Summary
This project was concerned with using multiple quality improvement initiatives simultaneously to drive improvements in HbA1c. The project achieved its aim with an 8mmol/mol improvement in the clinic median HbA1c over one year. It was also well received with positive patient/parental experience about the impact of the new initiatives and changes. This project is sustainable within its own centre and can undergo continuous evaluation and enhancement. It is also transferable to other centres or used in partnership across networks.
Innovation
This approach is novel to paediatric diabetes care in Wales and has been adapted from that used in a QI collaboration in Sweden which had demonstrated improvement. It utilised the concept of multiple themes which feed into an ultimate goal of reducing HbA1c, improving quality of life and reducing the burden placed on families and the NHS on chronic disease management.
Results
There were dramatic improvements in HbA1c results (median Hba1c fallen from 72mmol/mol in 2014/15 to 64mmol/mol 2015/16) for children and young people with diabetes cared for at the Children’s Hospital for Wales. During the first 12 months of the post, 160 school visits were undertaken through which 800 face-to-face contacts were made with school staff. Qualitative data collected from school staff and parents regarding the support provided by the educator demonstrate high levels of satisfaction with the service. A peer support day was held for children (aged ~11) and parents who were soon to be transitioning to high school. A service evaluation taken six months later demonstrated that 100% of those who participated would recommend the training day to a friend. The HbA1c improvements seen (8mmol/mol reduction) have reduced the risk of life-threatening complications by at least 32% (based on DCCT extrapolation). This improvement not only reduces the burden of disease on the child and his or her family improving quality of life, but also reduces long-term costs to the NHS by reducing expensive treatments for complications. NHS costs in Wales for diabetes are estimated at £500 million per annum with 80% of those costs related to complications.
Dissemination and Sustainability
The project is completely sustainable as it follows the principles of PDSA quality improvement. The success of the programme hinges on constant new ideas and quality improvement initiatives to drive the endpoint: each project goes through a continuous PDSA cycle to ensure it is effective and worth pursuing. It is easily reproducible. It can be used in a similar manner to us where a single centre has derived a fishbone structure to drive an outcome, but it can also be used as a quality improvement collaboration involving multiple centres and networks.
Method
The paediatric diabetes healthcare team at the Children’s Hospital for Wales care for ~200 children and young people with type 1 diabetes and were concerned that, despite providing the best quality care possible, the outcomes were suboptimal compared to other centres in Wales and England. The National Paediatric Diabetes Audit (NPDA) 2014/15 demonstrated the Cardiff & Vale University Health Board to be an extreme negative outlier for blood glucose control (HbA1c). Through invited external peer review (2014) we identified several serious concerns which were hindering change and improvement. These included: lack of psychological support, inadequate dietetic support and lack of continuing professional development for members of the team. Through business planning we were able to justify employment of an extra PDSN, Schools Educator, Psychologist and Dietician to be compliant with the shortfalls. A ‘fishbone’ initiative was drawn up to focus the new team on projects that could potentially improve outcomes and influence quality of life in children with diabetes and their families. This additional support has permitted restructuring of the multidisciplinary team to allow appointing one PDSN as a team leader to manage the service, a specialist PDSN for diabetes school education, a PDSN taking the lead in structured education and a PDSN taking the lead in transition to adult care. Furthermore, new dietetic support has permitted increased emphasis on dietary management. This restructuring has allowed several QI initiatives to progress in keeping with our fishbone concept, such as carbohydrate counting for all newly diagnosed children, enhancing the family’s knowledge of matching insulin injections to diet; intensified insulin management at diagnosis with the introduction of a new care pathway for the newly diagnosed patients; and point of care HbA1c testing made available in 2015 - greatly enhancing clinic consultations as we are able to provide instant results influencing advice provided during patient appointments. Other measures included: increasing clinic capacity to offer four appointments of 30 minutes duration per child/per year; a virtual clinic where the MDT review blood glucose profiles downloaded at home (using Diasend) by families and discuss treatment changes by telephone or via email, saving having to attend the hospital for additional appointments; and extra support for those with high HbA1c providing a targeted structured approach to help improve diabetes control. There was also the implementation of a quality assured (all Wales) structured education programme for patients from diagnosis, and peer support by running activity days for children with diabetes and staff ‘awaydays’ to foster ongoing relationships and team building.
