Leah McCauley & Razia Amin DAFNE EducatorsDiabetes CentreNHS Grampian

Grampian Diabetes Professional Conference27th May 2009

An insight into structured education for people with Type

1 Diabetes

What is Structured Education?

• Patient centred philosophy• A structured written curriculum• Trained educators• Be quality assured• Be audited

NICE Guideline 60

Contents

• DAFNE• Inclusion Criteria & Referral form• Evidence• Timetable• The Course• Patient Comments• Other Structured Education Packages• Questions

Welcome to DAFNEBackground

Dose Adjustment For Normal Eating

5 day structured education for type 1 diabetesSelf management, confidence and competencyStarted in UK in 2000 (Scotland in 2005)

BMJ 2002; 325; 746-751

DAFNE in Scotland

• 8 Scottish centres

• Aberdeen– 38 Courses since May 2005– 286 DAFNE graduates– Currently deliver one course per month– Expanding team of DAFNE educators

Inclusion Criteria

• Type 1 diabetes - post ‘honeymoon’ period• Over age 17 years• HbA1c < 12%• Motivated to improve diabetes control• Able to read and converse English• Willing to test and inject at least 4 - 5 times a

day• Able to attend a full 5 day course • Absence of ‘end-stage’ diabetes complications

8 participants per group

Referral FormNHS GRAMPIAN

DAFNE PARTICIPATION FORM

Participants Name: …………………………………………………………………. Address: ……………………………………………………………………………… ………………………………………………………………………………………….. ………………………………………………………… Post Code: ……………….. D.O.B: ……………………………………………….. Hospital No: ……………… Daytime Telephone No: ………………………….. Mobile No: ………………… GP Details: …………………………………………………………………………… ………………………………………………………………………………………….. What do I hope to achieve from attending DAFNE education course? Improve my knowledge of CHO counting Improve my understanding of blood glucose control Help with insulin adjustment e.g. coping will illness, exercise Reduce the frequency of hypos Reduce the risk of DKA (ketoacidosis) Education prior to consideration of insulin pump therapy Pregnancy planning Wish to improve HbA1c (average drop of 0.5% in UK Clinical trial) Other reason …………………………………………………………………........ Special Requirements i.e. dietary / mobility / barriers to learning / other: …………………………………………………………………………………………..

Employers Letter Required: Yes / No Able to Attend at Short Notice: Yes / No

DAFNE CHECKLIST Only individuals with type 1 Diabetes Mellitus who meet all the following criteria can be considered suitable for a DAFNE course: Able Able to attend for a full 5 day course and follow-up sessions

Over 17 years of age

Type 1 Diabetes for at least 6 months (and / or post ‘honeymoon’)

Willing to inject up to 5 times a day (i.e. Basal Bolus regime)

Willing to monitor and record Blood Glucose Levels at Least 4 Times Daily (long-term)

HbA1c < 12%

Absence of Late Diabetes Complications e.g. Renal Failure

Able to communicate in English

Absence of significant psychological distress (e.g. eating disorder would be a contraindication)

Participants Signature: .......………………………………Date…………………. HP Signature: ……………………………………………….Date…………………. Please return completed form to Aileen McKillop-Smith, Lead DAFNE Educator, Diabetes Centre, Woolmanhill, Aberdeen, AB25 1LD -------------------------------------------------------------------------------------------------------- Office Use Only

Agreed Allocation onto DAFNE Yes / No

Original Referral Source Re: Outcome

Letter to Patient

Patient Commitment

• Baseline clinic visit (individual appt)

• 5 day course

• Follow up within 8 weeks post DAFNE

• Follow up within 12 months post DAFNE

• Ongoing annual review

• 0.5 % reduction in HbA1c

• Improvements in QoL• No increase in hypoglycaemia• No weight gainBMJ 2002; 325; 746-751

NICE Guideline 60, Diabetes UK report

Evidence

DAFNE TimetableMonday Tuesday Wednesday Thursday Friday

09.15-09.45 INTRODUCTION

09.15-10.30 Group Discussion:Individual blood glucose levels`

09.15-10.30 Group Discussion:Individual blood glucose levels

09.15-10.30 Group Discussion:Individual blood glucose levels

09.15-10.30 Group Discussion:Individual blood glucose levels

09.45-10.45 WHAT IS DIABETES?

10.45-11.00 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee

11.00-12.30 NUTRITION 1Identify carbohydrates

10.45-12.30 NUTRITION 2Putting carbohydrate estimation into practice

10.45-12.30 NUTRITION 3Food PackagingRecipes

10.45-12.30 NUTRITION 4AlcoholEating outHealthy eating/ weight controlTHEORY OF GOAL SETTING

10.45-12.00 ANNUAL REVIEW AND SCREENING

12.00-13.00 QUESTIONS FOR THE DOCTORGOAL SETTING

12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 13.00 – 14.30 Lunch

13.30-15.00 SELF MONITORING

13.30-15.00 DAFNE INSULIN ADJUSTMENT

13.30-15.00 HYPOGLYCAEMIA(Relatives/partners welcome)

13.30-15.00 PHYSICAL ACTIVITYWalk – weather depending.

14.30-15.00 QUIZ

15.00-15.15 Coffee 15.00-15.15 Coffee 15.00-15.15 Coffee 15.00 – 15.15 Coffee

15.15-16.15 ALL ABOUT INSULIN

15.15-16.15 INSULIN INJECTION TECHNIQUE

15.15-16.15 SICK DAY RULES

15.15-16.15 SOCIAL ASPECTS(Contraception and pregnancy – optional)

15.00-15.30 EVALUATION AND FOLLOW UP

16.15-17.00 Group Discussion:Individual blood glucose levels

16.15-17.00 Group Discussion:Individual blood glucose levels

16.15-17.00 Group Discussion:Individual blood glucose levels

16.15-17.00 Group Discussion:Individual blood glucose levels

DAFNE Terms

• CP = Carbohydrate Portion– 1 CP = 10 g carbohydrate (CHO)– 1 CP increases BG by 2-3 mmol/l

• BG = Blood Glucose• QA = Quick acting insulin

– Humalog / Novorapid / Apidra– Lasts up to 5 hrs

• BI = Background insulin• Ratio (QA:CP)

DAFNE Targets

Target Blood Glucose Levels (mmol/l)

Before Breakfast

5.5 – 7.5

Before Other Meals

4.5 – 7.5

Before Bed 6.5 – 8.0

HbA1C = 6.0 – 7.0%

The Pack

The Props!!

• “…This is a must for all diabetics.”

• “Fantastic – it is like a light bulb being switched on after being in the dark for the past 25 years.”

• “Fantastic. This week has gifted me with the tools I have been missing over the years.”

• “To be in control of me for the first time ..”

• “I understand more about diabetes now than I managed to pick up in twenty years.”

• “Looking forward to life now, not dreading it.”

Patient Comments

• “This course is essential. The value of the course and it’s content cannot be underestimated.”

• “An amazing week, not only can I now eat what I want but I can live a normal life. Suddenly diabetes is no challenge.”

• “Instead of being ruled by my diabetes I will control it.”

• “This week has taught be how to live with diabetes rather than fighting it on a daily basis. Everyone with type 1 diabetes should have the opportunity to live a normal life.”

Patient Comments

Other Structured Education Packages

• BERTIE (Bournemouth Education Resources for Training in Insulin & Eating)– Many similarities to DAFNE– No RCT– One day a week for 4 weeks– TIM (Tayside Insulin Management) – NEW DEAL (Forth Valley)

Other Structured Education Packages

• RECLAIM (Royal Infirmary of Edinburgh Carbohydrate Learning and Insulin Management)– 2 x half day sessions

• CHO Counting Group Education Session– Approx 3 hrs

• Don’t meet all 5 key criteria to fulfil NICE requirements of …– A patient centred philosophy– A structured written curriculum– Trained educators– Quality assurance – Audit

Paediatric Services

• Kick-OFF (Kids in Control of Food)

– 11 – 16 yr olds

– RCT commencing

• X-Pert Junior• Group Education Session

– CHO Counting

Questions ??

www.dafne.uk.comwww.dafneonline.co

.ukLeah McCauleySpecialist DietitianDiabetic ClinicWoolmanhillAberdeenTel: (01224) 555221Leah.mccauley@nhs.n

et

Razia Amin

DSN

Diabetic Clinic

Woolmanhill

Aberdeen

Tel: (01224) 555471razia.amin@nhs.net