GUIDANCE ON MANAGEMENT OF CHILDREN AND ADOLESCENTS WITH NEWLY DIAGNOSED TYPE 1 DIABETES

Transcription

1 GUIDANCE ON MANAGEMENT OF CHILDREN AND ADOLESCENTS WITH NEWLY DIAGNOSED TYPE 1 DIABETES This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION This guideline is aimed at giving consistent treatment and care to children, young people and their families on the diagnosis of diabetes through a multi disciplinary team approach This guidance is for use by the paediatric medical staff on site at the Worcestershire Royal Hospital, Kidderminster Hospital and the Alexandra Hospital, the Paediatric Diabetes Nurses, Acute Paediatric Nurses and Orchard Service across the County. The patients covered by the guideline are children and young people who have been newly diagnosed with Type 1 diabetes across Worcestershire County. See also DKA in children WAHT-PAE-037. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: Paediatric Medical Staff, Paediatric Diabetes Nurse, Orchard Service Nurse with appropriate qualification or experience, Dietician. Dr N Ahmad Dr J Scanlon Diane Cluley Esther Anstey Victoria Howard Jane Francis Tracey Kirkwood Lead Clinician(s) Consultant Paediatrician Consultant Paediatrician Approved by Paediatric Clinical Improvement Committee: 19 September 2007 Approved by Medicines Safety Committee on: Extension approved by Trust Management Committee on: 25 September July 2015 This guideline should not be used after end of: 1 August 2016 WAHT-PAE-063 Page 1 of 10 Version 4.1

2 Key amendments to this guideline Date Amendment Approved by: (name of committee or accountable director) No amendments made to guideline Dr N Ahmad Changes of personnel (retirement of Dr Frost and Dr J E Scanlon appointment of additional Paediatric Diabetes Specialist Nurses and Dieticians The use of NovoPen Echo devices as the standard pens for use with Novo products Move to using basal bolus regime for all ages (which will include Levemir/Detemir insulin for the younger children) Re-approved Paediatric CG meeting 22 nd February Document extended for 3 months Dr A Gallagher Document extended for 12 months as per TMC paper approved on 22 nd July 2015 TMC WAHT-PAE-063 Page 2 of 10 Version 4.1

3 GUIDANCE ON MANAGEMENT OF CHILDREN AND ADOLESCENTS WITH NEWLY DIAGNOSED TYPE 1 DIABETES INTRODUCTION This guideline is aimed at giving consistent treatment and care to children, young people and their families on the diagnosis of diabetes through a multi disciplinary team approach This guidance is for use by the paediatric medical staff on site at the Worcestershire Royal Hospital, Kidderminster Hospital and the Alexandra Hospital, the Paediatric Diabetes Nurses, Acute Paediatric Nurses and Orchard Service across the County. The teams are as follows: Kidderminster Consultant Dr J Scanlon Radio Page/Switchboard to contact PDSN Victoria Howard/ Tracey Kirkwood Mobile Orchard Service Kidderminster Mobile Dietician Dorota Amador Bueno Redditch Consultant Dr N Ahmad Radio Page/Switchboard to contact PDSN Diane Cluley/ Tracey Kirkwood Mobile Orchard Service Redditch Ext Mobile Dietician Dorota Amador Bueno Worcester Consultant Dr J Scanlon PDSN Esther Anstey/ Jane Francis Mobile Orchard Service Worcester Mobile Dietician Sue Savin (additional dieticians who are occasionally involved include Naline Owen and Saimah Khalid) WAHT-PAE-063 Page 3 of 10 Version 4.1

4 GUIDELINE SEE FLOWCHART FOR MANAGEMENT OF NEWLY DIAGNOSED TYPE 1 DIABETES IN CHILDREN AND ADOLESCENTS - APPENDIX 1 Consultant Paediatrician (Dr Scanlon or Dr Ahmad) needs to be informed of all newly diagnosed children and young adults with Type I insulin dependent diabetes mellitus within 24 hours (even if they are not the consultant on-call) Initial Investigations Should include: Blood gases if clinically required (venous or capillary samples are often adequate) Laboratory blood glucose to confirm diagnosis Urea and Electrolytes Full blood count Coeliac Screen Thyroid Function Tests Thyroid auto antibody screen Islet Cell Antibodies and anti GAD antibodies HbA1c (For future audit) If diabetic ketoacidosis (DKA) is confirmed (i.e.: ph <7.3 and/or bicarbonate less than 15mmols/l with ketonuria or elevated blood ketones) then the existing guidelines for management of DKA should be used (British Society for Paediatric Endocrinology and Diabetes 2010, which are also the recommended DKA Guidelines - the management of diabetic ketoacidosis). Some children may be admitted with nausea and vomiting but not in DKA. They may need to be treated along the DKA guideline. If in DKA notify, the duty consultant immediately. If the child is clinically well and: 1. Blood glucose 30mmol/l or above. The child should have their 1 st subcutaneous insulin dose on the same day. They should remain an in-patient as they are on the verge of ketoacidosis. See below for suggested doses. Careful attention to their fluid balance may also be required. 2. Blood glucose between 15 29mmol/l. These children can start their treatment in hospital that day if they wish, or the next day after a night at home. If the children are under 9 they should be given NovoRapid/Aspart insulin at each main meal and Levemir/Detemir insulin at night. If they are above 9 years of age they should be given NovoRapid/Aspart insulin at each main meal and Lantus/Glargine insulin at night. 3. Blood glucose up to 14mmol/l. The diagnosis of diabetes needs to be questioned. The start of treatment is NOT urgent. WAHT-PAE-063 Page 4 of 10 Version 4.1

5 Starting Insulin under 1 year For a child under the age of one year, advice should be sought from the local Paediatric Consultant with an interest in diabetes, or from the on-call consultant at Birmingham Children s Hospital Starting Insulin 1 8 years The normal starting dose of insulin is 0.5units/kg as a total daily dose. 40% of this dose is required as analogue long acting insulin Levemir/Detemir and the remaining 60% should be given as the rapid acting analogue NovoRapid/Aspart insulin which is divided into 3 to be given before each main meal. NovoRapid/Aspart insulin can be given immediately prior to a meal or up to 15 minutes after a meal. Both injections will be given in the form of cartridges delivered via a NovoPen Echo device. Starting Insulin 9 years and over The normal starting dose of insulin is 0.5units/kg as a total daily dose. 40% of this dose is required as analogue long acting insulin Lantus/Glargine insulin, delivered via a SoloStar disposable insulin pen device (initially given at teatime) and the remaining 60% should be given as the rapid acting analogue NovoRapid/Aspart insulin which is divided into 3 to be given before each main meal. NovoRapid/Aspart insulin can be given immediately prior to a meal or up to 15 minutes after a meal, injections will be given in the form of cartridges delivered via a NovoPen Echo device. Perfect control of blood sugars is not something that we should be aiming for in the first day or two after the child has started insulin. We will try and achieve good control of the child s diabetes over the next few weeks. The local paediatric dietitian should be contacted to be informed of the newly diagnosed child/young person (they will be seen within 7 working days). If they are unavailable there is a leaflet entitled Healthy Eating with Diabetes, Initial Advice for young people with diabetes within the discharge information pack given by ward staff. The principles of healthy eating apply with more care required over timing of regular meals and snacks that include starchy carbohydrates. Water, sugar free/no added sugar drinks should be chosen. This advice is appropriate until the dietitian can see them and discuss the diet in more detail. If the PDSN or Orchard service is to support at home, it is impractical to make three visits in one day. It is therefore planned that the child will receive support for the NovoRapid injection pre/post breakfast and for the pre/post tea NovoRapid injection and the Lantus injection given at the same time but in different injection sites. The lunch time NovoRapid dose will be omitted until the child/family are competent and confident in self injecting which usually occurs within 1-3 days after diagnosis. All families, children and young people using a basal bolus insulin regimen will be taught to carbohydrate count in due course. The dietary leaflet A Guide to diet and basal bolus injection regime with Type I diabetes will be used by the dietician and the multi-disciplinary team to educate on the principals of the basal bolus regime. Hospital or Home Treatment? Before any decision is made, the Paediatric, Orchard Service, Dietician and the Paediatric Diabetes Consultant should be contacted to inform of the newly WAHT-PAE-063 Page 5 of 10 Version 4.1

6 diagnosed child/young person. This is to ascertain availability of support in the community and to assess the abilities and concerns of the parents/family to ensure a safe discharge. If well enough to go home, consider coming back to the ward the following morning to start insulin treatment as setting up Orchard service support may take 24 hours. On Discharge Ensure all parties above have been informed. Ensure the child/young person and family are confident to go home. Ensure there is appropriate or adequate community support. Appropriate TTO s are prescribed on paediatric newly diagnosed diabetes prescription sheet. In addition from the ward supply, irrespective of whether the pen devices (NovoPens or SoloStar disposable pens) are supplied by the pharmacy, ward staff or Orchard Team we need to make sure that they have appropriate supplies. Follow up arrangements have been made. Discharge letter to GP MONITORING TOOL How will monitoring be carried out? Audit will be carried out every 2-3 years to assess compliance with this guidance. Who will monitor compliance with the guideline? Paediatric Clinical Governance Committee STANDARDS % CLINICAL EXCEPTIONS All patients should be managed this way! 100 Patients transferred from other trusts. REFERENCES British Society for Paediatric Endocrinology and Diabetes (BSPED) (2010) Recommended DKA Guidelines for the management of diabetic ketoacidosis. London NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE) (2004) Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people. NICE clinical Guideline Number 15. London, National Institute for Clinical Excellence WILLIAMS M, AMIN R, SAUKKONEN T, DUNGER D (2003) Recent Advances in diabetes mellitus. Current Paediatrics 13, Leaflets used: A guide to diet and a basal bolus insulin regimen with Type 1 diabetes. Worcestershire Acute Hospitals NHS Trust Healthy Eating For Children with Type 1 Diabetes. Worcestershire Acute Hospitals NHS Trust Healthy Eating with Diabetes, Initial advice for young people with diabetes Worcestershire Acute Hospitals NHS Trust WAHT-PAE-063 Page 6 of 10 Version 4.1

7 APPENDIX 1 - MANAGEMENT OF NEWLY DIAGNOSED TYPE 1 DIABETES IN CHILDREN AND ADOLESCENTS Suspected Diagnosis of Type 1 Diabetes Investigations Blood gases if clinically required Serum glucose U&Es FBC Coelaic Screen Thyroid Function screen Thyroid Function Tests Thyroid antibody Screen Islet Cell Antibodies and anti GAD antibodies HbA1c DKA confirmed (i.e.: ph 7.3 & / or bicarbonate less than 15mmol/l with ketonuria 3-4+) Follow BSPED Guidelines NB: The child who is vomiting should be treated as per DKA Guidelines. Blood glucose 30mmol/l & over Start treatment as an inpatient. Start treatment the same day. Careful attention to fluid balance. Blood glucose 15-29mmol/l, clinically stable Regimens can be started the next day if more convenient. Under 1 year Contact Consultant regarding specific treatment 1 8 years Start basal bolus regime. Bolus NovoRapid/Aspart insulin Basal - Levemir/Detemir insulin 9 years and over Start basal bolus regimen Basal insulin Glargine Bolus meal doses - NovoRapid Blood Glucose up to 14mmol/l Question diagnosis, start of treatment not urgent. 9 years and over Under 1 year Advice from consultant Under 9 years 0.5 units/kg as total daily dose. 40% as Levemir/Detemir insulin delivered via NovoPen Echo 20% at each main meal as NovoRapid/Aspart insulin or up to 15 minutes after food, also delivered via NovoPen Echo. Ideal blood sugars are not an initial aim 0.5 units/kg as a total daily dose. 40% as Lantus/Glargine via SoloStar disposable pen device 20% at each main meal involving NovoRapid or up to 15 minutes afterwards via NovoPen Echo pen device Ideal blood sugars are not an initial aim No: Hospital Management Yes: Home Management Initial Hospital or Home Treatment? Assess families needs. Check availability of Community support: PDSN or Orchard Service On Discharge Inform all interested parties: Consultant, PDSN/Orchard Service and Dietitian Ensure community support in place Ensure family confident to go home Discharge TTO s see special prescription sheet on ward: NovoRapid Insulin 3ml penfill cartridges, Levemir 3 ml penfill cartridges or Lantus SoloStar disposable pen, BD+ Lancets, BD microfine + 5mm pen needles, Optium Freestyle blood glucose test strips box 10, Glucagon 1mg kit, Glucogel 1 box x 3 tubes, dextrose tablets, Safeclip Additional supplies from ward: NovoPen Echo devices as appropriate. Exceed Blood glucose meter and Sharps Box Information starter pack including Healthy Eating with Diabetes, Initial advice for Young People with Diabetes leaflet. Follow up arranged Discharge letter to GP WAHT-PAE-063 Page 7 of 10 Version 4.1

8 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Dr N Ahmad Consultant Paediatrician Dr J Scanlon Consultant Paediatrician Diane Cluley Paediatric Victoria Howard Paediatric Esther Anstey Paediatric Tracey Kirkwood Paediatric Jane Francis Paediatric Circulated to the following individuals for comments Name Designation Nalinee Owen Lead Dietician Sue Savin/Doroto Bueno/Saimah Khalid Dietician Sue Dickinson Dietician S Court Manager Orchard Service Orchard Service Worcestershire Royal Hospital Orchard Service Alexandra Hospital Orchard Service Kidderminster Hospital Dr Jenkins Consultant Endocrinologist Dr Babar Consultant Endocrinologist Dr Newrick Consultant Endocrinologist All Other Consultant Paediatricians H O Gorman B Jeans W Butters E Innes S King A Hall L Gilbert D Edwards A McCarthy Diabetes Education Facilitator S Rogers S Lisseman Dana Picken Matron Lara Greenway Ward Manager Ward 1 Alex Nell Pegg Ward Manager Riverbank Ward Sarah Scott Clinical Pharmacist Circulated to the chair of the following committee s / groups for comments Name Committee / group Alison Smith Medicines Safety Committee WAHT-PAE-063 Page 8 of 10 Version 4.1

9 Supporting Document 1 Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed. A completed checklist will need to be returned with the document before it can be published on the intranet. For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included. 1 Type of document Guideline 2 Title of document Management of children and adolescents with newly diagnosed type 1 diabetes 3 Is this a new document? Yes No If no, what is the reference number WAHT-PAE For existing documents, have you included and completed the key amendments box? Yes 5 Owning department Paediatrics 6 Clinical lead/s Dr J E Scanlon/Dr N Ahmad D Cluley. E Anstey, V Howard, J Francis T Kirkwood PDSN s 7 Pharmacist name (required if medication is involved) 8 Has all mandatory content been included (see relevant document template) 9 If this is a new document have properly completed Equality Impact and Financial Assessments been included? 10 Please describe the consultation that has been carried out for this document 11 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this document relates to. No Sarah Scott Yes Yes N/A No No Agreed initially by the Countywide Paediatric Diabetes Team. Circulated to individuals on contribution list and members of the Paediatric Clinical Governance Committee Management of children and adolescents with newly diagnosed type 1 diabetes Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval. WAHT-PAE-063 Page 9 of 10 Version 4.1

10 Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented Action Person responsible Timescale 1 Presentation to Clinical Governance, Paediatric Clinical Governance Committee Dr J E Scanlon Dr N Ahmad 2 Updates and the use of different insulin pens already briefed to junior medical staff and ward/orchard Services nurses and on-going education to Riverbank ward staff Dr J E Scanlon Dr N Ahmad 3 New pen devices (NovoPen Echo pens) will be ordered for routine use on the ward and change of ward stock Ward Manager and Paediatric Pharmacist Plan for dissemination Disseminated to Orchard Service, Ward staff, all paediatric medical staff and A&E departments on both sites. Date May Step 1 To be completed by Clinical Governance Department Is the document in the correct format? Yes No Has all mandatory content been included? Yes No Date form returned 2 Name of the approving body (person or committee/s) 09/05/2013 Paediatric Clinical Governance Committee Step 2 To be completed by Committee Chair/ Accountable Director 3 Approved by (Name of Chair/ Accountable Director): Dr Andrew Short 4 Approval date 22 nd February 2013 Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided (or approval from accountable director in the case of minor amendments). Office use only Reference Number Date form received Date document Version No. published WAHT-PAE /05/ /05/ WAHT-PAE-063 Page 10 of 10 Version 4.1