In order to continue supporting and educating its children and young people during the pandemic, the CHFT paediatric diabetes team analysed every process for patients and considered how to deliver it virtually. Every method of communication was used, including social media and DigiBete, to provide patients with upto-date advice, support and guidance. Virtual clinics were set up using Microsoft Teams to ensure patients could be seen safely. Despite 50% of the nursing workforce being redeployed internally, the transition to virtual diabetes management was successful.
Viewing glucose data is an essential aspect of the Paediatric Diabetes Specialist Nurse (PDSN) role, identifying patterns and variability in glucose levels, enabling insulin adjustments and improved glycaemic control. This had been done at a clinic appointment using the children and young people’s (CYP) glucose meter and downloading the data onto the diabetes management platform Diasend. For optimum overview of glucose data, weekly downloads were recommended. During the consultation the PDSN/family would review and discuss the downloaded data together, empowering the CYP/family to become part of their diabetes care. Preparing for the virtual clinic and pursuing CYP for their glucose data were time-consuming, but more CYP downloading data greatly improved their diabetes management. Every CYP was called to make sure they and the family knew their sick day advice and when to call for assistance. Being ill can affect diabetes management and it is imperative to provide clear guidance. In addition, they were asked to know their total daily dose; the amount of long-acting insulin plus meal time insulin, and advised extra insulin if ketones were present.
Equality, Diversity and Variation
During the pandemic, it was important that families could download at home via Diasend (and other packages) to keep communication going, enabling safe interventions and accurate clinical advice. However, without proactive interventions, some families would not have been able to access this option, leading to poor outcomes and, in some circumstances, a serious safeguarding issue. Pre-COVID-19, downloading in clinic had always been done for them on arrival, prior to their consultation. Between clinic appointments there had also been the safety net of school visiting to download meters in the community, or in the homes of the most vulnerable patients. A number of CYP live in socially deprived areas, in low income families, some with English as a second language. Not all families had access to a laptop some would find it challenging to install the software and order equipment from the meter suppliers. Schools were asked to support vulnerable families by providing loan laptops and installing the appropriate software drivers on to their school laptops, so low income families could download at home. Medical Welfare Staff in schools were given access to the cloud-based downloading packages, so they could upload the data for the team, while the child was in school. Five senior schools did this, with information provided to their IT departments and working via email and MS Teams to train the school staff. Schools were asked to provide loan home learning laptops so the patients’ families could be helped to do this themselves at home. In cases where English was a second language, the team called the pump/meter supplier to have dongles posted direct to the patient. Replacement cables were ordered for those patients who had “lost” the original ones, to ensure all patients had equal access.
A lower DNA rate for clinics resulted in a more cost effective service. Virtual working brought cost savings, with staff seeing more patients with less travel and time restraints. Follow-ups were more frequent, resulting in a fall in rate of admissions to the children’s ward. As the lockdown eased, annual review clinics were separated to ensure that the seven key health checks for CYP with diabetes were being met. Around 20-25% of patients were home downloading pre-pandemic, but 80-85% are home downloading now. In 2019-2020 the percentage for sick day rules was 51%, but during the pandemic, this reached 99%. In the Nursing Times awards the initiative was a fi nalist in the children’s service category.
Dissemination and Sustainability
In order to access CYP blood glucose readings, all CYP/families were called and helped to download their data at home via the sharing platform Diasend. The calls were made by the Diabetes Specialist Nurse (DSN), patient advocate or dietician. The CYP/family were given a telephone number to request a Real Tyme download cable. The team member explained that the cable would enable the CYP to share their blood glucose data, enabling the DSN to review blood glucose readings and make relevant changes. In order to optimise CYP glycaemic control it is essential to monitor their Hba1c level. This would normally have been done at a face-to-face clinic appointment. To overcome this issue the team developed the Hba1c drive-thru initiative, using the Standard Operating Procedure (SOP). Using SOP meant that other teams had a clear process to follow should they wish to replicate it. Information about the drive-thru was sent out to CYP/families via parent mail and the Facebook page, informing them of the time, date, place and contact number to make an appointment. Giving families new and sustainable ways to share and review blood glucose data and obtain a Hba1c result empowered them to optimise their diabetes management.
User feedback was gathered from Facebook, Twitter, parent mail, DigiBete, surveys and discussion groups. Suggestions for improvements were requested via social media. Patients indicated they wanted their long range results so social media was consulted on how this should look. A ‘drive-thru’ Hba1c service was set up, where patients were given a five-minute window for a point-of-care Hba1c check. Nearly half the CHFT paediatric diabetes team caseload was seen in one day. A quality improvement programme was established for the transition service at CHFT. Current and previous transition patients were invited to make suggestions. Social media was used to engage with families, spreading messages of positivity and hope.
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