Diabetes management: hospital or home?

Abstract

Denise Matthams BSc(Hons), RGN, RSCN is a Paediatric Diabetes Specialist Nurse, Worthing and Southlands NHS Trust, West Sussex Type 1 diabetes is the most common endocrine disorder in children. The initial management of the diabetic child and his or her family differs considerably from one area to another, dictated by local frameworks of care. Traditionally, children would be kept in hospital so that their early needs would be provided for, but increasingly this management approach is being challenged (Lowes and Lyne 2000a, McEvilly 1991, Swift et al 1993). The development of paediatric diabetes teams, with expertise in both paediatric and diabetes care, has had a direct effect on the management of the newly diagnosed child and family. At diagnosis, the trend is for home management or at the very least, a reduction in inpatient stay. Although home management at diagnosis is not explicitly recommended, the provision of paediatric diabetes teams is a consistent policy theme (British Diabetic Association 1996, DoH 2002) that has led to a growth in this style of management. Without adequate evaluation of the strengths and weaknesses of home management there is a risk that best practice will not be recognised and implemented. This article summarises the findings of a literature review of the effectiveness of home management at diagnosis. An initial search revealed very little information relating to hospital and home management at diagnosis but a broader search made it possible to link studies of chronic conditions and hospitalisation to the needs of the diabetic child at diagnosis. Implications for future practice are considered and recommendations are made, allowing for the limitations of the literature appraisal. Traditional practice Although literature and guidance relating to home management of newly diagnosed diabetic children is scarce, there is evidence that by the early 1980s some larger centres had started to provide this service (McEvilly 1991, Swift et al 1993). Traditionally, diabetes specialist nurses with a combined caseload of adults and children carried out paediatric diabetes care. In 1993, the Royal College of Nursing (RCN) paediatric diabetes special interest group argued that: ‘The child with diabetes has specific needs that can only be met by paediatric nurses with extended skills in diabetes care, working as educators, counsellors, managers, researchers, communicators and innovators, who are held responsible for their own actions and who are registered sick children’s nurses or equivalent’ (RCN Paediatric Diabetes Special Interest Group 1993). An audit evaluating the impact of the paediatric diabetes team in Worthing and Southlands NHS Trust revealed that in 1993 newly diagnosed children were admitted for periods of up to 10 days. By 1996 the adult diabetes team were providing support and the mean length of stay for well, newly diagnosed children was four days. By 2002 the mean length of stay had dropped to 0.75 days when the paediatric diabetes team was well established. In keeping with other centres it was found that this approach to care also had a positive effect on reducing bed days for children with established diabetes (Kirk et al 2003, Matthams 2002).