1. Clinic Organisation
Echelon 1 - 2

2. Programme 1 2 3 4 5 Equipping a clinic Ordering insulin Patient safety
External partners and donors
Diabetes camps
Patient safety
Ordering insulin

3. Equipping a clinic

4. Echelons of care Echelon 1 Primary care facilities
Hospitals where children with diabetes are rarely seen
Goals:
Diagnosis of diabetes
Recognise the role of insulin
Understand principles and priorities of treating children with diabetes
Understand storage and use of insulin
Assist with continuing care
Local support of the child with diabetes
If you are working at an echelon 1 facility, this slide is a reminder of what is expected of your facility in the management of children with diabetes .

5. Echelon 1: Equipment (1) Blood glucose meter with test strips
Urine strips for glucose, ketones & protein
Benedict’s solution, test tube and spirit lamp
Blood pressure set (child and adult cuffs)
Weigh scale
Height measure
Height and weight charts
The equipment that you will need includes read off this list.. Those items in red indicate equipment that would be good to have but not essential.
ELOUISE BARRET
United Kingdom
Elouise has type 1 diabetes

6. Echelon 1: Equipment (2) Regular insulin
Intermediate or long-acting insulin
100 U/ml syringes with needles
Drip setting equipment and IV fluids
Chart for diagnosis of diabetes mellitus
Chart with emergency treatment of DKA
Chart with management of sick days

7. Echelon 1: Support
Communication chain with access to an echelon 2-4 centre
Access to transport
A paper-based recording system
LIAM & JORDAN CARSTENS
South Africa
Liam & Jordan have type 1 diabetes

8. Echelon 2 Echelon 1 Echelon 2
Have basic exposure to diagnosis and treatment of diabetes
Have insulin and diabetes supplies on site
Know how to start treatment with insulin
Recognize and start basic measures for DKA
Distribute insulin and diabetes supplies to patients
Supervise care prescribed by an echelon 3 facility
For those of you that work at echelon 2 facilities, this is a reminder of roles that you fulfil.

9. Echelon 2: Staffing Project officer responsible
Order supplies
Collect and record data
Distribute insulin, needles, syringes and diabetes supplies
One or more clinic personnel would have attended a specialised workshop on the care of diabetes in childhood
Healthcare worker for administering the data collection and management of stocks of medications
You would need at your facility, dedicated or additional staffing to do the following tasks.

10. Echelon 2: Equipment (1) Glucose meters and strips
Filter paper strip for HbA1c determination or HbA1c point of care analyzer
Urine microalbumin strips
Urine glucose and ketone strips
Refrigerated storage and insulin supplies
Stadiometer
Weigh scale
Equipment needed would include ….

11. Echelon 2: Equipment (2)
Be able to send samples for laboratory testing
A computer to enter demographic data as part of a central registry
A computer programme to track attendees and defaulters
Display diagnosis posters
LIAM CARSTENS
South Africa
Liam has type 1 diabetes

12. Equipment for in-patient care
Blood glucose meter
Access to laboratory measurements
IV fluids for DKA management
IV infusion pump/3-way tap /Y connector
Chart for DKA management
Copies of the treatment plan (completed)
In addition, you would have an inpatient facility that would take of short term patients. This part of your facility should have the following.

13. Teaching support Recording booklets (diaries) Diabetes support group
Charts for:
Routine diabetes clinic visit
Sick days
Managing DKA patient
Teaching insulin injections
Blood and urine testing
Simple dietetic advice
Information for schools
Recording booklets (diaries)
Diabetes support group
For your teaching functions, you would need….

14. Ordering insulin

15. Maintaining supply of insulin
Insulin is a life-saving drug
Crucial to keep adequate supplies at the clinic
Needs transportation and storage at 2-8o C
It has a limited shelf life – take note of expiry dates
Excess stocks of insulin should be returned as soon as it is confirmed that they are not needed
Insulin is a life-saving drug. It is therefore crucial to order and keep adequate supplies at the clinic to cater for existing and any new patients, who may come before the next batch of insulin arrives.
Insulin needs to be transported and stored at 2-8o C. It has a limited shelf life of approximately 30 months from the date of manufacturing.
Excess stocks of insulin should be returned as soon as it is confirmed that they are not needed.

16. Ordering insulin
Should have at least double the amount needed by the hospital between resupply intervals
2 groups who require insulin 
Existing patients
New type 1 diabetes patients
Insulin requirements increase with growth
Increased requirement for illness / DKA
The clinic or hospital should ideally have on hand at least double the amount needed by the hospital between resupply intervals. For example, if the central medical supply store will send supplies of insulin to the hospital every four months, then the programme director should aim to have on hand enough supplies for existing and projected patients for an eight-month period.
Two groups of patients will require insulin:
existing patients, who get their supplies through this clinic or hospital and new type 1 diabetes patients
Children can be expected to require an increasing amount of insulin as they grow. Type 1 diabetes patients with other concurrent illnesses or diabetic ketoacidosis will temporarily need higher doses of insulin.

17. Information needed
How many vials or units of insulin did your centre use last year? Was it enough?
When was there a shortage of insulin during the year? Do you know the cause?
How many patients are in your clinic or centre now?
How many new patients tend to come each year (on average)?
information needed for calculating insulin requirements include  knowing how many vials or units of insulin did your centre use last year? Was it enough?
During which months of the year was there a shortage of insulin? Do you know the cause?
How many patients are in your clinic or centre now?
How many new patients tend to come each year (on average)?
When making your calculations, bear in mind the following:
If information about the total number of patients per year is not available, estimate it from number of patients in the last month x 12, or last 3 months x 4, and so on.
If your patients come on average every 3-4 months to collect medicine, the number of patients over the last 3-4 months will be the number of patients in your clinic.
Some places get seasonal surges – eg due to weather, road conditions and so on.
As type 1 diabetes (among others in children) becomes more widely recognised, there may be an increasing number of patients diagnosed. (Before type 1 diabetes was well recognised, they may well have died before being diagnosed.)

18. Patient safety

19. Patient safety
Children and adolescents with diabetes who are not well controlled (i.e. high Hb1C) are vulnerable to infection
Infection can cause DKA
Nosocomial infections possible during clinic visitS
Safety programme (WHO)
People with diabetes, and especially children, are vulnerable to infections. Respiratory disease or gastro-enteritis may lead to DKA, and have major consequences.
Healthcare professionals are exposed to contamination and can convey infectious diseases if they do not protect themselves. They expose their family and other people if they do not wash their hands carefully and change their clothes when leaving the clinic. Also, in the ward, and during the medical examination, the attitude and actions of the health care professionals is a learning opportunity for the child and family. Nosocomial infections are infections contracted during a stay in the medical environment, and are a very serious public health problem all over the world. Because of this, the World Heath Organization (WHO) has developed a Patient Safety programme, with guidelines and explanations how to produce locally cheap, but efficient, disinfectant solutions.

20. Safety programme Wash hands before and after examinations
Use standard precautions
Clean and disinfect equipment
Specimen transport to the laboratory
Handling and disposing of sharp and contaminated items
Ensure that the clinic is well ventilated
Regular cleaning
For these reasons, the diabetes clinic should become a model of safe care by always remembering to:
Wash hands before and after physical examinations
Use standard precautions when caring for a patient with an acute, febrile, respiratory illness
Ensure cleaning and disinfection of reusable equipment between patients
Follow applicable regulations and requirements for specimen transport to the laboratory
Use standard precautions when handling and disposing of sharps and contaminated items
Ensure that the clinic is well ventilated, and appropriately and regularly cleaned with water and usual detergent on soiled and/or frequently touched surfaces (e.g. door handles).

21. Diabetes camps

22. Diabetes camps
Camps are a great source of learning and support for both children and professionals
Can be organised just for children or just for adolescents
Can also include other family members, parents, siblings
Goal is to share knowledge about living with childhood diabetes
Live with other children who have diabetes for a few days
Teaching by healthcare professionals, children and parents
Diabetes camps are a great source of learning and support and are a valuable feature of childhood diabetes programmes across the world.
 The goal of a children’s diabetes camp is to share knowledge about living with childhood diabetes, by living for a few days in company with other children/young people who also have diabetes. Particularly with small children, parents or carers should be there and take part alongside the child, so that they are given the opportunity to learn more about caring for diabetes and the problems it can give the child.
 At the camp, it is not only the healthcare professionals who are doing the teaching. Children and their parents also learn from each other, and their views and suggestions can help the professionals to offer the sort of medical care and support that really makes a difference.

23. Goals of the camps Knowledge and confidence to:
Give injections
Test glucose levels
Estimate food portions
Deal with other illnesses
Understand why diabetes in children is different from adult diabetes
Learn how to live a normal life with diabetes with peer-to-peer teaching and role modelling
Parents learn how to give emotional and practical support to the child
The camp has several teaching aims: including giving children and their parents the knowledge and confidence to give injections, test glucose levels, estimate food portions, deal with other illnesses, and why diabetes in children is different from adult diabetes. It is also a way to demonstrate and explain how to use this knowledge to live a normal life with diabetes. Finally it helps to explain to parents how to give emotional and practical support to the child
Any activity that can fulfill these three objectives can be used as part of a diabetes camp. Sport activities can help to illustrate to the children how to adjust their dosage to physical activity, cooking with the children can involve a conversation on diet and nutrition, and so on.
Practical ideas on how to establish and run camps is included in the manual.

24. External partners and donors

25. External partners & donors
Reinforce the development of your clinic with support from external partners and donors
Knowledge
Manpower
Resources
Skills
Experience
Process and considerations in manual
You may reach situations that require that you consider reinforcing the development of your clinic. On occasion this development would require support from external partners and donors. Development may occur in a number of different areas including knowledge, manpower, resources, skills and experience. The process of accessing support and other considerations are included in the manual.

26. Organizations ISPAD (www.ispad.org)
International Diabetes Federation (IDF) (
World Diabetes Foundation (WDF) (
Life for a Child (
Children with Diabetes (
Rotary Club (
Lions Club (
Juvenile Diabetes Research Foundation (JDRF) (
Among these organizations are the following. There are numerous other organizations that you may also approach. More details on these organizations are included in the manual.

27. Questions
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28. 28
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