Rapid discharge of children with medical complexity (CMIC) from a specialist children’s hospital during the first wave of the coronavirus pandemic

BackgroundCMIC are well described to have high health care use and long lengths of time in hospital.1 In our specialist children’s hospital. Our specialist discharge team usually have 18–30 children with the most complex journeys on our caseload. A significant proportion of these children have non-medical barriers to discharge which include care and commissioning, housing, parental training and need for adaptations.2 Many of them were perceived to be at increased risk of deterioration should they have caught the SARS-CoV-2 variant.ObjectivesWe undertook to provide a rapid discharge for this group of children during the first wave of the pandemic.MethodsRapid discharge was undertaken using the creation of a virtual telephonic and then zoom space to bring together key stakeholders. It was led by silver command and fed into organisational architecture during the pandemic. Stakeholders included clinical teams across institutional boundaries, therapies, social care colleagues and voluntary sector collaborators. Rapid PDSA cycles enabled us to adapt to the changing landscape. Initially the meetings were three times a week, decreasing in frequency to once weekly until the present time. We relied on existing relationships and built new connections.ResultsFrom the start of the first lockdown 23rd March 2020 until the easing of restrictions on 15th June 2020 we discharged 23 long stay patients. The length of stay prior to discharge varied from 19–866 days. The median time to discharge in this group was 22 days from the start of lockdown. The barriers to discharge varied from need for housing and care provision to social care support. Apart from improvement in length of stay we also were able to solve problems innovatively by working together. Cots and white goods were sourced through social care funds and ordered on amazon by our occupational therapists. Donated housing capacity was identified by our covid command structure facilitated families moving there temporarily instead of staying in hospital. A local hospice was able to provide care for the most complex of our patients whilst awaiting onwards placements in social care and carer training. The feedback from stakeholders following discharge was used to refine processes. There were no adverse outcomes or readmissions.ConclusionsThis period of global health crisis has been devastating for many. In amongst the tragedy, there are glimmers of learning that would not have been achieved without this unprecedented challenge. This rapid discharge process is one such glimmer. It demonstrates that by working together across agency boundaries, thinking innovatively and putting the children and families at the heart of what we do, we can effect rapid change. We now need to harness and retain this learning to be able to continue sending children homeReferencesCohen E, Kuo DZ, Agrawal R, Berry JG, Bhagat SK, Simon TD, Srivastava R. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics 2011 Mar;127(3):529–38.Salama M, Shanahan R, Bassett E, et al. G157(P) A toolkit to identify barriers to discharge for children with medical complexity. Archives of Disease in Childhood 2020;105:A54.

A Worldwide Perspective on COVID-19 and Diabetes Management in 22,820 Children from the SWEET Project: Diabetic Ketoacidosis Rates Increase and Glycemic Control Is Maintained.

Aims: To investigate the short-term effects of the first wave of COVID-19 on clinical parameters in children with type 1 diabetes (T1D) from 82 worldwide centers participating in the Better Control in Pediatric and Adolescent DiabeteS: Working to CrEate CEnTers of Reference (SWEET) registry. Materials and Methods: Aggregated data per person with T1D ≤21 years of age were compared between May/June 2020 (first wave), August/September 2020 (after wave), and the same periods in 2019. Hierarchic linear and logistic regression models were applied. Models were adjusted for gender, age-, and diabetes duration-groups. To distinguish the added burden of the COVID-19 pandemic, the centers were divided into quartiles of first wave COVID-19-associated mortality in their country. Results: In May/June 2019 and 2020, respectively, there were 16,735 versus 12,157 persons, 52% versus 52% male, median age 13.4 (Q1; Q3: 10.1; 16.2) versus13.5 (10.2; 16.2) years, T1D duration 4.5 (2.1; 7.8) versus 4.5 (2.0; 7.8) years, and hemoglobin A1c (HbA1c) 60.7 (53.0; 73.8) versus 59.6 (50.8; 70.5) mmol/mol [7.8 (7.0; 8.9) versus 7.6 (6.8; 8.6) %]. Across all country quartiles of COVID-19 mortality, HbA1c and rate of severe hypoglycemia remained comparable to the year before the first wave, while diabetic ketoacidosis rates increased significantly in the centers from countries with the highest mortality rate, but returned to baseline after the wave. Continuous glucose monitoring use decreased slightly during the first wave (53% vs. 51%) and increased significantly thereafter (55% vs. 63%, P < 0.001). Conclusions: Although glycemic control was maintained, a significant rise in DKA at follow-up was seen during first wave in the quartile of countries with the highest COVID mortality. Trial Registration: NCT04427189.

Presentation of newly diagnosed type 1 diabetes in children and young people during COVID-19: a national UK survey.

In the UK, there have been reports of significant reductions in paediatric emergency attendances and visits to the general practitioners due to COVID-19. A national survey undertaken by the UK Association of Children's Diabetes Clinicians found that the proportion of new-onset type 1 diabetes (T1D) presenting with diabetes ketoacidosis (DKA) during this COVID-19 pandemic was higher than previously reported, and there has been an increase in presentation of severe DKA at diagnosis in children and young people under the age of 18 years. Delayed presentations of T1D have been documented in up 20% of units with reasons for delayed presentation ranging from fear of contracting COVID-19 to an inability to contact or access a medical provider for timely evaluation. Public health awareness and diabetes education should be disseminated to healthcare providers on the timeliness of referrals of children with T1D.