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Notes: This template is designed to provide a concise source of evidence of compliance with the National CYPD Network Self Assessment measures which are mapped to NICE and other national guidance. This document may be requested to provide verification of the Self Assessment and can also be used as evidence There should be a specific governance team or divisional meeting at which this plan is formally reviewed.

Keeping this up to date enables evidence of the current situation to be readily presented to CQC, HIW or other regulatory or commissioning teams. © RCPCH 2019 – shared for use by paediatric multidisciplinary diabetes teams in the UKFor more resources and information please see www.rcpch.ac.uk/diabetesquality

Operational Policy for the Children and Young People with Diabetes Multidisciplinary Team (MDT)

[Name of Trust]

Revised [Date]

This operational policy was agreed by the [Name of CYP Diabetes Team] on [Date]

Date for review: [Date]

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Table of Contents

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CYPD Hospital Measures

Introduction

Short description of service provided, locations used.

Aims and Objectives of the CYPD Team

Complete as agreed between the MDT and Trust.

Philosophy of Care

List as agreed

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Trust Wide Management Group (H1)

The Trust wide management group responsible for the co-ordination and care of children and young people with diabetes is the [name of team] at [name of Trust/Health Board] led by [name of lead clinician/lead for team], [Title].

Describe here how the team fits into the Trust /Health Board and Children’s Services structure.

Role Team Member*Trust Manager with responsibility for CYPD services*Lead Paediatric Consultant for CYPD*Lead Paediatric Specialist Nurse for CYPD*Lead Paediatric Specialist Dietitian for CYPD*Lead Psychologist for CYPD*Lead Consultant for care of adults with diabetesOther

[*These are the essential roles, others may be added according to size of team and other Trust requirements]

The accountability of this group is to the [name and show the governance structure]. The meetings are held [frequency] and minutes are documented electronically for governance purposes. The [name] is then accountable to the Trust Board. Terms of Reference are in Appendix x.

Twenty-four Hour Advice Service (H2)

The Children and Young People’s [name] Network has agreed the specifications for a 24 hour advice service, seven days a week (Appendix x) -

1) for telephone advice on diabetes management to patients/carers2) for telephone advice to health care professionals on the management of CYPs

with diabetes admitted to hospital3) for this local team’s escalation policy to tertiary centre at [name]

Describe the service provided here. Include local services and the escalation policy. If you are the tertiary centre providing escalated services then please describe this too.

Advice line rota and contact sheet in Appendix x

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Device Download Facilities (H3)

Out-patient services are based at [name all sites where outpatient clinics take place]. At each out-patient clinic visit [list which are provided - glucometers, insulin pumps or continuous glucose monitoring systems or all] are downloaded on arrival in preparation for the consultation. The downloading is performed by [who?] and this is mainly on the Diasend system [name others]. [If this does not happen then describe what does occur].

Other software such as [names] are also commonly used in clinic. Patients are encouraged to download at home using the appropriate software for their devices, and the clinic is able to view the information remotely or through email and give advice as required [amend as required].

Point of Care Testing for HbA1c (H4)

On arrival at clinic patients have their weight, height, and blood pressure measured [amend if this is not done] and the clinic nurse takes a blood sample for point of care testing of IFCC HbA1c measurement. [Is this available in all clinic settings? If not say where this does not occur, what is being done to address and what contingencies are in place]?

[How is the HbA1c reported -mmol/mol (IFCC) or %(DCCT) or both? Is this written on a record of care for patients and their families? Are all results available for the consultation and uploaded on to whichever electronic diabetes management system is in use? Add to or change as required]

The point of care HbA1c [DCA2000 or others?] machines are tested and calibrated [frequency]. Currently the UK [NEQAS /WEQAS/RIQAS/other] standards are complied with. Print outs can be provided as required.

Paediatric Ward Staff Training (H5)

Training for ward staff is provided on a [frequency] basis. [Describe the training and who undertakes]

The training programme for health care professionals for all wards where CYP with diabetes may be admitted includes:

• the management of children and young people newly diagnosed with diabetes;• the use of all equipment used specifically for children and young people with diabetes including insulin pumps and glucose monitors;• the principles of dietary management including offering Level 3 carbohydrate counting from diagnosis;• the safe use of insulin;• the management of hypoglycaemia;• the management of children and young people in diabetic keto-acidosis (DKA.);• the care of children and young people with diabetes undergoing surgery.

Paediatric medical trainees receive training about Diabetes emergencies [describe how].

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[Any other groups of AHPs trained? If so describe].

[Describe the records kept to show the content of training and attendance].

Outpatients’ Consultation Time (H6)

[Does a pre clinic meeting take place before the start of clinic to identify any current issues and to share information between the healthcare professionals in preparation for the consultations- if so describe]?

Describe how the clinic appointment works.

e.g. at each clinic appointment, is the CYP offered consultation with all members of the multidisciplinary team (MDT), defined as including a doctor, paediatric diabetes specialist nurse and paediatric diabetes specialist dietitian?

Do they routinely see all team members or how is it decided who they see? Do they see the consultant each time as decreed by BPT?

How do they access psychologists, are they in clinic?

Describe access to youth workers.

Is each appointment scheduled to last for at least 30 minutes to allow time for reviewing the equipment downloads, interpretation of results and discussion to gain a clear picture of current situation?

Describe transition clinics separately and include if young people in the transition clinics are offered the chance to be seen on their own before a joint consultation with their carer – if so describe.

Appendix x - Anonymised Clinic Template

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CYPD MDT Measures

Leadership arrangements and responsibilities

(M1)

[Name] is the clinical lead for the children and young people’s diabetes team MDT.

The Lead Clinician’s responsibilities include: Attend the CYPD network meetings. Ensure diabetes guidelines are updated. Coordinate the regular review of the MDT action log and high HbA1c meetings making

sure the minutes are recorded and acted upon. Review audit programme. Produce annual report and work plan Overseeing the professional development of multidisciplinary team members Maximise the opportunities for the team with the introduction of Best Practice Tariff and

Peer review.

[Change or add as required]

Deputy lead Clinician[Name if there is one]To provide cover for the Lead clinician at all times

Core Membership (M1)Example

Core TeamTeam member Role Start date in

PD ServiceQualification (see notes in audit tool)

Specified Time/WTE

Consultants Dr Ed Sheeran Lead Con Paediatrician 1998 Exempt 1.5PADr Taylor Swift Con Paediatrician 2012 SPIN 2011 0.5PA

PDSNEmilie Sande Lead PDSN 2010 Warwick

University Module

1.0

Pixie Lott PDSN 2012 Birmingham University Module

1.0

Celine Dion PDSN 1997 Exempt 0.5

Paediatric Diabetes Specialist DietitiansDoris Day 1996 Birmingham 0.5

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University Module

Mariah Carey 2013 York University Module

0.2

Clinical PsychologistsBruce Springsteen 2008 0.2

AdministratorsKylie Minogue Data Entry Clerk 0.5Lily Allen Medical Secretary 0.2

OthersBruno Mars Youth Worker 1.0

Extended Team Name Job TitleLink for child safeguarding Ward link nursePodiatryAdult Diabetologist

Responsibilities of Core Nurse Members: [add/change as required] Contribute to multidisciplinary team and patient assessment/care. Provide specialist educational and training support to patients, parents and schools,

promoting holistic care. Provide link nurse responsibilities to their named patients, contributing towards high

HbA1c meeting and informing team of specific problems. Liaising with key workers including schools on behalf of their patients. Contribute towards the efficient management of the team, completing templates and

utilising new ideas and research as discussed by the team. Contribute towards audit. Acting as advice and expert resource for other professionals. Maintain up to date knowledge base and understanding all aspects of diabetes care and

how it relates to dietetics and healthy living.

Responsibilities of Core Dietitian Members [add/change as required] Contribute towards the multidisciplinary discussion and patient assessment/care. Provide expert dietetic advice and support to other healthcare professionals. Lead on education of patients, parents, AHPs, kitchen staff and other staff on CHO

counting and dietary management. Advice for schools as necessary particularly in relation to school menus. Maintain up to date knowledge base and understanding all aspects of paediatric dietary

management and paediatric diabetes care and how it relates to dietetics, complication management and healthy living.

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Responsibilities of Psychologists Core Member(s) [add/change as required] Contribute towards the multidisciplinary discussion and patient assessment/care. Provide specialist assessment of mental health in CYP and their families and direct

psychological interventions in relation to psychosocial aspects of living with diabetes. Signposting and referral on to local and regional mental health and social care services. Coordination of annual screening for emotional well-being in CYP and their families. Provision of consultation and advice to MDT members and other professionals from

external agencies in relation to psychosocial adjustment. Ongoing service development in line with relevant policies/guidance to enhance the

overall psychological care provided to families. Development of information resources available to children and families in relation to

emotional well-being. Participation in service evaluation and audit to further improve psychological care and

incorporate patient-rated experience.

Responsibilities of Administrator [add/change as required] Act as consultant/team secretary. Support the team in organising meetings, liaising with parents etc. Ensure the diabetes letter templates are updated. Maintain diary of events, staff holidays etc.

Responsibilities of Data Clerk/Administrator [add/change as required] Act as data administrator for the team. Support the team in ensuring accurate data collected and validated by clinicians.

Ongoing Specialist Training (M1)

Initial training to qualify as a core member is listed in the core membership table above. The most recent Continuing Professional Development for those considered exempt will be itemised in the MDT’s Annual Report.

Clinical Guidelines (M3)

Make a statement about the guidelines the team follows [– e.g. the team works within the NICE guidelines (2015) and ISPAD (2014)/BSPED (2015) in all aspects of diabetes management]. [Include any local guidelines used].

[Describe how guidelines are reviewed regularly and where they are available e.g. the intranet for all staff to access].

Guideline Guideline Reference Number (if applicable)

Date last reviewed.

Date agreed by/endorsed by CYPD Network

Care of children and young people newly diagnosed with diabetes, including that, for Type 1 diabetes, children and young

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people from diagnosis must be offered insulin therapy with multiple daily injections (MDI) and Level 3 carbohydrate counting.

Care of children and young people with diabetes undergoing surgery.

Care of children and young people with diabetic keto-acidosis (DKA).

Care of children and young people with hypoglycaemia.

Care of children and young people with an HbA1c greater than 69 mmol/mol (8.5 %).

Sick day rules.

For Type 1 diabetes, the option of continuous glucose monitoring (either on-going or intermittently) should be offered to patients who meet the NICE criteria.

Others?

Guidelines - Appendix x

Patient Pathways (M4)

Describe general pathways for patients.

Pathway Pathway Reference Number (if applicable)

Date last reviewed.

Date agreed by /endorsed by CYPD Network

Referral of the newly diagnosed patient (aimed at primary care and general paediatric services); including that a child or young person with a new diagnosis of diabetes is discussed with a senior member of the children and young people's diabetes team within 24 hours of presentation to hospital.

That all new patients must be seen by a member of the specialist paediatric

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diabetes team on the next working day.

Management of complications of diabetes including DKA and hypoglycaemia.

[Describe how and when final agreed pathways for the referral of newly diagnosed patients in primary care have been distributed to the CCGs for onward distribution to GPs.]

Patient Pathways - Appendix x

Primary Care Communication (M5)

Informing the GP of the diagnosis and requirements for initial prescribing. Describe how this is undertaken following patient discharge to meet the timescale requirements.

Any methodology for ensuring this has been completed in the required timescale?

Letter Template to GP - Appendix x

Patient Choice of Insulin Pump Therapy (M6)Describe the process for initiating pump therapy.

Continuous Glucose Monitoring (CGM) (M7)Describe how all children and young people with type1 diabetes who have frequent severe hypoglycaemia and all other criteria as listed in the most recent NICE guidance, are offered on-going real-time continuous glucose monitoring with alarms.

Multidisciplinary Follow-Up Appointments (M8)Describe how this occurs and is monitored.

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HbA1C Measurement (M9)

Describe how this occurs and is monitored.

Dietetic Assessment (M10)

Describe how this occurs and is monitored.

Psychological Assessment (M11)

Describe how this service is provided and is monitored.

Additional Contacts (M12)

Describe how this occurs and is monitored.

Did Not Attend Policy (M13)

Describe how the policy works, how it links to trust policies, who is responsible, how it links to safeguarding and the date the policy was last revised.

Appendix x.

Support for Children in Education (M14)

Describe how this works and who is responsible at all stages and ensure all aspects below are included:

arrangements for liaison with schools and colleges; agreement of a school care plan for each child which is reviewed at least annually; visits to the school or college by a paediatric diabetes specialist nurse to discuss the

care of each newly diagnosed child;

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training and assessment of competence of school and college staff by the children and young people's diabetes team (including school day trips and residential trips);

storage of medicines while in school or college, including safe disposal of sharps; responsibilities of school and college staff for supervising the delivery of/or

administering insulin and the supervising of/or testing of blood glucose levels; guidelines on care of children with diabetes while in school or college; carbohydrate counting of meals; management of physical activity; guidelines on management of diabetic emergencies;

Has the policy been distributed to relevant local educational authorities? Describe how and when.

Appendix x

Screening of Children and Young People with Diabetes (M15)

Children and young people with diabetes must be screened according to current NICE guidance. Describe how this occurs and is monitored.

In Type 1 disease, for: Coeliac disease at diagnosis; Thyroid disease at diagnosis and annually thereafter until transfer to adult services; Retinopathy screening annually from the age of 12 years Moderately increased albuminuria (albumin: creatinine ratio [ACR] 3-30 mg/mmol;

'microalbuminuria') from diagnosis Standard anthropometric data Blood pressure annually from the age of 12 years Foot assessment/examination

In Type 2 disease, for: Hypertension annually starting at diagnosis Dyslipidaemia annually starting at diagnosis Retinopathy screening annually from age 12 years Moderately increased albuminuria (albumin: creatinine ratio [ACR] 3-30 mg/mmol;

'microalbuminuria') from diagnosis

Transition and Transfer Policy (M16)

Describe the process followed in the trust and include when this was agreed by the CYPD Network

Ensure locally relevant contact points are included.

Transition policy Appendix x.

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Key Worker (M18)

Describe the process for allocating named nurse (key worker), when is this done, who decides, how is it allocated?Who do patients contact if their named liaison is not available? [You may think it obvious but you need to describe the process]

Where is this documented and what information is given to families?

What happens during transition?

Patient Information and Support (M19)

What information is given, by whom and when?

How is information provided in alternative mediums eg languages, braille, disability and digital/electronic?

Transition – how does that work?

What about peers groups, social media?

Information Local or Nationally produced

If included in other documents identify which

Date revised/ published

Brief description of the condition and its impact.Treatments available (pharmacological and non-pharmacological).Management of high and low blood glucose crises.Management of diabetes during times of illness, including 'sick day rules'.Nutritional advice.Local arrangements for sharps disposal.psychological well-being.Disability living allowance advice.Travel advice.Possible complications and how to prevent these (including vaccinations).Information on local support groups on paediatric diabetes if available.what to expect at annual review.Description of the steps in the transition process to adult care.The opportunity for peer support to young people during the transition process to adult care.

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Where to go for further information, including useful websites and books.Lifestyle advice, including physical activity, smoking cessation, use of alcohol and recreational drugs, sexual health and contraception, pre-conception care and driving (where applicable).

Individualised Objectives (M20)

Each child and young person has agreed individualised objectives, which are reviewed and updated regularly. These must cover:

life-style goals; target blood glucose levels and how to achieve this through insulin adjustment; therapeutic interventions (pharmacological and non-pharmacological); self-care; individualised healthy meal planning for the child/young person and their family

including carbohydrate counting and co-morbidities that effect dietary management; education and education plan covering, as a minimum, school attended, medication

details, what to do in an emergency whilst in school, giving / supervision of injections by school staff and arrangements for liaison with the school;

early warning signs of problems, especially high and low blood glucose levels, and what to do if these occur;

who to contact for advice and their contact details; planned review date and how to access a review more quickly, if necessary.

How are these objectives that are individualised for each child and young person produced, agreed and reviewed regularly.

What written information summarising this is given to families before they leave clinic.

Diabetes Self-Management Education (M21)The aim of the [name] team is to provide consistent high quality, age and maturity appropriate education from the time of diagnosis and throughout the diabetes journey of the child and family so that the individual can eventually manage their diabetes with confidence and fit it into their individual lives.

Describe how it works, who delivers etc

An outline of the structured education programme is attached in Appendix x.

The Education programme needs to include the following.

DateIs the programme delivered by members of the CYPD MDT who have

[Names of those agreed to deliver programme]

N/A

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undertaken appropriate training in paediatric diabetes management and education?Is there a structured, written curriculum?

[Give name of document] Date last revised

Is the programme adjusted to the age and development stage of the child/young person?

[Describe age banding etc]

Is the programme quality assured against the programme agreed across the Network?

[How was this done?] Date

Does the programme fulfil the requirements of NICE NG18 2015 NICE QS125 2016?

[Who checked?] Date

Does the programme have a named core member of the CYPD MDT who is responsible for organising the diabetes self-management education programme on behalf of the CYPD MDT?

[Name]

Is the programme reviewed annually? [By whom?] Date

Record of Care (M22)

Describe what is given, by whom and when.

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Appendices

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