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SERVICE DEVELOPMENT: TAKING IT UP A GEAR
How British cycling success inspired a new emergency regimen! Justin Ward Paediatric Metabolic Dietitian, Bradford Teaching Hospital Justin has been a clinical Paediatric Metabolic Dietitian for the last 18 months. He has a passion for research, biochemistry, teaching and is aiming to raise the profile of the Metabolic Dietitian. He is currently working on introducing the dietary management of metabolic diseases into higher education academic courses.
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As a relatively new dietitian without much in the way of a professional profile, I suspect many readers will puzzle at the title of this article, stare blankly at my name, look at my photo and ask themselves, “Who is this bloke and what on earth is he writing about?” To make sense of the title we must first understand the recent history of Britain’s cycling performances. Don’t worry if you aren’t a particularly big cycling fan, I’ll keep it brief . . . Prior to 2003, cycling was (sadly) just one in a long list of sports that Great Britain struggled to get to grips with. After years in the doldrums, a man by the name of Sir David Brailsford was appointed as British Cycling’s Performance Director. Fast forward to the present day and we Brits are now the dominant force in world cycling. Achieving any sort of success in British sport instantly catapults the athletes and their managers into the spotlight in an attempt to reveal their secret winning formula. In Sir Brailsford’s case, he believes success was achieved by applying his ‘Marginal Gains’ theory to every aspect of the team’s preparation. “The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike and then improve it by 1%, you will get a significant increase when you put them all together.” (Dave Brailsford, 2012). This logic struck a chord and had me thinking, “How can I apply this theory to my clinical practice as a Paediatric Metabolic Dietitian?” STANDARD EMERGENCY REGIMENS (SER)
An SER is a drink protocol primarily intended as treatment for a number of inherited errors of metabolism (IEM). The SER drink consists of glucose polymer and water, carefully formulated to achieve a specific glucose concentration dependent upon the age of the child. Its consumption is advised during times of
illness, pyrexia, hypoglycaemia and/ or reduced nutritional intake, with the aim of preventing catabolism and providing sufficient fluid.1 At times of acute metabolic decompensation, patients typically stop their usual diet and consume their SER drink at regular intervals throughout the day and night. Two conditions that require an SER are Medium Chain Acyl CoA Dehydrogenase Deficiency (MCADD) and Ketotic Hypoglycaemia (KH). It is beyond the remit of this article to differentiate the pathological features of these two conditions; nonetheless, their respective dietetic management have similar themes, notably preventing excessive fasting and treating episodes of illness with an SER. Typically, a patient and their family receive their SER protocol during their initial visit to the consultant-led multidisciplinary (MDT) clinic. They receive a two-sided, A4 paper document detailing when an emergency drink is indicated, how to make it, how much of the drink to take and what to do should their child not tolerate it. A protocol to aid dietitians in devising an SER is presented in Table 1 overleaf. It is worth noting that any SER given to parents only details how to make the drink appropriate to the current age of the child. Once a child enters the next age range whereby a renewal is indicated, a dietitian will construct an updated copy of the SER. This specifies www.NHDmag.com April 2018 - Issue 133
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CONDITIONS & DISORDERS Table 1: SER renewal guidance2 Glucose concentration of Emergency Regimen
Scoops (5g) of glucose polymer (0.96g CHO/g) per drink and amount of water required
24-hour volume of Emergency Regimen required
0-3 months
10%
1½ scoops made up to 70ml
150-200ml/kg
3-6 months
10%
2 scoops made up to 100ml
150-200ml/kg
6-12 months
10%
2 scoops made up to 100ml
120-150ml/kg
12-18 months
15%
3 scoops made up to 100ml
100ml/kg-1000ml
18-24 months
15%
4 scoops made up to 120ml
100ml/kg-1200ml
2-3 years
20%
5 scoops made up to 120ml
1200ml
3-5 years
20%
6 scoops made up to 140ml
1300-1400ml
5-7 years
20%
7 scoops made up to 160ml
1500-1600ml
7-9 years
20%
7 scoops made up to 170ml
1700ml
9-10 years
20%
8 scoops made up to 180ml
1800ml
10-11 years
25%
9 scoops made up to 180ml
1800ml
11-14 years
25%
10 scoops made up to 200ml
2000ml
14-16 years
25%
11 scoops made up to 220ml
2200ml
>16 years
25%
12 scoops made up to 240ml
2400ml
Age of child
Figure 1: SER updating process (1) Construct latest SER paperwork based on age of child and give to family. (3) Insert patient name on rolling spreadsheet to ensure timely renewal once next age range is reached as per Table 1.
the latest recipe and is sent to the parents, the local paediatrician and the other members of the metabolic MDT. Finally, the dietitian will place the patient’s name on a rolling spreadsheet to highlight when the patient has reached the next age range on Table 1 and the updating process begins again (Figure 1). At the time of writing, the Bradford Metabolic Service cares for 114 patients with KH and 66 patients with MCADD across most of Yorkshire and the Humber. The service receives more referrals per year for patients with KH and MCADD than any other IEM and subsequently these form the two largest patient groups managed. 34
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(2) Update local paediatrician, Metabolic nurses and Metabolic secretary of latest SER by letter/email.
Patients with MCADD are typically referred to the service within days after birth following a positive newborn screening result. The majority of MCADD patients are cared for until they transition to the adult service in Salford at 16 years of age. The main exceptions are those who move outside the geographical boundary of the service prior to transition. KH is not an IEM but rather a descriptive term to highlight the symptoms that a patient presents with, i.e. hypoglycaemia with the presence of ketones. Whilst KH is not an IEM itself, it may be the result of an underlying IEM. However, the majority of children with KH managed within the Bradford service are thought not to fit this
Figure 2: New SER updating process (2) Update local paediatrician, Metabolic nurses and Metabolic secretary of New SER by letter/ email.
(1) Once patient >2yrs old, construct New SER and give to family once.
(3) Insert patient name on a non-rolling spreadsheet for our own reference.
Table 2: Six months following implementation of ‘New SER’ Number of existing SERs transferred to New SER
Number of prospective reviews avoided by transferring
Prospective time saved (hrs)
Saving (£s)
B7
8
32
10.6
195
B6
17
68
22.6
320
B4
61
244
81.3
945
344
114.5
1,460
Banding of staff undertaking update
Total:
category and many children are discharged following a significant period of time with no episodes of hypoglycaemia. In cases where an IEM is not detected, incidents of KH are thought to be as a result of the body’s immaturity and inability to manage an increase in physiological stress, such as during illness. This typically improves with age and by eight years of age, many are considered to have outgrown the condition.3 For these reasons, patients with KH managed in the Bradford service rarely require the same number of SER updates as MCADD patients because they are often referred into the service at an older age and are discharged before they reach transition. MARGINAL GAIN - FURTHER STANDARDISE THE SER
It was clear that a disproportionate amount of time was being spent on updating SERs and maintaining the rolling database. To ensure no errors were present on an SER, the dietitian updating it would typically have a colleague proof check the document prior to finalising the update, further increasing the time spent on each renewal. It was this process that I believed would benefit from a ‘Marginal Gain’. Rather than use SER renewal guidance (Table 1) as a tool for dietitians, why not incorporate this Table
into a new SER and send all the information the patient ever needs in one go (Figure 2)? From this point on, I will refer to this idea as the ‘New SER’ for clarification. It is worth noting here that, as a team, we agreed that a patient with either MCADD or KH would only receive the New SER once they had reached two years of age. Our rationale was that younger children who typically have their total fluid requirements based on their bodyweight thus require a tailored recipe. But once over two years old, total fluid requirements largely become standardised irrespective of weight or gender. The new SER offers a number of significant advantages over the previous version, but I would be lying if I said the main appeal wasn’t that it significantly reduces the number of manual renewals needed. That said, another distinct advantage of the New SER over the previous edition is an increase in patient safety. The more alterations a document or spreadsheet demands, the more likely an error will occur. The previous SER potentially required 14 stages as the paperwork and spreadsheet required physically amending; by comparison the New SER eliminates nine of those updates. Last but not least, there is a substantial time and cost saving attached to adopting the New SER (see Tables 2 and 3). www.NHDmag.com April 2018 - Issue 133
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CONDITIONS & DISORDERS Table 3: Time and cost comparisons of ‘Old’ vs ‘New’ SERs in future patients (based upon 14 prospective revisions) Old SER
New SER
2.60
0.16
B4
25.80
1.65
B6
36.92
2.30
B7
47.84
3.00
Time (hrs) Cost (£)
MOVING FORWARD
Obtaining feedback from the patients who have switched from the traditional version of the SER to the New SER is now necessary to thoroughly evaluate its impact. Should positive feedback be attained, then other IEMs requiring an SER, such as Carnitine palmitoyltransferase I deficiency, Carnitine palmitoyltransferase II deficiency and Carnitine transporter defects, should also be considered to embrace the New SER. In our case, the time saved has enabled our Band 4 Dietetic Assistant Practitioner to adopt a small Galactosaemia caseload since the New SER was implemented. This allows the dietetic team to review these patients more frequently than had been feasible when these patients were solely managed by a dietitian. It is important to view any time saving intervention as an opportunity to re-invest that time in other, more demanding areas of the service as opposed to it being perceived as a direct threat to job security. This can only be
NETWORK HEALTH DIGEST
Coming in the next issue May 2018 DIGITAL-ONLY - View it online at www.NHDmag.com
• Infant weaning and taste development • Cereals and wholegrains • Coeliac disease
• Adult food allergies
• Ketogenic diet therapy
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achieved if all members of the team are open to new ways of working, which luckily in Bradford, they are. So, I hope after reading this that you may be inspired to think about a ‘Marginal Gain’ that could improve the way you work. Innovation doesn’t demand a wholesale change and needn’t be overwhelming. As we have seen, minor tweaks to existing practice are usually all that is required. I do not expect anyone reading this to be blown away by the New SER, it is simply an amalgamation of various pieces of information collated onto one sheet of paper. However, if everyone in your department did something similar in their respective areas of work, collectively we could rid our entire practice of unnecessary paperwork. I don’t suspect you would have a hard time selling ‘Marginal Gains’ theory to any of your colleagues as, after all, I can’t imagine there is a single dietitian working who entered the profession because of their love for paperwork!
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