At most children’s hospitals, a multiday inpatient education process is the standard of care for children and teens presenting with the new onset of type 1 diabetes. Seattle Children’s Kate Ness, MD, MSCI, and members of the Endocrinology and Diabetes team believed there was a better solution. In late 2019, shortly before the arrival of the COVID-19 pandemic, they opened the Outpatient New Onset Diabetes Program. The results have been dramatic.

Kate Ness, MD, MSCI, Seattle Children’s Endocrinology and Diabetes team

Dr. Ness witnessed the positive effects of outpatient diabetes education during her fellowship training at Vanderbilt University Medical Center. When she arrived at Seattle Children’s in 2009, “it came as a surprise to me to see that we were keeping kids in the hospital for three days, primarily for educational purposes. We know that not all of our patients medically need an inpatient hospital bed, and there is literature that supports outpatient education being as safe and effective as inpatient education.”

Being diagnosed with diabetes is a life-changing event for children and families, and the sheer volume of new information — counting carbohydrates, calculating insulin doses, persuading a child to have their finger poked and to get an injection — to say nothing of the emotional rollercoaster, can be overwhelming.

When Joy Briggs, RN, MBA, MSN, was offered the opportunity to become the practice manager for the New Onset Outpatient Diabetes program in 2018, she jumped at the chance to make a difference for children like her son. Briggs had been a nurse leader for five years when her son was diagnosed in 2016. Said Briggs, “The clinical intake nurse said, ‘I don’t want you to be alarmed, but I want you to drop everything and take your child to the emergency room at Seattle Children’s where he will be admitted for education.’ And my initial gut was, why am I bringing my son to the emergency room for teaching, that’s ridiculous. My child did not appear to be sick enough to be an inpatient. Yes, he was being diagnosed with a chronic lifelong disease process that would need significant management, but it wasn’t something that was going to kill him today. And being an inpatient is really stressful and overwhelming. It’s like drinking water out of a fire hose.”

Joy Briggs, practice manager of Seattle Children’s Onset Outpatient Diabetes program, with her son, Garrett

Members of the new team visited two of the few existing pediatric diabetes outpatient education programs around the country. Said Dr. Ness, “We took the aspects of what we thought were best practices from these different places and brought them together to create our own program. One unique element of our program is that we embedded Child Life specialists into our program. These specialists help children understand their diagnosis in an age-appropriate way and normalize the finger pokes and injections which can be somewhat traumatic. We wanted to take away some of the trauma and make it an easier experience for the kids and parents.”

 

Unique algorithm determines outpatient vs. inpatient criteria

The new outpatient program opened in 2019, with goals to:

    1. Redirect children who are not in diabetic ketoacidosis to outpatient care
    2. Create a new-onset diabetes pathway for primary care physicians (PCPs), emergency department staff and families to follow
    3. Deliver necessary information and education to families in a caring way and digestible manner

The team created a unique algorithm to determine the criteria for admitting patients with new-onset diabetes. They share it broadly with referring PCPs and emergency department (ED) personnel to appropriately triage children who present with symptoms of new-onset diabetes.

Said Dr. Ness, “The diabetes team, our PCPs and our emergency department colleagues all use the same tool. It allows us to have a shared mental model of who we think are safe and appropriate kids to be outpatient and who should be inpatient.”

According to Briggs, “A primary care physician will call our doctor-to-doctor line and talk with an endocrinologist about why they think their patient may have diabetes. The endocrinologist uses the algorithm to make a determination of where that child needs to go. If they meet the outpatient criteria, they come in within 24 to 48 hours of that initial phone call for their new-onset teaching.”

Since its inception in 2019, the new program has reduced the new-onset diabetes inpatient stay from more than 2 days down to 24 hours or less. Everyone is thrilled with the outcomes: the Seattle Children’s team, patients and their families, PCPs, emergency room staff and medical insurers.

Children who are in ketoacidosis still have to be admitted to the hospital to be stabilized. “Those children receive their first day of diabetes education as inpatients and then come to our outpatient program for the second day of education,” said Briggs.  “A little less than half of our patients are admitted for that 1 day and the rest are outpatient.”

Patients and their families return to the clinic for their second day of education one week later. By then,  they have had time to process new information and to practice new skills. The second outpatient education day allows them to ask different questions and absorb more complex skills.

 

COVID-19 exploded the population of pediatric patients with diabetes

Simultaneously with the development of the outpatient program, a new freestanding diabetes clinic was designed and built with outpatient education in mind.

Two months after the new clinic opened, COVID-19 happened. Its impact on the clinic was immediate. The number of monthly new-onset diabetes patients doubled from 15 to 30 or more, while at the same time in-person classes were not allowed. The new team quickly had to pivot and figure out how to provide services via telehealth. The unexpected benefit has been that through telehealth, the team has been able to expand their services across the WAMI region (Washington, Alaska, Montana and Idaho).

According to Dr. Ness, the new-onset program acts as a gateway into the Seattle Children’s Diabetes Clinic, which treats thousands of children and teens with diabetes each year and is active in research to advance care of pediatric diabetes.

In 2021, the team launched an entirely separate program specific to type 2 diabetes. Patients and families complete an educational program first and then enter the Type 2 Diabetes (T2D) Clinic, where a team of specialists helps patients make lifestyle changes and manage their diabetes with the best medications for their condition.

Seattle Children’s Endocrinology and Diabetes program is consistently ranked as one of the top programs of its kind in the United States. The team provides long-term care for children and teens who have issues with growth, puberty, diabetes or other disorders related to hormones and the glands that make them.

 

If you would like to know more about this program or speak to one of our endocrinologists about a patient, please email joy.briggs@seattlechildrens.org.