Implementation and dissemination of gestational diabetes mellitus nutrition care guidelines

Gestational diabetes mellitus (GDM) occurs in upward of 13% of pregnancies and is increasing with the obesity epidemic. Poorly-controlled GDM can result in significant negative maternal outcomes such as increased caesarean sections, assisted deliveries and an increased risk of Type 2 diabetes mellitus. Associated adverse infant outcomes include macrosomia, hypoglycaemia, shoulder dystocia, and birth defects. 

Guidelines recommend Medical Nutrition Therapy as a cornerstone intervention strategy for managing blood glucose levels in women diagnosed with GDM. 

Improvements in important outcomes, such as reduced insulin requirements and improved blood glucose control, have been documented in a study validating American Dietetic Association Nutrition Practice Guidelines (NPGs). Australian NPGs for GDM do not exist and a national audit of maternal health dietetic services in 2008 demonstrated that there was no systematic delivery of dietetic care to women with GDM across Australia. These findings have been reiterated in a 2011 survey of Australian dietitians providing GDM care. 

Through iterative improvement cycles this project has implemented and evaluated a dietetic model of care based on the American NPGs schedule of visits, adapted to an Australian setting, using an implementation science approach. Following the development and trial of an implementation framework at a Queensland tertiary maternity hospital (Mater Mothers), the model of implementation has been applied and evaluated at four Queensland Health Hospital and Health Service (HHS) districts. Using a hub-spoke model of facilitated implementation at four sites (Cairns and Hinterland HHS, Darling Downs HHS, West Moreton HHS, and Metro South HHS) we have explored clinical and process outcomes to inform future application and adoption of the guidelines.

Research Team 

A/Prof Shelley Wilkinson, Sally McCray, Prof David McIntyre, and with collaborators from partner sites of Mater Mothers Hospital, Cairns & Hinterland HHS; Darling Downs HHS; West Moreton HHS; Metro South HHS.

Source of funding

Queensland Health-Health Research Fellowship and AHPOQ (Allied Health Professions’ Office of Queensland)

Outputs 

• Development of a best-practice decision tree flowchart. This tool facilitates best-practice local decision making by Gestational diabetes mellitus (GDM) teams wanting to implement nutrition practice guidelines to their service. It directs discussion and provides evidence-based solutions around space and human resources, recommended education materials and service monitoring processes. 
• Changes to four Hospitals and Health Services GDM models of nutrition care.
• Several academic publications, including;
  • Wilkinson, Shelley A., Palmer, Michelle, Smith, Shelley, Porteous, Helen, and McCray, Sally (2021). Evaluation of the implementation a best practice gestational diabetes model of care in two Australian metropolitan services. JBI Evidence Implementation, https://doi.org/10.1097/XEB.0000000000000295
  • Wilkinson, Shelley A., O'Brien, Maxine, McCray, Sally, and Harvey, Desley (2019). Implementing a best-practice model of gestational diabetes mellitus care in dietetics: a qualitative study. BMC Health Services Research 19 (1) 122 122
  • Wilkinson, Shelley A., McCray, Sally J., Kempe, Alison, and Sellwood, Bernadette (2018). Clinically relevant improvements achieved from a facilitated implementation of a gestational diabetes model of care. Nutrition and Dietetics: The Journal of the Dietitians Association of Australia 75 (3) 271-282
  • Wilkinson, Shelley A., McCray, Sally, Beckmann, Michael, and Mcintyre, H.David (2016). Evaluation of a process of implementation of a gestational diabetes nutrition model of care into practice. Nutrition and Dietetics 73 (4) 329-335
  • Wilkinson, Shelley Ann, McCray, Sally, Beckmann, Michael, Parry, Annette, and McIntyre, Harold David (2014). Barriers and enablers to translating gestational diabetes guidelines into practice. Practical Diabetes 31 (2) 67-72a

Impact 

Health

This work has resulted in a reduction in medication use in gestational diabetes mellitus, improved diet quality and increased physical activity levels through building capacity and improving systems to allow adherence to best practice.  This work has the future capacity to reach and influence >10,000 Queensland mother-baby dyads (>45,000 in Australia) a year.

 Knowledge

Important learnings about the process of co-creation with health services with clinical and process improvements.Key elements required for successful facilitation are:

• building confidence and capacity in local implementers through
  • regular contact,
  • encouraging local networking,
  • linking to higher management support,
  • assessing and/or influencing workplace or organizational culture,
• addressing and streamlining processes around governance requirements for health service redesign,
• using/determining methods of engaging stakeholders beyond ‘symbolic’ involvement, and
• enhancing/supporting the agility of project sites to adapt to organisational changes while continuing to deliver projects.