The Management of Children and Young People with Newly Presenting Diabetes Clinical Guideline V5.0 December 2018

Transcription

1 The Management of Children and Young People with Newly Presenting Diabetes Clinical Guideline December 2018

2 Summary GP suspects diabetes Under 16 years or still in School Year 11 NO Refer Adults YES Section 2.1: Refer to acute on-call Paediatric Diabetes team to be seen ON SAME DAY Section 2.3: Ward Nurse assessment Unwell Or PEWS 3 or more Or Blood ketones >3mmol/L Or vomiting, abdominal pain, drowsy, dehydrated, or abnormal breathing. Or headache Blood ketones mmol/L Junior doctor review soon within 30 minutes Blood ketones < 1.5mmol/L Junior doctor review within recommended triage times Inform registrar immediately: ABCDE primary survey. Venous access and bloods as per Section 2.6, including urgent venous blood gas. Blood glucose 11.1mmol/l Diabetes Symptoms NO Blood glucose 8-11mmol/l See Section 2.7 ph < 7.3 and/or bicarbonate < 18 mmol/l and blood glucose >11 mmol/l and blood ketones of 3 mmol/l Treat as per RCHT Guideline for Children and Young People with Diabetic Ketoacidosis YES Diabetes confirmed, therefore doctor should: Section 2.5: Complete full assessment. Section 2.6: Insert IV cannula and take bloods. Section 2.8: Discuss with parents, registrar and PDSN. Section 2.9: Prescribe Insulin. Ward Nursing Staff: Check blood glucose and ketone levels as per Section 2.10 a) and b). Inform on call Paediatric Diabetes Nurse within 24 hours as per Section 2.10 c). PDSN follow Section 2.10 d): Review on next working day and deliver education. Inform paediatric diabetes consultant, dietitian, research nurses and psychologist. Decide when ready for discharge and ask ward doctor to do discharge prescription as per Section 2.10 f) Arrange outpatient appointment within 6 weeks. Page 2 of 15 Paediatric Diabetes Dietitian: Section 2.10 e): Review at least once in hospital and commence carbohydrate counting. Arrange to assess competencies and start Level 3 carbohydrate counting within 1 month.

3 1. Aim/Purpose of this Guideline This guideline applies to medical and nursing staff caring for children and young people presenting with newly diagnosed diabetes. 2. The Guidance 2.1 Children under the age of 16 years with newly diagnosed, or suspected diabetes, should be seen on the Paediatric Observation Unit on the same day. Those aged 16 years, and still in school year 11, can be managed initially within paediatrics, to allow education of school staff. 2.2 Diabetes is diagnosed by (1,3,4,5) : The presence of symptoms of diabetes (polyuria and polydipsia) and a random laboratory plasma glucose of 11.1mmol/l or a fasting plasma glucose of 7mmol/L or a 2-hour postload glucose of 11.1mmol during an Oral Glucose Tolerance Test. If the random blood glucose is 11.1mmol/l but there are no symptoms, or a random blood glucose is 8-11mmol/l, or a fasting glucose is mmol/l, or a 2 hour glucose in an OGTT is mmol/L this may be stress-induced hyperglycaemia, or pre-diabetes: see section Ward nursing staff should: Perform baseline observations including BP, weight and height the child and apply topical local anaesthetic cream on arrival Do capillary blood glucose and blood ketones Inform a registrar immediately if: - they are concerned that the patient is unwell, - or the patient s observations meet Paediatric Early Warning Score of 3 or more, - or blood ketones are >3 mmol/l, - or the patient has any of the symptoms of possible DKA (section 2.4), - or the patient has a headache: this could represent cerebral oedema, even if they are not in DKA. If ketones mmol/L, inform a junior doctor and ask them to review within half an hour because the patient will need to receive a correction dose of Novorapid in the near future to stop DKA developing. 2.4 Consider Diabetic Ketoacidosis (DKA) in any child who is vomiting, or who has abdominal pain, is drowsy, dehydrated, or is breathing rapidly and deeply (Kussmaul respirations) If DKA is suspected then venous access should be obtained as soon as possible and bloods taken as per section DKA is diagnosed by (2) : - ph < 7.3 and/or bicarbonate < 18 mmol/l - blood glucose >11 mmol/l - and blood ketones of 3 mmol/l Page 3 of 15

4 If DKA is confirmed they should be managed by: - following the South West DKA Care Pathway (2), - informing the paediatric registrar and the consultant on call. 2.5 The majority of children presenting with diabetes will be well. In this situation document a full medical history including: medication history (particularly steroid use) family history (particularly of diabetes and other autoimmune conditions) social history school attended document a full examination, particularly signs of dehydration do fundoscopy to check no cataracts are present (these occur in 0.7% of children presenting with diabetes secondary to metabolic disturbance). (7) plot height and weight on a growth chart. 2.6 Insert an intravenous cannula and take bloods: All of these tests (except bedside glucose and ketones) are included in the Paed New Diabetic order set on Maxims which is on the right hand side of the Paediatrics specialty order page. Blood test Adult Vacutainer * Paediatric Bottle Form Blood gas Capillary tube (HDU or lab) Green clinical chemistry (if lab gas) Blood glucose and Bedside meter ketones N/A Laboratory glucose Grey Yellow Renal function, bicarbonate, immunoglobulins Gold Green (Li hep) Thyroid function Gold Green (Li hep) HbA1c Purple** Pink (EDTA)** FBC Purple** Pink (EDTA)** GAD, IA2 and ZnT8 antibodies*** Coeliac screen (anti TTG)*** 1 adult Gold bottle (does not have to be completely full) is better than multiple paediatric clear bottles Green, clinical chemistry Red, haematology Special instructions Hand deliver to lab N/A N/A N/A If possibility of infection: consider CRP, blood culture and urine MCS Page 4 of 15

5 If you want to fill Adult Vacutainers with blood from a syringe, then remove the lid before putting blood in the bottle (do not put the needle through the lid and push the blood in otherwise the lid will pop off and spray blood everywhere) Fill the EDTA bottle last because EDTA contamination can affect biochemistry results If any queries regarding these tests, contact immunology on ext Other causes of hyperglycaemia: If there are no symptoms and blood ketones are <0.6 mmol/l, consider stress-induced hyperglycaemia, which is likely to be transitory, or prediabetes. In this case, monitor capillary blood glucose and ketone levels and plan a fasting laboratory plasma glucose level with HbA1c and GAD and IA2 antibodies. Diabetes is confirmed by a fasting plasma glucose 7 mmol/l. An oral glucose tolerance test can also be considered and can be discussed with the diabetes consultants. (1,3,4,5) However if the blood ketones rise above 1.5 mmol/l at any point, then insulin should be started as per section 2.9. o If diabetes is not confirmed and the patient is discharged, in case they have pre-diabetes, they should be safety netted and told that if they develop symptoms of diabetes (polyuria, polydipsia, lethargy +/- weight loss or vomiting), they need to arrange a prompt medical review Consider type 2 diabetes if the child has a long duration of symptoms, is obese, has a family history of type 2 diabetes, or is of non-white ethnicity. In this case, examine the child for acanthosis nigricans, which is velvety, hyperpigmented skin in the body folds eg neck and axillae. Acanthosis is often associated with insulin resistance, although is not specific to this. However, even if type 2 diabetes is suspected, if the blood glucose is >11.1mmol/l it is safer to treat initially with insulin as per section If the diagnosis of diabetes is confirmed, a doctor should: Explain to the child and parents: - that the purpose of the admission is to confirm the diagnosis, initiate treatment and to start to educate them in how to manage diabetes. - a brief explanation of diabetes. They should be given the Diabetes UK magazine, which is available in the diabetes trolley in Polkerris treatment room, and encouraged to review this website and particularly watch the videos at Initial management must be discussed with: - the paediatric registrar - and the Paediatric Diabetes Specialist Nurses (PDSN) within 24 hours: available between and hours every day, Monday to Sunday (see contact details page 5) If the child is in DKA: - Treat as per DKA Care Pathway and inform consultant on call. Page 5 of 15

6 If the child is not in DKA: - The consultant on call can be informed the following day (weekday or weekend). NB The PDSN will inform the relevant diabetes consultant of the child s admission. 2.9 Subcutaneous Insulin Regime All children, even those with suspected type 2 diabetes, should start on a Multiple Daily Injection (MDI) insulin regime, which should be prescribed as follows using the instructions on the PAPER Paediatric Insulin Prescription Sheet: A. Lantus Insulin (long-acting) For all ages prescribe Lantus Insulin 3ml cartridges via JuniorStar pen. If less than 2 years old: Units/kg/dose once daily at bedtime Between 2 years old and 10 years old: units/kg/dose once daily at bedtime (round down to nearest half unit) If 10 years old and over: units/kg/dose once daily at bedtime (round down to nearest half unit) If admitted after their usual bedtime and before breakfast: - If it is within 6 hours of their normal bedtime, then the Lantus dose can still be given. - If it is more than 6 hours after their usual bedtime, then the first dose of Lantus will not be given until the next bedtime and Novorapid can be given as detailed below. B. NovoRapid insulin (Rapid-Acting) With Main Meals: - If less than 10 years: 0.1 units/kg/dose with main meals 3 times a day. - If 10 years or over: 0.15units/kg/dose with main meals 3 times a day (round down to nearest half unit) - This is usually given immediately before eating, but if their appetite is unpredictable eg toddlers, then it may be given immediately after eating. With Snacks: - Prescribe quarter the main meal dose to cover all snacks (rounded down to nearest half unit if works out to less than 0.5 units then do not give any Novorapid to cover snacks) Novorapid Correction dose: - Should be prescribed to be given if: blood ketones 1.5 mmol/l and blood glucose 15mmol/l at ANY TIME, including overnight. OR if Blood glucose >20 mmol/l and ketones <1.5mmol/L, only during the day and at bedtime. - Calculated as 0.05 units/kg (rounded down to nearest 0.5 unit). - Maximum 2 hourly as stated on the prescription chart. Page 6 of 15

7 2.10 Ongoing Management in Hospital The aim of the hospital admission is to provide support and education (1,5) and to turn off any ketone production and to start aiming for optimal diabetes control. This will be achieved over the next few weeks. The child and/or carer should be encouraged to perform blood glucose testing and insulin injections as early as possible Capillary blood glucose: Frequency: Should be performed pre-meals, 2 hours after meals/before snacks, pre-bed, and at 2-3 am and should be recorded on the Paediatric Insulin Prescription Sheet (Section F on page 4 or on the continuation sheets). Will need to be done more often, 2 hourly, if: the blood glucose falls to 5 mmol/l or blood glucose rises to 15 mmol/l or blood ketones are 1 mmol/l. or 2 hours after a Novorapid Correction dose. Action: If blood glucose 15mmol/l, check blood ketones and see Section 2.10b) below Blood ketones: Frequency: If the blood glucose is 15 mmol/l. 2 hourly if the previous ketone level was 1 mmol/l or above. Action: If ketones <1.5mmol/l, but blood glucose >20mmol/l, and it is daytime or bedtime, give a Novorapid Correction dose. If ketones 1.5 mmol/l and blood glucose >15mmol/l at ANY TIME, including overnight, give a Novorapid Correction dose AND INFORM DOCTOR The ward nurses should make sure that the on call Paediatric Diabetes Specialist Nurse has been contacted within 24 hours of admission: they can be paged 8am 8pm every day via switchboard A Paediatric Diabetes Specialist Nurse will see the child and family on the next working weekday: They will deliver the required education and decide when the child and family are ready for discharge. To know that the child is safe from developing DKA (ie has a reasonable insulin level to turn off ketone production), the child needs to have blood ketones < 0.6 mmol/l before discharge and tolerate their blood glucose between 4 and 20mmol/l. They will contact: the relevant Paediatric Diabetes Consultant who will ideally see the child and family before discharge. the Paediatric Diabetes Dietitian who should see the child and family during admission as per Section 2.10e) below. the Paediatric Research Nurses who will ideally see the child and family before discharge. the Paediatric Diabetes Psychologist who will contact within 1 month. Page 7 of 15

8 They will arrange an outpatient appointment within 6 weeks The Paediatric Diabetes Dietitian will: - See the child and their family within 2 working days of admission. - Start carbohydrate counting education in hospital and when they are competent start insulin dose adjustment (Level 3 carbohydrate counting) within 1 month from diagnosis. - The family should be seen by the Dietitian twice within the first week of diagnosis. If the family are discharged before their second review they will need to return to the Diabetes Centre to continue dietetic education. Please ensure this appointment is arranged before discharge Discharge prescription for pharmacy: E-discharge EPMA: use the Insulin Treatment protocols as follows: i. PAEDIATRIC LANTUS & NOVORAPID INSULIN REGIMEN ii. And the PAEDIATRIC DIABETIC ACCESSORIES. This excepts Insulin Pen 4mm Needles which are not a pharmacy line and are provided by the PDSN/ward nurses. Need to remember to change Glucagon dose according to weight (see below). If JACS is not working and you need to do a handwritten TTO, they should be prescribed the following: - Lantus (Glargine) Insulin 3ml cartridges x 1 box of 5 - Novorapid 3ml Penfill cartridges x 1 box of 5 - Glucagon 1mg/ml x 1 GlucaGen HypoKit (second to be prescribed by GP): Body weight less than 25kg give 0.5mg PRN Body weight of 25kg or more give 1mg PRN - Glucose 40% oral gel, 1 tube = 62.5mls = 10g of glucose, as required, x 1 box of 3 tubes (second to be prescribed by GP) - Glucose 4g tablets, 3 tablets = 12g of glucose, as required, x 1 box - Optium beta ketone blood test strips x 1 box of 10 - Accu-Chek Aviva blood glucose test strips x 2 boxes of 50 - Accu-Chek Fastclix Drums x 1 box of 204 lancets - Insulin Pen needles 4mm, 1 box of 100 and sharps bin (given by PDSN/ward nurses as non-pharmacy items). Contact details Paediatric Diabetes Specialist Nurses: , daily Monday to Sunday, by pager via switch. Office ext Paediatric Diabetes Consultants - Dr Katie Mallam: ext 2637 or mobile via switch - Dr Simon Robertson: ext 2695 or mobile via switch Paediatric Dietitians: ext 4567 messages can be left Play Specialists for procedure therapy: Bleep 3092, available 8am 6pm. Paediatric Research Nurses: ext 5138 or contact via at rchtr.paediatricresearch@nhs.net Page 8 of 15

9 3 Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Compliance with guidance Diabetes team (Dr Katie Mallam) Audit If any problems identified, or minimum 3 yearly Diabetes team and Directorate Audit and Guidelines meeting Audit lead and diabetes team Required changes to practice will be identified and actioned within a specified time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4 Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 9 of 15

10 Appendix 1. Governance Information Document Title Date Issued/Approved: November 2018 The Management of Children and Young People with Newly Presenting Diabetes Clinical Guideline Date Valid From: December 2018 Date Valid To: December 2021 Directorate / Department responsible (author/owner): Katie Mallam paediatric consultant Contact details: Brief summary of contents Guideline for standardised care of children and young people with newly presenting diabetes. Suggested Keywords: Target Audience Executive Director responsible for Policy: Diabetes Children Diagnosis New RCHT CFT KCCG Medical Director Date revised: November 2018 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Clinical guideline for the management of children and young people with newly presenting diabetes. Version 4 July 2015 Paediatric Diabetes team Paediatric consultants Directorate audit and guidelines Care Group Manager Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Not Required {Original Copy Signed} Name: Caroline AMukusana Page 10 of 15

11 Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? {Original Copy Signed} Internet & Intranet Paediatrics Intranet Only (1) NICE Guideline NG18. Diabetes (type 1 and type 2) in children and adults: diagnosis, and management. August 2015 (2) The Southwest Diabetes Regional Network Integrated Care Pathway for Children with Diabetic Ketoacidosis 2015 (based on BSPED (British Society of Paediatric Endocrinology and Diabetes) Recommended DKA Guideline 2015). (3) Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia. Report of WHO/IDF Consultation (4) ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. Carlo Acerini, Maria E Craig, Carine de Beaufort, David M Maahs and Ragnar Hanas. Published in Pediatric Diabetes 2014: 15(Suppl. 20): calpract (5) Care of the well child newly diagnosed with Type 1 Diabetes Mellitus, Clinical Guideline, Association of Children s Diabetes Clinicians, Version 3, July No Version Control Table Date March 2012 Versio n No V1.0 Initial Issue Summary of Changes Changes Made by (Name and Job Title) Dr. Mallam, Dr. Robertson, Anita England, Trish Shaw, Michelle Skews, Pip Ali- Diabetes Team. Page 11 of 15

12 October 2013 November 2014 V2.0 V3.0 Update Review and Update Re format in current template Dr. Mallam- Paediatric consultant Tabitha Fergus- Deputy ward manager Dr Mallam and Paediatric Diabetes Team May 2015 V4.0 Update (main changes: reduced Novorapid snack dose and changed PDSN on call hours) Dr Mallam and Paediatric Diabetes Team August 2017 Update to Section 2.2 Diagnosis of diabetes, Section 2.4 Criteria for diagnosis of DKA, Section 2.7 safety-netting for hyperglycaemia not in diabetes range, Section 2.9: Lantus at bedtime for all ages, Section 2.10 clarification of actions on blood glucose and ketones and roles and responsibilities and TTO s, and updated references. Minor name change. Dr Mallam and Paediatric Diabetes Team All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 12 of 15

13 Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed The Management of Children and Young People with Newly Presenting Diabetes Clinical Guideline Directorate and service area: Is this a new or existing Policy? child health Existing Name of individual completing assessment: Telephone: K.Mallam 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? To provide clear standardised care for children and young people with newly presenting diabetes. 2. Policy Objectives* Clear standardised care for children and young people with newly presenting diabetes. 3. Policy intended Standardised care for children and young people with newly Outcomes* presenting diabetes. 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. audit Children, young people and families Workforce Patients Local groups x Please record specific names of groups Paediatric Diabetes team Paediatric consultants Directorate audit and guidelines External organisations Other Page 13 of 15

14 What was the outcome of the consultation? Guideline ratified and accepted 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No x 9. If you are not recommending a Full Impact assessment please explain why. Not required Page 14 of 15

15 Signature of policy developer / lead manager / director K.Mallam Date of completion and submission October 2018 Names and signatures of members carrying out the Screening Assessment 1. Paediatric Consultant 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed K.Mallam Date 18/10/18 Page 15 of 15