The role of teamwork in achieving good patient outcomes for children with type 1 diabetes

The aims of paediatric diabetes management are to normalise blood glucose levels (BGL) and help the child in everyday activities. Keeping the child’s BGLs in the normal range will prevent hypoglycaemia, ketoacidosis and other complications. Doing this in a way that allows the child to have a normal life and lifestyle requires an experienced paediatric diabetes multidisciplinary team (MDT) (International Diabetes Federation, 2011).

The MDT has been well described (de Beaufort et al, 2012a). The team should include experienced health professionals (such as doctors, paediatric diabetes educators, dietitians, social workers, psychologists and ward staff) and non-health professionals involved with the child (such as the family, teachers and coaches). It is now well recognised that the MDT needs to talk and work together in order to achieve good practice and this can be strengthened by using written protocols, guidelines and targets (Brinks, 2010; Goss et al, 2010).

Common sense would suggest that if centres had experienced MDTs and the same access to treatment regimens, then the outcomes should be the same in all centres. However, the Hvidøre Childhood Diabetes Study Group has shown that this is not the case (Danne et al 2001; Swift et al, 2010; de Beaufort et al, 2012b). These studies found marked differences in patient outcomes (based on HbA_1c and incidences of hypoglycaemia) in 21 paediatric diabetes centres that were committed to MDT management across 17 countries. Although socioeconomic status, age, regimen type and other factors have been shown to influence individual outcomes, they have not explained the marked differences between these centres. This suggests that there may be fundamental differences in the approaches taken by the MDTs at the different centres that may account for the varied outcomes.

This is supported by the fact that although the Hvidøre Group recognised an improvement in the average HbA_1c from 70 mmol/mol (8.6%) in 1995 to 64 mmol/mol (8.0%) in 2009, this was not associated with changes in insulin regimen such as the introduction of analogue insulins or the use of insulin pumps. Instead “non-medical” variables, including setting targets and effective communication within families, were strongly associated with good metabolic outcomes (Cameron et al, 2013).

It is important to remember that the families receive their diabetes education and BGL targets from the MDT. A study by the SWEET consortium has shown significant differences in the training of MDTs in Europe, suggesting fundamental differences in approach that may contribute towards the different outcomes. The SWEET consortium has recommended that MDTs have clear leadership, philosophies, policies, procedures and evidence-based targets, while the team members need to have clearly defined roles and consistent training and education (Waldron et al, 2012).

One unit’s experience
The John Hunter Children’s Hospital Diabetes Unit (JHCH) in New South Wales, Australia has three paediatric endocrinologists, one paediatric diabetes educator, one dietitian and one social worker. It provides care to 550 children with type 1 diabetes (350 children in the outpatient setting and 200 in rural outreach settings). Patients are seen four times a year because of staffing limitations. Before 2004, the majority of children and adolescents were on twice daily insulin therapy and the average clinic HbA_1c was 70 mmol/mol (8.6%).

In 2004, following the annual International Society for Pediatric and Adolescent Diabetes (ISPAD) scientific meeting in Singapore, the JHCH team decided that good control was critical and that clinic outcomes needed to be improved urgently. The team held meetings and decided that a multidisciplinary approach with defined treatment targets and coordinated management plans was required to improve patient outcomes. By 2007, all patients were on intensive insulin regimens, the average HbA_1c was 62 mmol/mol (7.8%) and severe rates of hypoglycaemia were decreased (consistent with findings from the Hvidøre study [Danne et al, 2001]). This was achieved without increased resources or more staff. In 2013, the average clinic HbA_1c had decreased to 56 mmol/mol (7.3%) without increased rates of severe hypoglycaemia.

The “spacing effect” model of education
The “spacing effect” is where people remember and retain facts more consistently when they are repeated a few times spaced over a long time span (spaced presentation) rather than repeated in a short span of time (massed presentation) (see http://en.wikipedia.org/wiki/Spacing_effect [accessed 04.12.13]).

The JHCH began using this concept in diabetes education. All MDT members were involved in development of coordinated management plans. Each team member (within their specialty area) discusses the management plan with the child and family. This means that patients and their families hear the same messages repeated over a longer time span. Hence, the patient and family receives a cohesive and coordinated management plan addressing all aspects of daily diabetes care (Table 1).

Role of the multidisciplinary team
In order for an individual and their family to perform the daily tasks that are involved in diabetes care, they must believe that their actions will produce outcomes that outweigh any inconvenience. The primary role of the MDT is to deliver a specifically tailored plan that meets the needs of the individual and their family. For the individual and their family to act on the plan, the MDT must develop and present a plan that is consistent, achievable and believable. If the MDT is to achieve this it must have appropriate team members, defined treatment targets, a coordinated approach and clear channels of communication. 

Team members, such as paediatric diabetes educators, dietitians and social workers, need to be appropriately qualified and be specialised in paediatric diabetes (Waldron et al, 2012). The management of paediatric diabetes involves an appreciation of family dynamics, child psychology and the science behind the care of a child with diabetes. Professionals who are not specifically trained in paediatric diabetes may not appreciate the subtleties of these interplays. For example, ward-based paediatric nurses are available to help families while the child is in hospital, but the nurse may have limited experience of children with diabetes and may end up giving them inappropriate or conflicting advice.

At JHCH, the ward paediatric nurses are trained to educate families on some aspects of management, including insulin administration and carbohydrate counting. The nurses are educated on training days and during ward in-services. Only nurses that have had the training are allowed to care for children with diabetes and this ensures that the families receive consistent and appropriate education which is invaluable in reinforcing what they have learnt from the team.

Defined treatment targets
The Hvidøre International Study Group demonstrated that the patient’s perceived ideal HbA_1c closely correlated to their actual HbA_1c. Additionally, they showed that a clinic’s average HbA_1c was lower in centres where the MDT members had agreed on an HbA_1c target (Swift et al, 2010). Hence, it is important that teams define their targets.

Defined treatment targets are goals that are clearly stated and agreed to by all members of the management team. Targets cover a range of aspects of management, such as type of regimen to be used, BGL targets, frequency of reviews and dietary principles. When targets are clearly defined it improves the team’s ability to develop a coordinated plan (Box 1). For instance, if team members do not agree on BGL targets before exercise then divergent advice will be given to families. When MDT members have defined treatment targets the individual and their family will hear the targets regularly. Repetition improves learning and changes beliefs (Cunningham et al, 1984; Foster et al, 2012). When MDT members do not have consistent targets they may inadvertently undermine what other team members are saying (Table 1).

Coordinated management plans
Coordinated management plans are required for everyday issues such as approaching exercise, managing hypoglycaemia and sick-day management. Defined treatment targets underpin the development of management plans. For example, if the treatment target was to have BGLs between 3.9–8 mmol/L then this is the target BGL before exercise and directly influences how carbohydrate and insulin are adjusted for activity.

A coordinated management plan occurs when all team members have decided how to approach an issue and each member reinforces the other team members’ message. When all team members repeat the same message it results in improved message retention by the family and also gives subconscious validity to the message (Cunningham et al, 1984; Foster et al, 2012). A lack of a coordinated plan causes the family to receive varied recommendations from different team members. The family then have to decide themselves whose advice they will follow.

The family is the critical lynch pin in paediatric diabetes management as they provide the day-to-day care. Hence, it is critical that they and significant others, such as staff at the child’s school, are involved in the plan development. Families of children with diabetes are often required to understand quite complex information, so it is important that messages are consistent, repeated and work appropriately for the individual.

Communication
Clear channels of communication are essential for teams to set targets and to establish coordinated management plans. All members must be committed to the targets and management plans. This is essential if the families being seen by the team are to believe in the approaches that are recommended. 

JHCH uses a number of communication strategies, including planning days, weekly team meetings, case conferences, clinics, ward rounds and individual discussions. The development of guidelines and education resources (Box 2) also ensures continuity, particularly when new staff members join the MDT.

Planning days are used to discuss and determine overall management philosophies and strategies. For example, “we will aim for all BGLs to be in the normal range 80% of the time” and “this will be achieved by use of multiple daily injections and insulin pumps”. Weekly meetings are used to discuss approaches to specific issues, such as whether to use juice rather than jelly beans when a child is recovering from hypoglycaemia. Case conferences are used to discuss how particular problems should be approached. For example, using regular overnight BGL monitoring to help maintain good control and prevent nocturnal hypoglycaemia.

Clinic and ward rounds allow members of the team to see what the other members are saying to patients and how they are addressing issues, and allows team members to clarify how other team members address issues. Resources and guidelines are written to help the team ensure conformity to the team message. For example, “ten top tips” for people on injections (Box 2) is used by the MDT as the basis for all advice. This A4 sheet is laminated and given to families to put on their fridge door.

For communication to be effective it is essential that all members of the team are valued and respected equally. This must be perceived not only by the team members but also by the patients and their families. It is a common misconception by families that one particular team member (such as the doctor) has more to contribute than other members. Discussing the roles of each team member in a positive and constructive manner highlights their importance to the family. Emphasis on team management should occur from the first meeting with the family. Families who only listen to the doctor may miss out on the benefits that being treated in a multidisciplinary setting can bring. Part of the doctor’s role is to ensure this does not occur.

Conclusion
Members of an MDT must be trained paediatric specialists who communicate regularly to ensure defined treatment targets and coordinated management plans. When MDT members communicate the same messages to patients and families, then the families receive consistent, reinforced and functional messages, which help them achieve glycaemic control and quality of life.