4Echelons of care Echelon 1 Primary care facilities Hospitals where children with diabetes are rarely seenGoals:Diagnosis of diabetesRecognise the role of insulinUnderstand principles and priorities of treating children with diabetesUnderstand storage and use of insulinAssist with continuing careLocal support of the child with diabetesIf 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 .
5Echelon 1: Equipment (1) Blood glucose meter with test strips Urine strips for glucose, ketones & proteinBenedict’s solution, test tube and spirit lampBlood pressure set (child and adult cuffs)Weigh scaleHeight measureHeight and weight chartsThe 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 BARRETUnited KingdomElouise has type 1 diabetes
6Echelon 1: Equipment (2) Regular insulin Intermediate or long-acting insulin100 U/ml syringes with needlesDrip setting equipment and IV fluidsChart for diagnosis of diabetes mellitusChart with emergency treatment of DKAChart with management of sick days
7Echelon 1: SupportCommunication chain with access to an echelon 2-4 centreAccess to transportA paper-based recording systemLIAM & JORDAN CARSTENSSouth AfricaLiam & Jordan have type 1 diabetes
8Echelon 2 Echelon 1 Echelon 2 Have basic exposure to diagnosis and treatment of diabetesHave insulin and diabetes supplies on siteKnow how to start treatment with insulinRecognize and start basic measures for DKADistribute insulin and diabetes supplies to patientsSupervise care prescribed by an echelon 3 facilityFor those of you that work at echelon 2 facilities, this is a reminder of roles that you fulfil.
9Echelon 2: Staffing Project officer responsible Order suppliesCollect and record dataDistribute insulin, needles, syringes and diabetes suppliesOne or more clinic personnel would have attended a specialised workshop on the care of diabetes in childhoodHealthcare worker for administering the data collection and management of stocks of medicationsYou would need at your facility, dedicated or additional staffing to do the following tasks.
10Echelon 2: Equipment (1) Glucose meters and strips Filter paper strip for HbA1c determination or HbA1c point of care analyzerUrine microalbumin stripsUrine glucose and ketone stripsRefrigerated storage and insulin suppliesStadiometerWeigh scaleEquipment needed would include ….
11Echelon 2: Equipment (2)Be able to send samples for laboratory testingA computer to enter demographic data as part of a central registryA computer programme to track attendees and defaultersDisplay diagnosis postersLIAM CARSTENSSouth AfricaLiam has type 1 diabetes
12Equipment for in-patient care Blood glucose meterAccess to laboratory measurementsIV fluids for DKA managementIV infusion pump/3-way tap /Y connectorChart for DKA managementCopies 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.
13Teaching support Recording booklets (diaries) Diabetes support group Charts for:Routine diabetes clinic visitSick daysManaging DKA patientTeaching insulin injectionsBlood and urine testingSimple dietetic adviceInformation for schoolsRecording booklets (diaries)Diabetes support groupFor your teaching functions, you would need….
15Maintaining supply of insulin Insulin is a life-saving drugCrucial to keep adequate supplies at the clinicNeeds transportation and storage at 2-8o CIt has a limited shelf life – take note of expiry datesExcess stocks of insulin should be returned as soon as it is confirmed that they are not neededInsulin 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.
16Ordering insulinShould have at least double the amount needed by the hospital between resupply intervals2 groups who require insulin Existing patientsNew type 1 diabetes patientsInsulin requirements increase with growthIncreased requirement for illness / DKAThe 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 patientsChildren 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.
17Information neededHow 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.)
19Patient safetyChildren and adolescents with diabetes who are not well controlled (i.e. high Hb1C) are vulnerable to infectionInfection can cause DKANosocomial infections possible during clinic visitSSafety 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.
20Safety programme Wash hands before and after examinations Use standard precautionsClean and disinfect equipmentSpecimen transport to the laboratoryHandling and disposing of sharp and contaminated itemsEnsure that the clinic is well ventilatedRegular cleaningFor these reasons, the diabetes clinic should become a model of safe care by always remembering to:Wash hands before and after physical examinationsUse standard precautions when caring for a patient with an acute, febrile, respiratory illnessEnsure cleaning and disinfection of reusable equipment between patientsFollow applicable regulations and requirements for specimen transport to the laboratoryUse standard precautions when handling and disposing of sharps and contaminated itemsEnsure 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).
22Diabetes campsCamps are a great source of learning and support for both children and professionalsCan be organised just for children or just for adolescentsCan also include other family members, parents, siblingsGoal is to share knowledge about living with childhood diabetesLive with other children who have diabetes for a few daysTeaching by healthcare professionals, children and parentsDiabetes 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.
23Goals of the camps Knowledge and confidence to: Give injectionsTest glucose levelsEstimate food portionsDeal with other illnessesUnderstand why diabetes in children is different from adult diabetesLearn how to live a normal life with diabetes with peer-to-peer teaching and role modellingParents learn how to give emotional and practical support to the childThe 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 childAny 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.
25External partners & donors Reinforce the development of your clinic with support from external partners and donorsKnowledgeManpowerResourcesSkillsExperienceProcess and considerations in manualYou 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.
26Organizations ISPAD (www.ispad.org) International Diabetes Federation (IDF) (www.idf.org)World Diabetes Foundation (WDF) (www.worlddiabetesfoundation.org)Life for a Child (www.lifeforachild.org)Children with Diabetes (www.childrenwithdiabetes.com)Rotary Club (www.rotary.org)Lions Club (www.lionsclub.org)Juvenile Diabetes Research Foundation (JDRF) (www.jdrf.org)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.