Education is a critical component of diabetes treatment and is crucial education plan for new onset diabetes in a hospital setting must be …
Continuing Education Series
Establishing a Standard for Pediatric Inpatient Diabetes Education
Michele Habich
educational programs Moore et al, 1997; Siminerio et al, 1999 Many institutions use a diabetes clinical nurse expert, such as a certified diabetes educator CDE, to provide patient education across the continuum Llahana, Poulton, Coates, 2001; Powell Austin, 1998 The American Diabetes Association recommends an acute care education program that provides the minimum skills survival skills necessary for a safe discharge Additionally, the association supports a continuum of education that transcends to the outpatient setting The acute care new onset diabetes concepts and skills include a an overview of diabetes, b recognizing and treating hyperglycemia and hypoglycemia, c blood glucose monitoring, d insulin administration, and e meal planning Leyden et al, 2000; Moore et al, 1997; Page, Mackowiak, Bratt, 1999 Unfortunately, the first three days of hospital diabetic management are far from the reality of home life Many children have difficulty achieving metabolic control during their hospitalization Siminerio et al, 1999 Meals, activities, and schedule vary significantly in
the home environment Siminerio et al, 1999 Unfortunately, this reality may make the transition home difficult The transition to the pediatric outpatient diabetes program must be smooth Inpatient education concepts must be used as building blocks to introduce advanced management skills The majority of the education provided by the bedside nurse occurs informally in the context of general patient care London, 2004 The patient and family are not taught by only one nurse Instead the team builds on one anothers assessments and teaching progress to provide optimal educational experiences Barber-Parker, 2002 The multi-disciplinary team must use clear communication and documentation Education is best received over a period of time and with repetition London reports that Nurses already teach throughout hospitalization, in 113
Education is a critical component of diabetes treatment and is crucial to achieve self-management outcomes in the pediatric patient The education plan for new onset diabetes in a hospital setting must be goal oriented, consistent, and structured Balancing the education needs, psychosocial response to diagnosis, family social support, and developmental needs of the
child is often difficult considering hospital resource utilization and shortened length of stay Leyden, Caravalho, Saylor, 2000 Through analysis of current literature and current diabetes education processes within the hospital, a standard was developed that supports patient and family education from the moment of admission The staff nurse is now the primary patient and family educator; therefore, educational opportunities are no longer compromised by off-shifts, weekends, and holidays, potentially increasing the length of stay
T
he Juvenile Diabetes Research Foundation 2004 reports that more than 13 million Americans have type 1 diabetes Each year over 13,000 children are diagnosed with diabetes in the US That equals 35 children each and every day Diagnosis with type 1 diabetes occurs most often in childhood As the literature demonstrates, patients that establish and maintain an effective diabetic self-management plan at diagnosis experience less longterm morbidity Siminerio, CharronProchownik, Banion, Schreiner, 1999 A childhood diagnosis of diabetes requires a lifetime of precise management Given these statements, the healthcare team has a crucial role to ensure that
appropriate and consis-
Michele Habich, MSN, APN/CNS, CPN, is a Pediatric Clinical Nurse Specialist, Advocate Lutheran General Childrens Hospital, Park Ridge, IL Acknowledgments: The author acknowledges the support of Diane Arndt, MS, APN/CNS, APRN, BC, CDE, the multidisciplinary pediatric diabetic task force, and the pediatric nursing staff at Advocate Lutheran General Childrens Hospital
The CE Posttest can be found on pages 125-126
tent information is given to these families The education plan from diagnosis forward must be standardized in a manner that supports key concepts, consistency, flexibility, and patient and family autonomy This standard needs to be fluid to apply to both the inpatient and outpatient setting Many children with new onset type 1 diabetes are hospitalized at diagnosis Lowes Gregory, 2004; Moore, Kaiser, Aisenberg, 1997 Approximately 20-40 of those hospitalized for diagnosis of type 1 diabetes present with diabetic ketoacidosis Rosenbloom Hanas, 1996 Therefore, the majority of individuals diagnosed with childhood diabetes are receiving their initial education in a hospital setting New onset diabetes is special in that the length of stay LOS is
traditionally short It becomes very difficult to balance the impact of diagnosis and the need to provide critical education in anticipation of a LOS less than three days The trend to decreased hospital LOS has put increasing pressure on nurses to teach only what is necessary or what are called survival skills Suderman, Deatrich, Johnson, SawatzkyDickson, 2000 The child and family would then continue their diabetes management education in the outpatient setting The literature supports a blend of diabetes inpatient and outpatient
PEDIATRIC NURSING/March-April 2006/Vol 32/No 2
Series
Table 1 New Onset Diabetes Education Program New Onset Diabetes Patient and Family Education Objectives Admission 1 Consult: CDE, Dietician, Social Work Services 2 Distribute Patient and Family Educational Material Childrens Hospital Diabetes Guidebook Starter Supply Kit Pink Panther Text Other age appropriate material as indicated General Diabetes Overview 1 General concepts 2 Interrelationship of insulin, food, activity, stress, and diabetes control 3 Evaluate for minimally safe diabetes skills for discharge 4 Evaluate for minimally safe diabetes emergency care for discharge Blood Glucose
Monitoring Obtain BGM Procedure for obtaining sample Procedure for using BGM Documentation of blood glucose levels and insulin dose in logbook Recognizing Hyperglycemia and Hypoglycemia Basic symptoms and treatment for hypoglycemia Glucagon action and procedure for administration Basic symptoms and treatment for hyperglycemia Procedure for urine ketone testing Sick day management Insulin Administration Insulin action, onset, peak, duration Procedure for drawing up insulin Procedure for injecting insulin Insulin storage Meal Planning Impact of food on insulin needs Review dietary exchanges Create written meal plan with snacks Impact of high fat meals on blood glucose and insulin peak times Importance of consistent times for insulin and meals/snacks Effect of exercise on blood sugar Label reading Provide reinforcement re: above nutritional teaching points Evaluate for minimally safe discharge nutrition management skills Bedside Nurse CDE Dietician X X X X X X every communication with the patient and family Once they acknowledge it, consciously focus on it, and work with the rest of the team to move teaching forward, discharge teaching can successfully be done in the limited time
available London, 2004, p 212
Description of the Project
X A general pediatric unit located in the Midwest, housed in a childrens hospital within a general hospital, admits approximately 60 newly diagnosed children with diabetes each year Until recently, the unit relied on the institutions CDE to provide education to the pediatric patients and their families The CDE provides care management to a large number of inpatient and outpatient adult diabetics Given this workload, this shared arrangement was no longer feasible To develop an alternative education program, key individuals were asked to become part of a multi-disciplinary Pediatric Diabetes Task Force These individuals included pediatric endocrinologists, care coordinators, advanced practice nurses, nutritionists, and the CDE The goals of the task force were to: 1 Examine the current processes associated with pediatric diabetes education and length of stay; 2 Review the related literature and hospital benchmarking associated with education and discharge criteria for newly diagnosed children with diabetes; 3 Identify variances and limitations in current practice; and 4 Develop a revised educational model for these patients,
including a structured educational program and explicit discharge criteria and processes The task force finalized the program in 2000 A literature review was completed searching for standard skills required for safe diabetes discharge Once identified, the next step was to identify the most appropriate method and skilled personnel to deliver these concepts Each concept was assessed for education content, complexity, goals, and method of evaluation Each member of the multi-disciplinary team also was assessed for clinical expertise, patient education experiences, and availability It became clear that all members of the team could easily be used to provide excellent patient and family education for this complex dis-
X
X X X X
1 2 3 4
X X X X
1 2 3 4 5 1 2 3 4 1 2 3 4 5 6 7 8 9
X X X X X X X X X
X
X X X X X X X X X
114
PEDIATRIC NURSING/March-April 2006/Vol 32/No 2
Series
Table 2 Data Analysis
n
2000 2003 2004 Note:
a b
a
Mean LOS 292 324 309
Median LOS 3 3 3
Readmit 0 0 0
b
24 35 28
n the total number of patients from January-June of each year Readmissions, primary diagnosis diabetes, within 60 days of discharge
mary patient and family educator and, therefore,
educational opportunities are not compromised by off-shifts, weekends, and holidays, without an increase in the length of stay Future study is needed to determine the impact of this standard on the outpatient clinic setting, patient and staff satisfaction, and discharge preparedness References
ease In particular, the staff nurse assumed an expanded role in patient/family education for this population see Table 1 The CDE role was retained to provide the opportunity to assess patient and family discharge readiness The CDE also serves to bridge the transition from inpatient to the outpatient management programs Patient and family education continues to be a priority in the outpatient program Based on the work of the task force, new processes and responsibilities were developed By maintaining the CDE role in the process, the team is able to evaluate discharge preparedness, via role play scenarios, and validate the role of the staff nurse in education It is imperative to incorporate the various styles of learning when preparing a patient and family education program Adult learning theories encourage flexible education programs that offer a variety of learning methods such as
discussion, visual/audio opportunities, and opportunities to repeat and demonstrate what has been learned Walker, 1999 Teaching and learning principles, when applied to children, must reflect the developmental and cognitive level of the child Llahana et al, 2001 In support of these theories, various forms of patient educational materials were evaluated and ultimately selected to be included in the educational program The team developed two pediatric diabetic management tools: a patient and family guidebook and a nursing diabetes resource binder All education materials are readily available on the pediatric units All pediatric nurses attended an eight-hour comprehensive pediatric diabetic class, which included case discussions and a written exam Key program components included diabetes management, growth and development, nutrition, and patient/family education principles Each nurse must demonstrate continued competency annually through direct patient care opportunities and case study participation
Quantifiable Results
It appears that disseminating education to the unit level is feasible The data points measured include mean and median length of stay for new onset diabetes and the
number of readmissions, primary diagnosis diabetes, within 60 days of discharge Due to the need to collect 2004 data that reflect readmissions within 60 days, the team chose to focus on months JanuaryJune Baseline data from January 2000-June 2000 was collected on 25 patients The mean LOS was 292, the median LOS 3, with no reported readmissions Post implementation data collection was delayed until 2003 to avoid variables such as change in endocrinologist as well as the length of time to educate all staff 2003 data from January-June included 37 patients The mean LOS was 324, median LOS 3, with no reported readmissions The 2000 and 2003 groups were further compared using asymptotic significance 2-tailed analysis, which found no significant difference in LOS between the two groups p316 A secondary analysis was conducted in 2004 to demonstrate continued effectiveness in this education program Thirty-four patients were included in data collection from January-June, 2004 The mean LOS was 309, median LOS 3, with no reported readmissions The asymptotic significance 2-tailed analysis for 2000 and 2004 found no significant difference in LOS between the two groups p788 Further, the readmission
rate for all three years remained comparable at zero see Table 2
Conclusion
The team is pleased to implement standard processes that support patient outcomes and excellence in pediatric diabetic care The process facilitates patient and family education from the moment of admission The program supports learning theories based on incremental education and the impact of stress on the learning process The staff nurse is now the pri-
Barber-Parker, ED 2002 Integrating patient teaching into bedside patient care: A participant-observation study of hospital nurses Patient Education and Counseling, 48, 107-113 Juvenile Diabetes Research Foundation 2004 Annual report 2004 Retrieved December 15, 2004, from http:// w w w j d r f o r g / i n d e x c f m ? f u s e actionhomeviewPagepage_id14 AF69BC-BE51-42DA-B1B41955029 FBC7F Leyden, C, Caravalho, J, Saylor, C 2000 An evaluation of a nurse casemanaged program for children with diabetes Pediatric Nursing, 26, 296 Llahana, SV, Poulton, BC, Coates, VE 2001 The paediatric diabetes specialist nurse and diabetes education in childhood Journal of Advanced Nursing, 33, 296-306 London, F 2004 How to prepare families for discharge in the limited
time available Pediatric Nursing, 30, 212214, 227 Lowes, L, Gregory, J 2004 Management of newly diagnosed diabetes: Home or hospital Archives of Disease in Childhood, 89, 934-937 Moore, J, Kaiser, C, Aisenberg, J 1997 Care and management of the child with diabetes Home Health Care Management Practice, 9, 33-51 Page, N, Mackowiak, L, Bratt, K 1999 Identifying and caring for the child with new onset type 1 diabetes Journal of the Society of Pediatric Nursing, 4, 128-129 Powell, E, Austin, A 1998 Developing a pediatric diabetes critical pathway Pediatric Nursing, 24, 558 Rosenbloom, A, Hanas, R 1996 Diabetic ketoacidosis: Treatment guidelines Clinical Pediatrics, 35, 261-266 Siminerio, L, Charron-Prochownik, D, Banion, C, Schreiner, B 1999 Comparing outpatient and inpatient diabetes education for newly diagnosed pediatric patients The Diabetes Educator, 25, 895-906 Suderman, E, Deatrich, J, Johnson, L, Sawatzky-Dickson, D 2000 Action research sets the stage to improve discharge preparation Pediatric Nursing, 26, 571-576 Walker, EA 1999 Characteristics of the adult learner Diabetes Educator, 25, 16-24
PEDIATRIC NURSING/March-April 2006/Vol 32/No 2
115
