Ambulatory Stabilisation Program for Newly Diagnosed Children and Adolescents with Diabetes (DDCP)

The Children's Hospital at Westmead

This project was entered in the Baxter 2006 NSW Health Awards, Effectiveness of Health Care category

Contact: Catherine Kay

Abstract

Type 1 diabetes is a complex chronic disease with acute and chronic complications capable of leading to urgent and unplanned admissions. Prior to November 2000, virtually all newly diagnosed children and adolescents with type1diabetes in NSW were admitted to hospital.

The Children’s Hospital at Westmead (CHW) was awarded funding under the NSW Health Priority Health Care program (PHCP) to implement a model of ambulatory stabilisation, known as the Diabetes Ambulatory Care Program.  The program, now known as Diabetes Day Care Program (DDCP) is a hospital based model of ambulatory stabilisation in which the child and family travels to CHW Diabetes Centre on a daily basis for the first few days after diagnosis or after early discharge to be provided education and management as outpatients.

This project was conducted in 4 phases over 6 years and was the first ambulatory stabilisation program introduced in a paediatric diabetes centre in Australia.

Aim

Program aims are, preventing hospital admissions, reducing length of stay and providing care for children and young people in the best setting for them which is an ambulatory care model.

Background

Newly diagnosed children with diabetes traditionally receive initial medical management and diabetes education as inpatients with average lengths of stay of up to 7 days.  Although this process leads to a satisfactory outcome in terms of diabetes management and knowledge, it involves significant periods of hospitalisation and disruption to the family.

During the last 10 years, several different models of ambulatory stabilisation have been successfully developed overseas for children and adolescents with newly diagnosed diabetes (Frank & Daneman, 1998).

This model of care will lead to a decrease in length of stay and offer less disruption to the family.

Method

The DDCP involves:

1. Initial assessment - Patients presenting with newly diagnosed diabetes will be assessed in the Emergency Department by the Endocrinology Registrar.

• Clinical assessment, particularly of hydration status and any intercurrent illness
• Estimation of urinary glucose and ketones
• Blood collection for venous pH, glucose and electrolytes, type I diabetes Antibodies, endomysial Antibodies, thyroid Antibodies and ThyroidFunctionTests

2. Diabetes Team Consultation - The registrar will inform the Ambulatory Stabilization Diabetes Nurse Educator (DNE) and Diabetes Consultant on the patient’s arrival and when the initial assessment has been completed. A team decision will be undertaken regarding suitability for ambulatory stabilization.

3. Suitability for ambulatory stabilization - In general ambulatory stabilization will be deemed suitable under the following conditions:

• Absence of moderate or severe dehydration or significant intercurrent illness
• Venous pH > 7.20 and/or serum bicarbonate > 15
• Age > 2 years• Suitable time of day (patient arrives before 4 pm on a weekday; patients arriving after 4 pm may have to stay overnight for practical reasons)
• No adverse psychosocial factors identified
• Family speaks sufficient English
• Travelling time to hospital 45 minutes or less (non-peak hour)
• Family willing and able to travel to hospital for ambulatory program
• DNE and dietician available for initial stabilization/education session

4. Decision stream - On the basis of the above assessment and criteria, patients will be streamed into one of the following:

• Ambulatory Stabilisation Program (no admission or overnight admission)
• Short stay program (short assistance)
• Inpatient program (4-6 days)

In the hospital based model of ambulatory stabilisation, the child and family travels to the paediatric diabetes centre on a daily basis for the first few days undertaking the stabilisation and education as outpatient or day-stay admission. This model has been used in big city centres such as Toronto, Pittsburg and Denver. (Frank & Daneman, 1998; Swift et al, 1993; Chase et al, 1992)

Two US studies have reported significant cost savings, the average cost of 3–5 day hospital stay reduced from $US 2,500 – 3000 per patient to $US 600 for outpatient management. (Chase et al, 1992)

Planning and Implementation

The planned objectives for the project were to:

• Develop and evaluate an ambulatory stabilisation program for children and teenagers with newly diagnosed diabetes.
• Enhance human resources at the Diabetes Centre, The Children’s Hospital at Westmead to allow an ambulatory stabilization program
• Develop a facility for ambulatory care

The NSW Health PHCP grant provided funding for a dietician and a social worker whilst the hospital provided 1.6 FTE of nurse educators.  The Diabetes Clinical Nurse Consultant and an endocrinologist spent a week at the Toronto Children’s Hospital (Canada) centre to observe and develop skills and knowledge on how the ambulatory stabilisation program was structured and managed in order to implement a similar model at CHW. 

The hospital has been very supportive in implementing this model of care.  4 ward beds were closed to accommodate this new program and to provide the program facility.  The DDCP also received some donations from the community to provide the day care furniture, furnishings, toys and educational materials for the children whilst in the day-care program.

The program has provided an exciting new model for the initial management and education of children and adolescents diagnosed with Type 1 diabetes in Western Sydney.

Outcomes and Evaluation

Outcomes for the DDCP include:

• significant reduction in hospitalisation for majority of newly diagnosed children and no hospitalisation for some;
• reduced average length of stay (ALOS);
• initial stabilisation and education in family environment with support from the health care team;
• diabetes educator, dietitian, social worker and paediatric endocrinologist;
• rapid return to normal activity eg school;
• comparable metabolic outcome and frequency of readmissions as traditional inpatient management; (Srinivasan, 2004)
• freed up hospital beds for other patients; and
• reduced the costs of treating these patients in a hospital.

The ALOS for children diagnosed with diabetes in the six months prior to the introduction of the day care program was 5.14 days. There was significant reduction in ALOS since the program was introduced as shown below:

*The DDCP has also reduced the in-patient LOS, as once stabilised, patients are discharged and followed up the next day at DDCP.

Future Scope

With increasing incidence of Type 1 diabetes (Taplin, 2005) the DDCP will ensure

• a more appropriate and cost effective way to manage the increasing numbers of children with Type 1 diabetes,
• offer an ambulatory care model,
• frees up beds for acute and chronic care patients.This model of care is appropriate to other clinical areas across NSW.

References

FRANK M and DANEMAN D.1998. Defining quality of care for children and adolescents with type 1 diabetes. Acta Paediatr ; Suppl 425: 11-19.

SWIFT PG et al. 1993. A decade of diabetes: keeping children out of hospital. BMJ; 307: 96-98.

CHASE HP et al.1992. Outpatient management vs in-hospital management of children with new-onset diabetes. Clinical Pediatrics; 31: 450-6.

SRINIVASAN S et al. 2004. An Ambulatory stabilisation program for children with newly diagnosed type 1 diabetes. Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead. Med J Aust. Mar 15;180(6):277-80

TAPLIN CE et al. 2005. The rising incidence of childhood type 1 diabetes in New South Wales, 1990-2002. Institute of Endocrinology and Diabetes, CHW, Australia. Med J Aust. Sep 5;183(5):243-6