6 months, 2 hour session– Insulin to carbohydrate ratios and insulin

sensitivity reviewed– Carbohydrate counting quiz– Diabetes Knowledge questionnaire

What worked well• Relaxed learning environment

• Mixed groups of all ages and lengths of diagnosis

• Getting all family members on board

• Sharing experiences and establishing networks

• Pace of teaching dictated by group

• Group interaction, hands on approach

Group InteractionHands on tasks and games• Food models / labels• Plate models• Healthy eating quiz• Travel bags• Real Food

What worked well• Use of flip charts and matching patient folders

– New modules given out each week

• Getting a new meter• Not having to keep a blood glucose diary

– Downloads

Expert Downloads • Actual data• Real-time• Trends

• Hypo Frequency• Individual tailored

advice – invaluable

• Evening groups

• Rigid curriculum

• Paperwork! Limited administrative support

• Separating groups into age groups / sex

• Children under 7yrs attending the groups

• Large groups

• Patients travelling long distances

• Forgetting the kettle…

Not so good…

Facts and Figures• Attendance rates

– 100% attendance at the group– 85% attendance at 4 week follow up– 60% attendance at 6 month follow up

• Baseline data– At 12 months post completion,

average reduction of Hba1c =0.4%• Hospital in-patient days

– 12mths pre-course 94 hospital days – 12mths post course 68 hospital days

• Quality of life (questionnaire at baseline,1mth and 6mths)– Definite improvement in family life concerning

diabetes

Key areas of improvements in quality of life

• Improved ability to control their blood glucose levels

• The children/young adults feel more able to do what they needed to in order to look after their diabetes

• Reduction in fear regarding their diabetes e.g. hypos

• Overall they felt an improved ability to self manage their diabetes

Success Story• Jason, 19 years old, diagnosed with diabetes at 5

years old• Prior to CHOICE, 3 successive admissions with DKA

totalling 9 hospital days, HbA1c peaked at 14.2%• Completed CHOICE in 2011, he has reduced and

maintained his HbA1c around 8% and has no further hospital admissions

• Jason now feels in control of his diabetes, enjoys the freedom surrounding his food choices and family life is much improved

• Mum….wants to know why it wasn’t available 10 years ago!

Where are we now• Running 3 x 4 hrs groups over a 4 week

period • Mixed groups (age/sex/length of diagnosis)• Children under 7yrs not required to attend• Maximum group size, 8 children and

their family members• Ongoing amendments in accordance

with latest guidelines• Morning sessions • Refresher days

We are changing the way our children and young adults think about diabetes

but we have some way to go…

Thanks• Diabetes team, Avril

McCloskey DSN, Anne Griffin DSN

• Roche, Rhona Keaveny,

Steve Williamson • CAWT and CHOICE team