Consulted With Post/Committee/Group Date Alison Cuthbertson / Miss Divisional Director for Women s and Children s June 2017

Transcription

1 CHILDREN AND YOUNG PEOPLE S DIABETES SERVICE OPERATIONAL POLICY Type: Policy Register No: Status: Public Developed in response to: DQUINs peer review Contributes to CQC Outcome number: 1, 4, 6 9 Consulted With Post/Committee/Group Date Alison Cuthbertson / Miss Divisional Director for Women s and Children s June 2017 Rao Melanie Chambers Lead Nurse Children and Young People June 2017 Mel Hodge Senior Sister Phoenix Children s Unit June 2017 Mary Stebbens Clinical Facilitator Paediatrics June 2017 Dr Agrawal Paediatric Consultant June 2017 Dr Cyriac Paediatric Consultant June 2017 Dr Hassan Paediatric Consultant June 2017 Dr Joseph Paediatric Consultant June 2017 Dr Lethaby Paediatric Consultant June 2017 Dr Muthumeenal Paediatric Consultant June 2017 Dr Nambiar Paediatric Consultant June 2017 Dr Ottayil Paediatric Consultant June 2017 Dr Thomas Associate Specialist Paediatrics June 2017 Victoria Machell Clinical Governance Facilitator June 2017 Claire Fitzgerald Paediatric Pharmacist June 2017 Professionally Approved by: Dr Datta Clinical Director Children s Services June 2017 Version Number 2.0 Issuing Directorate Women s & Children s Ratified by: DRAG Chairman s Action Ratified on: 9 th August 2017 Executive Management Board Sign Off Date September 2017 Implementation Date 30 th August 2017 Next Review Date July 2020 Author/Contact for Information Dr Sharon Lim Policy to be followed by (target staff) Children s Diabetes team, Phoenix ward staff, Children s OPD Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction n/a with) Document Review History: Version Number Authored/Reviewed by Active Date 1.0 Dr Sharon Lim May Sarah Moon 30 August

2 Index 1. Purpose 2. Introduction 3. Aims 4. Equality and Diversity 5. Scope 6. Staffing and Training 7. New Referral Flow Chart 8. Responsibilities 9. Key Worker Policy 10. Key Relationships 11. Admission Overview 12. Admission Process 13. Outpatient Environment/Appointments 14. Provision of Written Patient Information 15. Clinical Guidelines / Patient Management 16. Transition of young people to adult care 17. Breach Reporting 18. Audit 19. Contacts and Further Advice 20. References 2

3 1.0 Purpose 1.1 To describe in detail the Children s Diabetes Service provided jointly by MEHT and PROVIDE in Primary and Secondary care. 1.2 To outline the key working relationships between the members of the multidisciplinary team (MDT) to ensure that there is a consistent, coordinated approach to the management and treatment of children and young people diagnosed with diabetes in Mid Essex. 1.3 The Children and Young People Diabetes Team follow and adhere to the standards set out in the Best Practice Tariff for paediatric diabetes, introduced in April The D numbers that are referred to in the headings of this policy reflect the Standards set out in the Best Practice Tariff. 2.0 Introduction 2.1. The Children s Diabetes Multidisciplinary Team is an integrated service (Mid Essex Hospitals NHS Trust and PROVIDE) serving the population of Mid Essex and the surrounding areas. The Children s Diabetes Team in collaboration with the Adult Team delivers inpatient and outpatient diabetes services to 0-19 year olds within a population base of around people across Mid Essex. 2.2 This service is delivered as part of the East of England Children and Young People s Diabetes Network. 2.3 The MDT consists of: 0.5 wte Consultant paediatrician with a special interest in diabetes, 1.0 wte Consultant with a special interest in diabetes 3.0 wte Paediatric Diabetes Nurse Specialists (PDSN) 1.0 wte Paediatric Diabetes Dietician 2.4 There is a Diabetes Team Secretary and a Diabetes Administrator who both work part time hours who provide administrative support for the team. A Podiatrist attends clinic for 6 sessions a year and aims to assess the feet of all children and young people over 12 years of age. Phoenix Ward staff provide care to any children with diabetes requiring hospitalisation and Children s Outpatient staff support the smooth running of diabetes clinics. 2.5 The service currently holds MDT clinics based in the Children s Outpatients Department and all patients are offered appointments a minimum of 4 times a year. Extra contacts with patients are also offered in the community by the PDSN s and Dietician. The service works closely with the Adult Diabetes service and hold transition clinics jointly in the Children s Outpatients department twice a year. 2.6 Psychotherapy services are provided by the Psychotherapy and Counselling team by individual referral of patients to Psychological support is available for both inpatients and outpatients. 2.7 In terms of Local Education Authorities, the MDT liaises with schools in the Mid Essex area and provides training / support for staff working with families/children and young people. 3

4 2.8 Inpatient facilities are provided for young people under 16 years of age on the Children s Ward (Phoenix) at Broomfield Hospital. Young people between the ages of 16 years and 19 years with DKA (diabetic ketoacidosis) are admitted to Phoenix /Medical HDU and are cared for jointly by the adult and children and young people teams. 2.9 Trust Wide Management Group for Children and Young People's Diabetes (D12-1D-101) The MDT sits in the Women and Children s Directorate of the Trust. There are 3 children s groups that meet quarterly. Children s Urgent and Emergency Group, Children s Safe Surgery Group and the Safeguarding Children s Group are all groups that feed into the Directorate Governance monthly meetings A Trust wide management group has been formed and the first meeting was held on 2 May The Children and young people s Diabetes MDT hold regular meetings to review caseload and training needs, the remit of this group includes review of service relating to: DKA prevention Hypo-glycaemia HbA1c performance Junior doctor/staff nurse training MDT members training and personal development 3.0 Aims of Service 3.1 The MDT aims to provide consistent co-ordinated care to children/families and young people with diabetes with the ultimate aim of empowering them to manage their diabetes and to embrace a healthier lifestyle. 3.2 The MDT is committed to: Work with children/families and young people (C&YP) with diabetes to support their diabetes education to gain confidence in self-management and to enable them to achieve all aspects of normal development Providing comprehensive and updated information to the families as part of their educational programme including interactive group sessions Involving parents, children and young people in the evaluation and organisation of the service To submit data annually to the National Paediatric Diabetes Audit To maintain an up to date database of children under the care of the Multi- Disciplinary Team (MDT) To hold 3 monthly governance meetings and high HbA1c review sessions 4.0 Equality and Diversity 4.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals 4

5 5.0 Scope 5.1 The Trust s Children and Young People s Diabetes MDT adhere to the network clinical guidelines which are based on the BSPED* and ISPAD** guidelines. * British Society for Paediatric Endocrinology and Diabetes ** International Society for Paediatric and Adolescent Diabetes 5.2 The service, in partnership with the adult diabetes team provides care to children and young people from birth up to 19 years with Type 1 and Type 2 Diabetes. 5.3 A service specification for the delivery of the children and young people s diabetes services at Broomfield Hospital has been agreed between MEHT and the local children s commissioners, following the criteria set out in the Paediatric Diabetes Best Practice Tariff, introduced from 1st April Staffing and Training 6.1 Children and Young People s Diabetes MDT membership (D12-2A-103 / 105) Team Member Role Cover Dr Sharon Lim Consultant Paediatrician Dr Sharmila Nambiar With interest in Paediatric Endocrinology & Diabetes Dr Sharmila Nambiar Consultant Paediatrician with Dr Sharon Lim interest in diabetes Cerys Bronze Paediatric Diabetes Nurse Carol Newman Carol Newman Paediatric Diabetes Nurse Anna Owen Anna Owen Paediatric Diabetes Nurse Cerys Bronze Misbah Ajmal Paediatric Diabetes Dietician Mandy Giles Paediatric Psychologist Psychotherapy team Yvonne Williams Paediatric secretary/diabetes Paediatric secretaries administrator Tina Massey Provide Administrator Extended Members Team Member Role Cover Emily Edwards/Georgiana Shipperd Social Work Representative Inpatient Ward Link Nurse Referral to Essex Social Services Anna Owen Michelle Goodeve Podiatrist Referral to Community Podiatrist Dr Jeremy Fletcher Adult Diabetes Clinician Dr Alan Jackson Acute Paediatricians Acute Paediatricians On call with other Paediatricians 5

6 6.3 Specialist training of MDT members (D12-1D-107 / D12-2A-108 / 109 / 110 /111) The Trust s Children and Young people Diabetes MDT is committed to meeting the on-going training needs of all core and extended team members. Any necessary training needs are satisfied by accessing relevant internal training courses, working with consultant team members, shadowing existing staff, or attending recognised external courses All clinical core team members will take part in at least one educational training session that has been agreed by the Children and Young People s Diabetes Network All core nurse members have successfully completed or are undertaking a programme of study in diabetes for nurses, which have been accredited for at least 20 credits at first degree level Medical consultants of the CYPD MDT have undergone training in Paediatric diabetes as defined by the Royal College of Paediatrics and Child Health or have met the exemption criteria The State Registered Dietician core team member of the CYPD MDT should have successfully completed a programme of study in paediatric dietetics as defined by the British Dietetic Association or equivalent in-house training and have two years experience in paediatric diabetes. 6.4 Paediatric Ward Staff All qualified paediatric Ward Staff are trained to use: Use of equipment used for children and young people with diabetes Management of low blood glucose (hypoglycaemia) Management of a child in diabetic keto-acidosis (DKA) Safe use of insulin - course module (NHS Diabetes) Principles of dietary management including carbohydrate counting Care of children with diabetes undergoing surgery 6

7 7.0 Flow chart for management of new referrals where diabetes is suspected. Urgent referral to paediatric department via General Paediatric oncall team. Children are directly assessed in the Children s Assessment unit if well or in the Paediatric Emergency Unit if unwell Unwell, vomiting Well Perform blood tests in PED as per Diabetes new diagnosis guideline (available on Intranet If ph <7.3, follow Diabetic ketoacidosis ICP andstart IV fluids and insulin infusion Send to Children s Assessment Unit and perform blood tests as per Diabetes new diagnosis guideline (available on Intranet If ph >7.3, follow new diagnosis protocol and start subcutaneous insulin (multiple dose insulin) Phone diabetes on-call and diabetes nurse office within 24 hours of admission to inform them newly diagnosed patient Patient will be reviewed on the next working day by a senior member of the MDT; structured education is commenced and usually seen by every member of the MDT before discharge. Out-patient appointment with MDT 4-6 weeks after discharge, with regular contact with PDSN in the interim by home visits, local clinic appointments, contact via phone/text/ (Out of Hours telephone advisory service contact number given) MDT hospital appointments are offered every 3 months. 7

8 8.0 Responsibilities 8.1 Lead Clinician (D12-2A-101 / 102) Responsibility for the overall management of the service To chair the Diabetes Management Group meetings and ensure accurate minutes are taken Represent the Trust at the network Paediatric Diabetes meetings attending at least two-thirds Ensure guidelines are updated Review audit programme Produce annual report Ensure that adequate cover arrangements are in place for MDT members during periods of absence Act as an advocate for patients as appropriate Ensure that all relevant patients are included for any clinical trials Act as or identify a Service Improvement Lead for the MDT Ensure that all clinical core team members will take part in at least one educational training session that has been agreed by the Children and Young People s Diabetes Network 8.2 Core Nurse Members Contribute to multidisciplinary team and patient assessment/care Provide educational and training support to patients and parents, promoting holistic care Provide link nurse responsibilities to their named patients, contributing towards high HbA1c meeting and informing team of specific problems. Liaise with key workers including schools on behalf of their patients. Contribute towards the efficient management of the team, completing templates and utilising new ideas and research as discussed by the team. Contribute towards audit. Act as advice and expert resource for other professionals. Provide link to the inpatient wards and be actively involved in the education of new patients parents and staff. 8

9 8.3 Core Dietician Contribute towards the multidisciplinary discussion and patient assessment/care Provide expert dietetic advice and support to other health professionals Lead on education of patients, parents and staff on CHO counting and dietetic issues generally Advice for schools as necessary particularly in relation to school menus Maintain up to date knowledge base and understanding all aspects of diabetes care and how it relates to dietetics and healthy living 8.4 Psychologist Contribute towards the multidisciplinary discussion and patient assessment/care Provide expert psychological advice and support to other health professionals Lead on psychological issues including education of patients, parents and staff 8.5 Paediatric Diabetes Administrator/Secretary Act as secretary to Diabetes consultants Support the team in organising meetings, liaising with parents Make sure the diabetes templates are updated. Maintain diary of events, staff holidays To work with the paediatric team to submit to NPDA and BPT 9.0 Key Worker Policy 9.1 The caseload is shared and there is no single named key worker for any particular patient. We do however have a key worker policy for Insulin Pump patients (Hannah Savage), diabetic inpatients (Anna Owen), and also for Transition Adolescents (Carol Newman). The single named key worker will provide care co-ordination, information and communication with the patient and be an integral member of the patient s multidisciplinary team. The aim should be to provide continuity of care throughout the patient pathway. 9.2 Responsibilities of the Key Worker for Insulin Pump, diabetic inpatients and Transition care patients Continuity of care: to achieve continuity of care, so that the patient knows who to contact for information or support. To introduce themselves proactively to the patient and provide contact details. 9

10 9.2.2 Management: to be present when the patient is initiated in their insulin pump therapy or where possible to be present when the adolescent starting the transition process is introduced to the adult diabetes nurse Initial assessment: to ensure that a holistic assessment is carried out of the patient s needs On-going assessment: to ensure that assessment is repeated at regular intervals to maintain an up-to-date picture of the patient s needs Care planning: to ensure that a care plan is drawn up, in conjunction with the parent/guardian and based on information obtained from the initial assessment. Ensure that the care plan is updated at regular intervals as part of the on-going assessment with the patient Liaise with primary care: to establish and maintain contact with the patient s GP so that they are kept informed of key developments in treatment and prognosis Provide information: to provide timely information to meet needs expressed by the patient, family members and carers Notify a change of key worker: whenever a change of key worker is proposed, the original key worker should seek agreement from the patient and the new key worker. Once agreed, the original key worker should notify all professionals involved in the patient s care Respond to patient choice: to make the patient aware that they can request a change of key worker if they feel the existing arrangement is not working successfully, and to act upon any such request. 9.3 The Key worker for inpatients will be responsible for co-ordinating the training needs of the nursing staff on the wards. 9.4 The required competencies for the key worker role are: Ability to co-ordinate the input of MDT members (liaising with MDT co-ordinator if hospital based) Basic listening skills Ability to treat patients, family members and carers with kindness, dignity and respect Ability to offer general support and to communicate honestly and compassionately Ability to inform patients, carers and family members about the range of support services available to them Ability to recognise psychological needs Specialist knowledge of paediatric diabetes Ability to elicit worries and other feelings by establishing trust and listening in permissive and non-judgemental manner 10

11 10.0 Key Relationships 10.1 Key Relationships with other Departments Acute paediatricians Phoenix Ward Phoenix Assessment Unit Children s Outpatient Department Psychotherapy Department Podiatry Phlebotomy Dietetics Department Adult Diabetes Team Ophthalmology 10.2 Key External Relationships Local Authority Schools GPs East of England Children and Young People Diabetes Network 11.0 Admission Overview 11.1 Children requiring planned admission to hospital will be admitted to Phoenix Ward or Wizard Day Surgery Unit. Children admitted as an emergency will go to Phoenix Assessment Unit first and will be transferred to Phoenix Ward if they require in-patient treatment If children are very unwell at diagnosis (e.g. severe DKA), they will be admitted to Phoenix HDU and the Diabetic Ketoacidosis Integrated Care Plan will be initiated and the on call consultant paediatrician will be notified of the admission. Resuscitation equipment is provided on all wards Young people over the age of 16 years who have started the transition process may be admitted either to Phoenix Ward via Children s ED or to the Adult Unit via adult ED dependent on bed availability Admission Process (D12-2A-104 / 126 / 127) 12.1 All children will be initially assessed in the Phoenix Assessment Unit and transferred to Phoenix ward if they require inpatient care Any inpatients will be reviewed by a member of the MDT within 24 hours of admission to hospital unless the admission is over a weekend. Newly diagnosed children admitted over a weekend should be discussed with the Children and Young People Diabetes MDT on admission. Out of hours the care of children with diabetes will be managed by the on call general paediatric registrar and consultant. 11

12 12.3 Advice on the management of new patients or those admitted with DKA as well as advice for any children admitted as an emergency with a surgical problem can be found on the intranet in the Diabetes guidelines section Children being admitted for routine surgery should be discussed with the paediatric diabetes team when the admission date is set. This should be done by calling the Diabetes team on Any plans for a change in treatment prior to admission to hospital will be discussed with the family by one of the PDSNs or the admitting surgical team, following guidance from the children and young people diabetes team. Guidelines for the management of diabetes during surgery are available on the intranet as above Treatment Planning Discussion (D12-2A-104) Following admission a child or young person with a new diagnosis of diabetes is discussed with a senior member of the children and young people's diabetes team within 24 hours of presentation Treatment commenced immediately and explained to children/ families and young person the types of treatment offered Diabetes Self-Management Education (D12-2A-126) At the time of initial diagnosis each patient is offered a diabetes self-management education programme. Content is varied according to age and this is continued in the form of updates throughout the child or young person's attendance at the Paediatric Diabetes Clinic. The children and young people have their knowledge and competence assessed using an assessment proforma Meal Planning (D12-2A-127) As part of the education at diagnosis children/parents are taught the principles of meal planning including carbohydrate counting All educational activity that has occurred is recorded in the patients notes GP notification (D12-2A-106) Following receipt of a diabetes diagnosis, the patient s GP is notified by end of the second working day following discharge. The manner of communication is by electronic discharge summary Outpatient Environment / Appointments (D12-1D-103 / 104 / 105 / 112 / 113 / 114 / 115 / 117 / 118 / 120) 13.1 Once a new diabetic is discharged from Phoenix ward, they will be followed up in the community by the PDSN and dietician. A multidisciplinary clinic appointment in Children s Outpatients is given within 4-6 weeks of discharge. All children with diabetes have their HbA1C (DCA200) taken, weight, height, BP and urinalysis prior to being seen. All clinics are supported by a clinic nurse and nursery nurse Each patient is offered at least 4 hospital appointments per year in a multi-disciplinary diabetes clinic, with an annual assessment to decide whether clinical psychologist 12

13 input is required. In addition to this the MDT makes 8 additional contacts in the form of clinic appointments/visits/texts/phone calls/ s, recording contacts electronically (System 1) Patients may also receive separate appointments with the Paediatric Diabetes Dietician Patients with HbA1c >9% will have an individualised action plan 13.5 Minimum Consultation Period (D12-1D-103) During an Outpatient visit all patients will be seen at 30 minute intervals. In addition to this further support will be provided by the MDTs Dietician Availability of Information (D12-1D-104) Facilities exist in hospital clinic which enable the download of timely and accurate information from insulin pumps and blood glucose meters so that the results can be discussed with patients at their clinic appointment Point of Care Testing (D12-1D-105) Glycosylated Haemoglobin (HbA1c) is available using DCA2000 machines, so level of control is available for discussion in clinic Did Not Attend (DNA) Policy (D-12-2A-117) The process for managing children who DNA is outlined in the Trust Patient Access Policy, all failure to attend appointments, if the appointment was not cancelled in advance, are contacted by the PDNS and a new appointment is sent. Repeated non - attendance is discussed at Multidisciplinary Team meeting and appropriate action taken. The Children s Diabetes team has drafted DNA letters taking into account local safeguarding policies Individualised Objectives (D12-2A-118) Each child and young person will have an agreed plan of individualised objectives, which are reviewed and updated regularly covering: Life-style goals Target blood glucose and how to achieve this through insulin adjustment Therapeutic interventions (pharmacological and non-pharmacological) Self-care Education and education plan covering, at least, school attended, medication details, what to do in emergency whilst in school, giving / supervision of injections by school staff and arrangements for liaison with the school Early warning signs of problems, especially high and low blood glucose, and what to do if these occur Who to contact for advice and their contact details Planned review date and how to access a review more quickly, if necessary 13

14 13.10 Support for children in education (D12-2A-128) The CDT liaise with schools and colleges to: Agree individual school care plan for each child Visits to the school or college to discuss the care of each newly diagnosed child with joint partnership of parents Train and asses competence of school and college staff (including school trips including residential) Discuss storage of medicines while in school or college The responsibilities of school and college staff for supervising injections and giving injections; follow CECS infection policy for disposal of sharps Discuss care plan for the management of diabetic emergencies 14.0 Provision of Written Patient Information (D12-2A-121) 14.1 Patient information provided to children and parents includes: Brief description of the condition and its impact Treatments available (pharmacological and non-pharmacological) Management of high and low blood glucose crises Management of diabetes during times of illness, including "sick day rules" Llifestyle advice, including exercise, smoking cessation, use of alcohol and recreational drugs, sexual health and contraception, pre-conception care and driving (where applicable) Nutritional advice Possible complications and how to prevent these (including vaccinations Local arrangements for sharps disposal Disability living allowance advice Travel advice Transition to adult care Local Support Groups (if available) Where to go for further information, including useful websites Clinic letters describing changes to treatment, strategies to improve control 15.0 Clinical Guidelines / Patient Management (D12-2A-122 / 123 / 124 / 125) 15.2 This service is structured in line with agreed national and local standards and is reflective of that documentation as follows: 15.3 Clinical Guidelines (D12-2A-122) This service is delivered as part of the East of England Children and Young Peoples Diabetes Network which has adopted the BSPED and ISPAD guidelines. These include details on: care of children and young people newly diagnosed with diabetes; care of children and young people with diabetes undergoing surgery; care of children and young people with diabetic keto-acidosis (DKA); care of children and young people with hypoglycaemia; optimising glycaemic control; Insulin pump therapy in children and young people or up to 19 years 14

15 care of children and young people with an HbA1c greater than 75mmol/mmol (9%)(123) Sick day rules 15.4 Policy for the Screening of Children and Young people Policy for Type 1 Diabetes (D12-2A-124) The MDT offers a screening policy in line with the NICE guideline NG18, this includes: Thyroid function and TPO/Coeliac /lipid screen at diagnosis and at annual review, Thyroid check every year Micro albuminuria screen annually in all diabetics who are in puberty, or who have had diabetes for over 5 years 15.5 Policy for Patient Choice of Insulin Pump Therapy (D12-2A-125) All patients fulfilling the NICE clinical guideline CSII TA151 are offered the option of insulin pump therapy as an alternative to multiple daily injection (MDI) Transition of young people to adult care (D12-2A-129) 16.1 The young person and their family are involved at an early stage regarding transition arrangements and will have met the Adult Diabetes nurse in clinic prior to the Transition clinic held jointly by the Adult Diabetes physician and Paediatrician in the Children s Diabetes clinic. These clinics are held twice a year, and co-ordinated by the Lead Consultant and PDSN This policy is in accordance with year of care principles and specifies: involvement of the young person and their family in the decision about transfer to adult care involvement of the young person's general practitioner in planning the transfer a joint planning meeting between paediatric and adult services allocation of a named coordinator for the transfer of care responsibilities for giving information about transfer to adult care a preparation period prior to transfer arrangements for monitoring during the time immediately after transfer 17.0 Breach Reporting 17.1 Breaches of this policy that result in harm must be reported on a risk event form (Datix) There are 3 children s groups that meet quarterly. Children s Urgent and Emergency Group, Children s Safe Surgery Group and the Safeguarding Children s Group are all groups that feed into the Directorate Governance monthly meetings, where risks, incidents and audits are shared Risks are escalated to the Board via the Risk Assurance Framework and Patient Safety Group which is a sub-committee of the overall Trust Executive Board. 15

16 18.0 Audit 18.1 The MDT is committed to improving its service through clinical audit and participates and submits data to the National Paediatric Diabetes Audit (D12-2A-130). Outcome of Patient Reported Experience Measures (D12-2A-119) 18.2 The Children and Young Peoples Diabetes MDT undertake regular exercises to obtain feedback from their patients and are participating in the PREM exercise. Results are discussed at the MDT governance meetings Contacts and Advice 19.1 In the event of patients or health professionals requiring expert advice on diabetes management, this can be obtained by contacting (D12-1D-102): During normal office hours (0900 to 1700) on Monday to Friday patients can seek advice by contacting the Children s Diabetes team on or PDSN until 1700 hours on , , After 1700 hours and at weekends patients should contact the Out of Hours telephone advisory service on Generic address for diabetes nurses and dietician: mie-tr.broomfieldcdt@nhs.net Out of hours contact information is provided to the patient/parent on diagnosis through an age-banded New diagnosis pack References Nice Guideline /032 New guideline for the NHS on the diagnosis and management of type 1 diabetes in children (2004) Nice Guideline TA151 Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus 92008) Best Practice Tariff for Paediatric Diabetes 16