A Community Pediatric Diabetes Program: Innovation, Technology & Best Practice
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1 A Community Pediatric Diabetes Program: Innovation, Technology & Best Practice
2 Markham Stouffville Hospital Opened in 1990 in the heart of Markham Demographics include 14% growth (provincial average only 4%) with a high proportion of young families 33% of Emergency volumes are pediatric patients 210 beds including 5 pediatric inpatient beds, 10 NICU beds. Expansion to 8 pediatric beds and 14 NICU underway
3 Our Program Provides initial survival skills training and follow up Average of 40 newly diagnosed patients per year 2500 visits per year in the outpatient clinic 450 families presently followed every three months (majority with Type 1)
4 Challenges to Community based Pediatric Diabetes Program Start up challenges Building up a client base Building a solid reputation Part time clinic / Part time staff Infrastructure restrictions (space) Development of policies, procedures and medical directives to support all areas of program Provision of 24/7 on call support without tertiary care resources (i.e. residents, fellows) Documentation of on call support Specialized training program for pediatric nurses We have overcome most of these challenges
5 Ongoing challenges Ongoing training and specialized education to emergency department (physicians, nurses) Continuing education and maintaining current, evidence based practice Increased time demands associated with technology advances (pump s, CGSM, downloading meters, research, new insulin analogs and therapy options) Building nursing confidence in the provision of survival skills training Lack of space Maintaining primary centered care with large volumes Trends relating to decreased age at time of diagnosis
6 Multidisciplinary Team approach Pediatric Endocrinologist Pediatricians Diabetes Nurse Educators Registered Dietitian Social Worker Child Life Specialist Inpatient registered nurses
7 Benefits of the Program Multidisciplinary focus Convenience of community based care: Promotes family attending appointments together Promotes continuity of care Initial survival education and all follow up is provided in the same location by the same team improves compliance with regular clinic visits and follow up.
8 Program Design 1. 3 Day education program for newly diagnosed children and families provided in our Pediatric Diabetes Day Unit (PDDU) 2. Follow up education / support in the pediatric outpatient diabetes clinic 3. 24/7 on call service for support, illness management, and emergencies 4. Special programs Pumps and sensor education and follow up Lean on me adolescent support program elementary school education High risk follow up (regular phone support and participation in at risk youth retreat support system Transition program 5. Research opportunities
9 Lean on Me
10 Pediatric Diabetes Day Unit (PDDU) Patient arrives after being referred by local pediatrician, GP, or emergency department Patient arrives before breakfast Patient goes home after dinner with phone numbers to call for support Survival skills training for 3 consecutive days Program is individualized to meet each families needs (may need less time or more )
11 Survival Skills Training Provided by pediatric RN s on the unit Basic anatomy and physiology of glucose metabolism and diabetes Blood glucose testing Administration of insulin Hypoglycemia and hyperglycemia (signs and symptoms) Dietary considerations Urine ketone testing
12 PDDU continued Provision of emotional support Child life specialist provides age appropriate activities and distraction as needed Social Worker makes initial contact Registered Nurses on the inpatient unit as well as the diabetes team provide encouragement, support and answer questions as they arise.
13 Painted ceiling tiles
14 Family Resources Families are given an information support package upon arrival to the PDDU which includes: Book When your child has diabetes Handbook on what to expect during their PDDU stay Handout on frequently asked questions regarding diet and diabetes References on hypoglycemia and hyperglycemia Phone contacts for support JDRF phone numbers to contact for mentoring support Teaching doll and cart with supplies including insulin, syringes, needles, lancets, etc are provided for practice
15 PDDU Teaching Cart
16 Teaching cart
17 Teaching supplies on cart
18 Pediatric Diabetes Clinic Team members have already connected with the patient and family in the PDDU Follow up appointments (usually 3 based on need) occur in the 2 weeks following PDDU program Child and family will then be seen every 3 months until the age of 18 Transition to adult care, using the transition guide, starts at 16 with specialized focused education (e.g.. smoking, university, alcohol, sex).
19 Clinic Waiting Room
20 Clinic
21 Diabetes Educator
22 Endocrinologist
23 Dietitian
24 On going education and support provided in Diabetes Clinic 3 one hour sessions with the pediatric diabetes nurse educator (over 3 visits) 3 one hour sessions with the registered dietician (over 3 visits) One hour with social worker and more if required One month follow up visit with the full multidisciplinary team
25 Communication For non urgent concerns only Patients are encouraged to insulin dose adjustment questions Patients are given an information package Consent is signed s are answered daily information is scanned to the electronic record
26 24/7 on call support Diabetes nurses take shared call to 2200 hrs and endocrinologist is on call over night Urgent calls, illness management, newly diagnosed questions Already established medical directives utilized Advice provided as per reinforcement of teaching Documentation occurs at time of the phone call through blackberry to hospital designated for diabetes Blackberry is password protected documentation is printed off and registered as telephone visit is scanned to the electronic record and becomes part of the chart
27 Technology benefits Use of and blackberry for communication: Reduces ER visits Reduces adverse events through consistent management of diabetes by diabetes experts Increases patient satisfaction with care (reassured that support is always available) Real time contact with patients as issues arise Real time communication with MDT re: patient updates Convenience for staff taking frequent call Improves compliance with documentation which is more timely and complete Risks mitigated through information package given to parents, consent to use signed by family Policy developed for communication to support the program
28 Education of Inpatient Nurses Pediatric Diabetes Education Day (6 hrs) Facilitated by professional practice leader (PPL) Assigned pre reading When Your Child has Diabetes Taught by pediatric diabetes educators, registered dietitian, social worker, and PPL Combination of theory, hands on learning and case studies Educational resources provided to nurses Diabetes Resource Binder is available on the unit for reinforcement
29 Nursing Education Theory Healthy glucose metabolism, Pathophysiology of Type 1 Diabetes Hypoglycemia, signs and symptoms Long term effects of hyperglycemia Ketoacidosis Insulin therapy Dietary implications Management of illness
30 Nursing Education, continued Hands on Activities Blood glucose testing using a variety of glucometers Preparation of Insulin Site selection and rotation Insulin injections
31 Learning Package When staff attend the workshop they are provided with handouts and materials for ongoing reference: Day 1, 2, 3: step by step curriculum and sequence of care Injection site information including site selection and rotation Copy of the PowerPoint presentation Hypoglycemia/hyperglycemia hand out Glucose ranges and types of insulin PDDU education cart with contents outline ER Type 1 Diabetes Management Guidelines Documentation of care and teaching
32 Philosophy Although education is standardized, we approach each family individually Assessment of family s emotional needs and readiness to learn is completed prior to education Communication to the team regarding deviations from standardized education is key to providing patient centered care Collaboration with outpatient clinic is maximized so that any learning needs are identified and addressed in follow up
33 Goal: Happy Patients
34 Ongoing Improvement: Next Steps Continue to prioritize primary care Continue to keep abreast of current technological advances in diabetes management Enhance social media as a method of communication and information Build in regular reinforcement of teaching for staff in PDDU and ED
35 Questions
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