Summary
Carbohydrate counting is an effective skill and tool used to optimise the management of blood glucose in type 1 diabetes. The Paediatric Diabetes Team at Southport and Ormskirk NHS Trust developed a 360 degree approach to education for health care professionals, carers, children and young people with the condition. Joint drop-in specialist nurse and diabetes dietitian clinics were set up weekly, dietitian home visits and school visits were initiated, and large group carbohydrate counting education workshops were implemented. After the initiatives, it was demonstrated that MDI regimen with carbohydrate counting education can be initiated at the point of diagnosis by competent ward staff. Surveys showed that patient/carer and staff knowledge and their confidence were significantly improved.
Results
Prior to the carbohydrate education, staff knowledge was demonstrated at an average of 42% on baseline scores. This rose to 91% following the rolling carbohydrate education programme. Patient and carer knowledge of carbohydrate counting was also improved with an overall satisfaction of 98% from 138 completed questionnaires. In addition, following the carbohydrate education programme for patients and carers, the annual surveys from 2012-2104 consistently showed:
- 127 out of 138 ( 92%) of participants met their goals in the programme
- 136/138 (98%) of participants feel they benefitted from attending the course
- Average HbA1c levels fell consistently for the last 3 years (mean 8.2% from 9.2% in 2012)
Challenge
Understanding about MDI regimen and how to match insulin dose to the amount of carbohydrate eaten is an important aspect to ensure optimal diabetes management. Carbohydrate counting is a dietary management in diabetes that is currently a source of concern with many diabetes units relying solely on the local diabetes dietitian in providing patients and carers with adequate knowledge and education. This has resulted in delays in appropriate MDI management. In 2010, a survey showed that baseline knowledge and confidence of healthcare professionals in carbohydrate counting education and their confidence in implementation carbohydrate counting in the wards were demonstrated to be very poor. To date, many units do not establish carbohydrate counting in the wards due to lack of knowledge, and education is only implemented by the dietitian weeks after diagnosis.
Objectives
It was important that all healthcare staff, patients and carers had access to teaching materials and understood basic carbohydrate portion guides, practical estimation of foods, interpretation of carbohydrate values on food packets and calculation of carbohydrate in recipes. The team ensured that the following objectives were fulfilled at the end of the carbohydrate counting programme for all healthcare professionals, patients and their carers:
- Understanding of target blood glucose levels
- Ability to apply all aspects of basic carbohydrate counting
- Understanding of the action of insulin and the basal-bolus insulin concept
- Ability to carry out pattern management
- Understanding good nutrition and how diabetes can affect health, and what they can do to stay healthy
Solution
The Paediatric Diabetes Team at Southport and Ormskirk NHS Trust developed a rolling education programme to tackle the staff’s need for proper training on carbohydrate counting and nutritional advice in diabetes. Joint drop-in specialist nurse and diabetes dietitian clinics were set up weekly, and an individualised education programme involving dietitian home visits and school visits were initiated. In addition large group carbohydrate counting education workshop days were implemented annually. Specifically designed to introduce the principles of carbohydrate counting and insulin dose adjustment, basic carbohydrate counting approach, assessing education level, ability to perform basic math and conception of portion control, the team led by the dietitian developed a series of in-house teaching booklets such as:
- Basic Carbohydrate Counting Approach
- Carbohydrate Tables
- Insulin pump bolus doses for carbohydrate
- Carb-free snack ideas
- Nutritional Advice
- Glycaemic Index
- Sweeteners
Teaching materials were also given at the point of diagnosis to all newly-diagnosed patients. The team established joint drop-in specialist nurse and diabetes dietitian clinics weekly, and an individualised education programme involving dietitian home visits and school visits were initiated. In addition large group carbohydrate counting education workshops were implemented annually. To address the staff education, the team with the support of ward managers, clinical director and matron, incorporated carbohydrate counting and diabetes education to healthcare professionals on the mandatory paediatric education days each month and developed a rolling teaching programme.
Learnings
This is a 360-degree approach to carbohydrate counting, developed to tackle an area identified nationally as a source of concern both in adult and paediatric diabetes. It is a unique approach but yet easily transferable to other teams and organisations to ensure that the quality of care in managing diabetes is improved. Every patient diagnosed deserves to have optimal management of their diabetes from the point of diagnosis and carbohydrate counting is an important aspect of that journey towards optimal control.
Evaluation
A staff knowledge assessment based on a questionnaire completed by 142 health care professionals.
