Context Kettering General Hospital, Distric Hospital, United Kingdom. Number of paediatric patients with type 1 diabetes - 140.
Multidisciplinary Team: Paediatric Diabetes Specialist Consultant, paediatric registrars, diabetic nurses, dietician.
Problem For paediatric diabetes patients, effective glucose control with less variability is always challenging. Inadequate control can lead to recurrent hospital admissions affecting patient’s quality of life.
Assessment of problem and analysis of its causes MDT identified following potential causes for inadequate control.
Clinic HbA1C is performed 4 times a year to monitor glycaemic control but it may not truly reflect day to day control of patient’s blood sugar levels at home which can be significantly up and down.
Maintaining a hand written sugar diary can be difficult for patients with compliance issues.
Interpretation of an inadequately filled paper diary can be challenging for doctors as well as patients as it does not give an idea of trends of sugar levels and therefore does not reflect glycaemic control and variability.
Patients can also experience difficulties in calculating right dose of insulin at home.
Intervention Patients were provided SMART metres after an education about their use.
They were taken through a process of on-going learning to review and analyse the SMART metre downloads and make appropriate changes to their insulin needs to prevent high and low sugars.
The MDT had an oversight of the process to actively facilitate the learning to decrease admissions aiming for diabetes home care.
In 3 monthly clinics near patient HbA1c testing as well as SMART metre downloads were used to analyse patient compliance and treatment results
Study design Prospective data collection during clinics from January to June 2014.
A retrospective analysis of prospectively collected database of blood sugar downloads from SMART metres and near patient A1C tests.
Strategy for change Change was implemented through education with MDT approach. Families were supported through the process of changing metres and offered open access to MDT.
Measurement of improvement The effect of the planned changes were measured by patient confidence in self-management, glycaemic control, Variability of blood sugars versus A1C levels and need for hospital admissions.
Better understanding amongst the patients of their own control led to the patient empowerment in a friendlier home environment.
Mean A1C for 100 downloads was 61.67 mmol/mol (9.8 mmol/L) that was comparable to a mean blood sugar of 9.6 mmol/L with a mean standard deviation of 4.7. However this correlation changed when the data was stratified based on Standard deviation (SD).
SD <2: mean A1C was 45.7 mmol/mol (7.6 mmol/L) compared to average mean blood sugar 5.53 mmol/L.
SD 2–4: co-related to mean A1C 53.9 mmol/mol (8.7 mmol/L) to average mean blood sugar 7.9 mmol/L.
SD >4: mean A1C 63.4 mmol/mol (10 mmol/L) and average mean blood sugars-9.97 mmol/L were exactly same.
SD >6: mean A1C of 73.89 mmol/mol (11.6 mmol/L) compared to average mean blood sugar of 12.4 mmol/L.
Admissions due to DKA and hypoglycaemia decreased by half.
Effects of changes Better control closer to home improving patient experience and quality of life at reduced heath care cost.
There was initial hesitation around new metre and tight targets which was overcome by education, close supervision and reflection.
Lessons learnt SMART metre download review is a good way of analysing blood sugars targets, variability and control over a period of time.
They are better predictors of glycaemic control
It has its advantages in empowering patients at the comfort of their own homes.
Message for others SMART metres have taken paediatric diabetes management closer to home.
Mean blood sugars are a better indicator of glycaemic control and variability when the standard deviation is between 0–4.
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