A new report from the National Paediatric Diabetes Audit (NPDA) has been published regarding hospital admissions in children and young people (CYP) with diabetes. The results show that, disappointingly, the national improvements in diabetes control and completion of health checks highlighted by successive core national NPDA reports have not been accompanied by reductions in the number of diabetes-related admissions to hospital. Furthermore, efforts to reduce the rate of diabetic ketoacidosis (DKA) in those with newly diagnosed type 1 diabetes have yielded little fruit across the last three years of the audit.
Admission rates remained stable between 2012 and 2015, with increasing numbers of admissions reflecting increasing numbers of CYP with diabetes. However, variations in care were identified, with females, teenagers and those living in deprived areas at greater risk of hospital admission. Furthermore, variation in admission rates between diabetes units was also identified.
DKA at diagnosis occurred in around 23% of new cases of type 1 diabetes, and a quarter of all DKA admissions were at diagnosis. Furthermore, 40% of admissions, including DKA, were within the first year following diagnosis.
With these findings in mind, the authors recommend that multidisciplinary paediatric diabetes teams should:
- Ensure that all families and CYP with diabetes receive structured education for self-management during intercurrent illness and episodes of hypoglycaemia. This education should include:
– Use of “sick day rules”.
– Use of blood ketone testing from diagnosis.
– Use of nationally agreed hypoglycaemia management guidelines. - Be aware of the patient characteristics associated with greater risk of admission and develop anti-admission strategies tailored to meet the needs of these groups.
In addition to demographic risk factors, poor glycaemic control was associated with increased risk of hospitalisation, with a 90% increased risk for those with median HbA1c >80 mmol/mol (9.5%) compared to those with a median HbA1c <58 mmol/mol (7.5%). Therefore, multidisciplinary paediatric diabetes teams are encouraged to:
- Aim for all CYP to achieve the (individualised) 48 mmol/mol (6.5%) HbA1c target set by NICE from diagnosis, with emphasis on self-management education, and psychological support.
- Actively work towards improving the blood glucose levels of CYP that are currently out of target range.Pay particular attention to the care needs of the vulnerable subgroup with persistently high HbA1c levels.
– Appropriate engagement, education, technology and psychosocial support for this subgroup are paramount so that they are not lost to follow up and are helped as individuals to improve their diabetes control. - Provide each child with an individualised care plan to achieve the best possible HbA1c given the many reasons for the gradual increase of HbA1c that occurs with duration of diabetes.
- Be aware of the socioeconomic and patient demographic factors associated with worse diabetes control (adolescence, non-white ethnicity, female gender and living in a deprived area), and adapt communications and structured education provision in order to be able to meet the different needs of vulnerable subgroups.
- Inform patients and their families of the increased risk of admission associated with HbA1c levels above the target.
There is a lot of detail in the report, but the key findings and recommendations have been summarised at the beginning, and the authors encourage healthcare professionals to read this section at least. The report can be accessed at:
http://www.rcpch.ac.uk/system/files/protected/page/NPDA%20Hospital%20Admissions%20Report%2011.07.2017_0.pdf
