Designing a Structured Insulin Pump Program Pathway and Reducing Wait Times in the Diabetes Clinic at BC Children’s Hospital Free

BC Children’s Hospital (BCCH) is the only tertiary care, academic children’s hospital in the province of British Columbia, located in Vancouver, Canada. The pediatric diabetes clinic provides in-person and telehealth services to a large, ethnically diverse pediatric population living with diabetes across the province in urban and rural communities. It also has a diabetes telemedicine outreach program that involves BCCH endocrinologists partnering with local care teams to allow individuals to access a diabetes care provider virtually, while remaining closer to home.

The pediatric diabetes clinic follows approximately 710 children <18 years of age with type 1 diabetes. It is staffed with 11 endocrinologists, trainees (six endocrinology fellows and rotating pediatric residents and medical students), eight registered nurse (RN) certified diabetes educators (CDEs), three registered dietitian (RD) CDEs, a program manager, and three clerical staff members. Half of the RN CDEs (four of eight) are trained to initiate insulin pump therapy internally within the institution for at least one of the four insulin pumps available in Canada (manufactured by Insulet, Medtronic, Tandem, and Ypsomed).

This quality improvement (QI) project aimed to improve the insulin pump initiation process at BCCH by 1) implementing a structured pump program pathway and 2) shortening the wait time for pump training from 9 to 3 months over 1 year.

Before this initiative, BCCH patients who were interested in switching from a multiple daily injection (MDI) insulin regimen to insulin pump therapy were asked to attend a pump readiness workshop organized by the RN and RD CDEs. The purpose of this workshop was to educate families about the features of various insulin pumps, diabetes management with pump therapy, and the funding process for obtaining an insulin pump in British Columbia. After completing the workshop, families who chose to proceed with pump therapy completed a paper readiness assessment, which included questions about insulin dosing, carbohydrate counting, and sick-day management on pump therapy. The RN and RD CDEs reviewed these assessments to identify any knowledge gaps in diabetes self-management. Families who successfully completed the assessment were placed on a waitlist for pump training, which was offered internally by the RN CDEs trained in insulin pump therapy. The RN and RD CDEs contacted any families who were unsuccessful in completing the assessment to provide education to remedy the identified knowledge gaps. This process in its entirety took approximately 9 months. Both the health care providers (HCPs) and families of BCCH patients expressed concerns and frustration about the long delay in initiating insulin pump therapy. The delay also led some families to seek pediatric diabetes care elsewhere and identify other avenues for pump training, such as using an external trainer not affiliated with the BCCH diabetes clinic. The delay in initiating pump therapy led us to conduct a gap analysis and develop this QI project.

For the first aim of this project, focus group sessions were conducted with the RN and RD CDEs, the program manager, and two endocrinologists to identify problems with the existing pump pathway process (Supplementary Figure S1). Frequency and follow-up of insulin pump starts, availability of resources, hospital policies and procedures, number of RN CDEs available for pump training, effectiveness of the readiness assessment, and patient education were discussed.

For the second aim, 15 random patient chart audits from the pump training waitlist were performed to assess the pump workshop date attendance, date of readiness assessment completion, successful completion of the readiness assessment (yes/no), additional patient education provided by RN and RD CDEs (if applicable), duration of time on the waitlist, and initiation of insulin pump therapy (yes/no).

The focus group sessions revealed that there was a lack of consistent practice and incorporation of the International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines (1) among the diabetes HCPs, specifically with regard to following the indications for use of pump therapy in the pediatric population. Three insulin pumps starts occurred each month. RN CDEs reported that, because of staff turnover, only 50% of the clinic’s RN CDEs were trained in insulin pump therapy, prohibiting an increase in the number of insulin pump starts per month. The RN CDEs highlighted limited engagement in the pump readiness workshops and that the readiness assessment did not accurately test families’ knowledge about pump therapy. Furthermore, the RN and RD CDEs noted that the process of evaluating completed readiness assessments and following up with families who were unsuccessful was lengthy and burdensome. The RN CDEs stated that the endocrinologists provided limited guidance on prioritizing patients on the waitlist, leading to longer wait times for some patients, while others were fast-tracked without completing a readiness assessment.

The random patient chart audits revealed that it took approximately 9 months for families to get trained on insulin pump therapy after attending a pump readiness workshop.

This 2-year QI initiative began on 1 October 2021 and ended on 31 October 2023.

The core QI team included the division head of pediatric endocrinology, two endocrinologists, four RN CDEs who are certified insulin pump trainers, one RD CDE, and the program manager. The program manager is responsible for the operations management of the division’s clinical services, oversight of nonphysician human resources, monitoring and addressing quality concerns, and serving as a liaison with staff at all levels in the program. One endocrinologist served as the project leader because of her clinical expertise in diabetes technology and specialized education in QI implementation science.

In October 2021, a gap analysis was conducted through focus group sessions (Supplementary Figure S1) to identify missed opportunities in the initiation of insulin pump therapy and develop a structured insulin pump program at BCCH. Between November 2021 and September 2022, the core QI team held meetings every 2 weeks to review progress on implementing a pump program pathway, identify strengths and barriers, and iteratively modify future Plan-Do-Study-Act (PDSA) QI change cycles. The development of this pathway for HCPs underwent multiple iterations based on feedback gathered from the larger diabetes team at monthly meetings (Supplementary Figure S2). Families were given a copy of the pump program pathway required to initiate an insulin pump at BCCH to set realistic expectations and goals from the beginning of their journey (Supplementary Figure S3).

The pump readiness workshop was shortened to include only pertinent education related to pump therapy (as determined by the core QI team and the broader diabetes team), and a digital recording of the workshop was created through the Digital Lab at BCCH for independent viewing. Representatives from all four insulin pump companies were invited to attend these workshops to allow families the opportunity to ask specific questions.

The pump readiness assessment was also digitized, and automated grading was enabled using the REDCap (Research Electronic Data Capture) survey and database web application (REDCap Consortium, Nashville, TN) (2). Between September 2022 and January 2023, the core QI team developed pump program protocols, including standardized pump order templates, initiation and adjustment of insulin pump doses, and educational handouts on the features available in the four different insulin pumps. These protocols were disseminated to all endocrinologists, endocrinology fellows, and RN and RD CDEs. The information was also stored in a binder in the diabetes clinic, and a digital copy was stored in the shared clinical drive accessible through the hospital computers.

Between January and April 2023, the QI team focused on shortening the pump training waitlist. Focus group sessions were conducted to discuss increasing the number of pump trainings conducted per month. After considering the clinical workload of the RN CDEs, a pilot program was initiated during which the RN CDEs would double their insulin pump starts from three to six per month. To facilitate communication between the endocrinologists and RN CDEs, the core QI team’s lead endocrinologists and RN CDEs did all of the pump start orders using the newly developed standardized protocols. The team also consulted with the BCCH Ethics Department to highlight principles of utility, equity, and accountability for the insulin pump program; these principles were used to guide reprioritization of the pump training waitlist.

The team was successful in doubling the number of insulin pump starts in this time frame, but this did not shorten the pump training waitlist because there was a natural increase in demand from families wanting to switch to pump therapy. The RN CDEs stated that, with the competing demands of the pump program and their clinical workload, along with the growing waitlist, they were unable to keep up with the increasing number of insulin pump starts.

Because this effort did not result in reduced wait times, a pilot team, including a dedicated lead RN CDE, was assigned for all pump start orders and pump training in collaboration with the two lead endocrinologists from May to October 2023. The lead RN CDE first contacted each family on the waitlist to ensure that they were still interested in pump therapy. Factors that could affect a patient’s insulin pump start, such as planned vacations, parental work demands, moving or changes in home environment, changes in insurance coverage, or transition from the BCCH diabetes program, guided revision of the pump training waitlist.

At the end of each month, we counted the total number of pump starts, determined the time required for follow-up for each pump start, and identified patient- and HCP-related barriers. The most common patient barriers included the time it took to communicate with each family, last-minute cancellations by the families, and families’ expectations around pump therapy that were different from what the clinic could provide. The most common HCP barriers included the time it took the lead RN CDE to meet with one of the lead endocrinologists for pump start orders and to reach agreement on the best course of action for families that were presented at the biweekly diabetes psychosocial rounds. After 5 months, there were a total of 26 pump starts. During this time frame, group pump starts with two to three families at a time were also done to maximize the number of pump starts that could occur in the minimal amount of time. The wait time for the 26 patients ranged anywhere from 1 to 3 months, and the goal was to get through the waitlist backlog as quickly as possible.

In ongoing collaboration with the BCCH ethics team and in light of the ISPAD guidelines (1), children who were <7 years of age and those with recurrent severe hypoglycemia and needle phobia were prioritized on the waitlist. The waitlist was made accessible to all members of the diabetes team to ensure transparency. To ensure equity, families dealing with challenges such as low socioeconomic status, English as a second language, mental health comorbidities, children in multiple parental households, or significant suboptimal glycemic control (A1C >14.0%) were presented at the biweekly diabetes psychosocial rounds. These cases were presented to better understand why the primary diabetes team deemed some families not ready to initiate pump therapy and to create actionable plans for those families to be successful, while ensuring an open, transparent, and safe space for discussion. To ensure that families had realistic expectations of the diabetes program and were available for close follow-up in the first month of insulin pump therapy initiation, a patient agreement was developed with expectations set out by the diabetes program. This agreement was signed by families and the lead RN CDE prior to the initiation of insulin pump therapy.

After about a year (November 2021 to January 2023), the diabetes clinic was able to implement a structured pump program pathway, which included redesign of the pump education workshop and pump readiness assessment, development of program protocols and educational materials, and the adoption of a patient agreement form that was signed by families and the diabetes team.

Over the next 9 months (January to October 2023), the diabetes clinic was able to shorten the pump training waitlist from 9 to 3 months, measured from first attending the pump workshop to starting insulin pump therapy. The pump training waitlist was also reprioritized per the ISPAD guidelines with collaboration from the BCCH ethics team. At the time of writing this manuscript in November 2023, the BCCH pump training wait time had decreased to 1 month.

The intervention was successful with a pilot team of one lead RN CDE and two endocrinologists. We now aim to expand this process to include all four RN CDEs who have been trained in pump therapy and all endocrinologists, while using the newly developed standardized pump program protocols and distributing the patient agreement and pump program pathway information to all families at the beginning of their journey. We plan to conduct ongoing group family pump starts, especially with patients who are close in age and starting on the same insulin pump, which will allow us to maintain an acceptably short waitlist. Furthermore, we plan to involve the endocrinology fellows in writing pump initiation orders and following patients for the first month after their pump start, which will strengthen their diabetes technology education.

Through this QI initiative, we learned that it was crucial for all key stakeholders to be involved in the design and implementation phase to ensure the program’s success. This included our RN and RD CDEs, program manager, ethicists, and endocrinologists. We also learned the importance of leadership and having a core QI team to drive improvement. Through the process, it became crucial for us to reevaluate the leadership roles and assign a lead CDE to achieve change.

For a project to be sustainable, we realized the importance of performing ongoing PDSA iterations and seeking buy-in from the larger diabetes team. We were able to do this during our monthly diabetes team and physician meetings. These recurrent opportunities for team engagement allowed us to review the development of the pump program pathway multiple times and obtain feedback regarding workflow issues. It also allowed us to seek guidance and work through the barriers experienced by families and HCPs.

We also realized the importance of having the program manager involved in this project to ensure that the RN CDEs could devote the time needed for this QI initiative while meeting the ongoing demands of their clinical workload and to guide implementation of solutions for the challenges encountered by families and HCPs. Furthermore, we were fortunate to have a clinical ethics team available at BCCH from whom we could seek guidance when we were reprioritizing our pump training waitlist per the ISPAD guidelines.

Running PDSA cycles and reprioritizing the project’s goals as time passed was also important. Doing so helped us re-strategize our focus as we worked toward shortening our pump training waitlist by assigning one lead RN CDE and two endocrinologists on the pilot team. Although we achieved our goal, we realized that this would be an impractical solution to continue indefinitely. To ensure sustainability and success of the pump program pathway at BCCH, we are now reviewing the re-engagement of all four RN CDEs who are trained in insulin pump therapy along with all of the endocrinologists, while ensuring that the other RN CDEs get certified in insulin pump therapy as quickly as possible.

No potential conflicts of interest relevant to this article were reported.

F.S.A. conceptualized the idea for the QI project, served as the project lead, and led the manuscript preparation. S.B. served as a co-lead and reviewed and edited the manuscript. D.M., H.B., E.V., and J.C. were the RN CDEs on the core QI team and reviewed the manuscript. T.M. was the RD CDE on the core QI team and reviewed the manuscript. S.H. developed the initial pump educational handouts and reviewed the manuscript. S.M. served as the program manager on the core QI team and reviewed the manuscript. S.A. served as a co-lead and as a mentor for F.S.A. and S.B. and reviewed and edited the manuscript. F.S.A. and S.B. are the guarantors of the work and, as such, had full access to all of the data reported and take responsibility for the integrity of the data and accuracy of the data analysis.