A pre-post study evaluating the implementation of a paediatric diabetes management program that results in world-leading glycaemic outcomes for children and young people with type 1 diabetes.

The Success with Intensive Insulin Managment (SWIIM) program is a management program for young people with type 1 diabetes (T1D) developed at the John Hunter Children's Hospital (JHCH) over the last 18 years. It comprises management of type 1 diabetes from diagnosis to transition to adult services and is delivered by a multidisciplinary team. Aspects of the program include: 1. Inpatient education program for newly diagnosed type 1 diabetes The aim of the initial admission is to manage diabetic ketoacidosis, commence subcutanoeus insulin and provide education to patients and family members. Individual inpatient education is delivered by diabetes educators and dietitians. This includes 180 minutes of diabetes education, 180 minutes of dietary education and social work support is provided as required by the families. 2. School education Schools, preschools and daycare centres receive a 3 hour education session delivered by a diabetes educator on insulin administration, management of hypo/hyperglycaemia and activity. An individualised school plan is provided for each patient. Schools may contact diabetes educators by phone during business hours. If there is a change in therapy or the child attends a new school, the school visit is repeated. 3. EzyBICC insulin adjustment EzyBICC cards are individualised dosing cards that calculate the meal insulin dose based on an insulin to carbohydrate ratio and correction factor. This allows flexibility for the amounts of carbohydrate eaten and provides correction for hyperglycaemia. Doses are adjusted by the clinician throughout the inpatient admission and at outpatient reviews. Families are encouraged to change to a different card if the postmeal blood glucose is not in target. 4. Insulin pump therapy Insulin pump settings are individualised in accordance with the manufacturer’s recommendations. Doses are adjusted by the clinician throughout the inpatient admission and at outpatient reviews. Families are encouraged to change to adjust the setting if the blood glucose is not in target. 5. Written resources The following written resources were developed by the JHCH team and are provided to families prior to discharge after initial diagnosis: - 10 Essential Habits for diabetes management - How to use ezy-BICC cards - Hypo treatment (pictorial education) - How to communicate with school - How to access NDSS supplies - Identification of carbohydrate, protein and fat - School and lunchbox ideas - How to read food labels 6. Outpatient reviews Families can contact diabetes educators by phone/email during business hours and are encouraged to maintain phone contact daily for the first 1-2 weeks after discharge to allow ongoing dose adjustment and to address queries and concerns. Patients are reviewed face-to-face in outpatient clinic 2-6 weeks after discharge by diabetes nurse educator and dietitian for a 60 minute review. 30 minute face-to-face reviews with the paediatrician occur on a 3 monthly basis following discharge. During these visits height, weight and HbA1c are measured. Continuous glucose monitor downloads, blood glucose records and insulin pump downloads are reviewed and insulin doses are adjusted. Families are given the opportunity to discuss issues and concerns. Education is provided as needed. Families are seen by diabetes nurse educator, dietitian and social worker for a face-to-face 30 minute review once per year but can be reviewed more frequently if there is a clinical need. The SWIIM program will be implemented in two centres in the Mid-North Coast Local Health District (MNCLHD) in rural NSW over a 2 year period. The program will be implemented with the following steps: 1. 5 day outreach visit (3 days Coffs Harbour, 2 days Port Macquarie) from paediatric endocrinologist where the program will be introduced to local clinicians and patients/their families. 2. Delivery of written resources described the program to clinicians and the above written resources for families will be delivered at the beginning of the implementation. 3. Mentoring sessions for MNCLHD healthcare providers with JHCH healthcare providers (physicians, diabetes educators and dietitians) - 3 hour sessions twice per year. 4. Six monthly 5 day site visits from the paediatric endocrinologist where an outpatient review will be conducted for each patient. 5. Twice yearly collaborative review meetings with JHCH and MNCLHD teams to assess progress of the implementation, refine implementation strategies and monitor data collection.