Home care for children and adolescents with type 1 diabetes: Is it feasible?

Journal of Diabetes Nursing, Jan, 2006 by Jeremy Kirk, Emma Thomas

At presentation of type 1 diabetes most paediatric patients are well and could be home-managed if appropriate facilities were available. Initial diabetes home care from diagnosis appears to be equivalent to hospital-based care in terms of metabolic control, acute diabetic complications and readmission rates. Our own two-decade experience of diabetes home care at Birmingham Children's Hospital confirms its benefit--including a reduction in readmission rates for new and existing patients. Costs of the service are far outweighed by its savings (direct and indirect). One of a variety of models of home care may be applicable to many paediatric diabetes units.

Type 1 diabetes is one of the most common chronic illnesses of childhood, with an increasing frequency in the UK (Gardner et al, 1997). The diagnosis of diabetes has profound implications for the individual and his/her family and its impact is considered by some as a 'psychological crisis' (Galatzer et al, 1982). Only a minority of children with newly diagnosed diabetes are unwell at diagnosis and consequently require hospital admission for medical reasons (Smith et al, 1998); potentially the child could, if well, commence therapy in the home environment. Disruption to the child and family could, therefore, be kept to a minimum.

Outpatient management of type 1 diabetes has been advocated for over 50 years (Walker, 1953), yet most children in the UK and abroad are still admitted to hospital for stabilisation at diagnosis, regardless of their clinical condition (Clar et al, 2003). Recently, the shift in emphasis away from hospital to home management of children with chronic and non-urgent conditions has recognised the need for hospital-based, community orientated paediatric services (Meates, 1997).

In the light of this evidence the recent National Institute for Health and Clinical Excellence (NICE) clinical guidelines on management of children and adolescents with type 1 diabetes (NICE, 2004) has recommended that:

   At the time of diagnosis, children and young people with type 1   diabetes should be offered home-based or inpatient management


    

    

    
    
  according to clinical need, family circumstances and wishes, and

    

    

    
    
  residential proximity to inpatient services. 

It also goes on to state that:

   Home-based care with support from the local paediatric diabetes care   team (including 24-hour telephone access to advice) is safe and as   effective as inpatient initial management' (NICE, 2004). 

Is this true? A Cochrane database review by Clar and colleagues (2003) attempted to systematically review the evidence for routine hospital admission compared with outpatient or home-based management in children newly diagnosed with type 1 diabetes who are not acutely ill. They assessed the type of care on metabolic control, well-being and self-efficacy of the patient and their family. The review itself was inconclusive due to the generally low quality and limited applicability of the studies, many of which had been performed retrospectively. Despite this, it indicated that outpatient/home management of type 1 diabetes in children at diagnosis did not lead, at follow-up, to a worsening of metabolic control (and in the best study, to an improvement), acute diabetes complications, hospital admissions, psychosocial variables and behaviour. However, total financial costs were the same, being improved for parents but counterbalanced by increased health costs.

Paediatric diabetes home care in the UK and Birmingham

Although the Audit Commission (2000) indicated a general reduction in the length of hospital admission at diagnosis of diabetes, apart from publications from a small number of units (Swift et al, 1993; Lowes and Gregory, 2004) there are limited data on home care at diagnosis in the UK. At Birmingham Children's Hospital, in response to a perceived need, a paediatric diabetes home care (DHC) unit was established in 1981. The initial benefits of the service were published in 1984 (Rayner, 1984), and the 20 year results in 2005 (McEvilly and Kirk, 2005). During this time the unit has grown from 230 children with diabetes based on a single site to 400 children spread over two (350 at the Children's Hospital and a further 50 at City Hospital). In order to cope with this increase, the numbers of paediatric diabetes specialist nurses (PDSNs) has increased from 2.0 to 3.6 whole-time-equivalent (WTE; currently there is a ratio of one WTE nurse to 111 patients), along with increases in medical, dietetic and administrative staff. As with many other UK units the recommended ratio of one WTE nurse per 100 patients is not achieved, and psychological support is very limited (Edge et al, 2005). The workload and activity of the unit has also risen during this time, and it has now also been successfully extended to another unit in Birmingham--City Hospital (Kirk et al, 2003).

The DHC service is available 24 hours a day. PDSNs are the first line of contact and work a shift system four days a week (0730-1730 and 1015-2000). PDSNs also provide routine and emergency visiting and on-call at the weekend. The consultant staff are on-call one in three for endocrinology and diabetes and also cover the PDSNs at times of holiday, illness or study leave.