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O’Gorman et al. SpringerPlus (2015) 4:727
DOI 10.1186/s40064-015-1469-6
SHORT REPORT
Knowledge ofcarbohydrate counting
andinsulin dose calculations amonghospital
sta ina regional general paediatrics unit
Jennifer R. O’Gorman1, Orla O’Leary1, Natalie Finner1, Anne Quinn1 and Clodagh S. O’Gorman1,2,3,4*
Abstract
The aim of this study was to assess the carbohydrate and insulin knowledge of the staff at Children’s Ark at the Uni-
versity Hospital, Limerick. Carbohydrate counting and insulin dose calculations based on carbohydrates and blood
sugars are integral to intensive insulin management of type 1 diabetes mellitus (T1DM). The PedCarbQuiz, a validated
questionnaire, was modified, and applied to the staff on our general paediatrics ward. 48/70 eligible staff responded
(rate 68 %). Overall knowledge was good: 75.5 % was the average score for correctly identifying foods containing car-
bohydrate. However, poor scores were obtained for calculating multiple items and meal values (average score 29 %),
and exact values of insulin required (average score 38 %). These results highlight the need for re-education among
staff on a general paediatrics ward, to empower ward staff to contribute effectively to the education and manage-
ment of patients with T1DM.
© 2015 O’Gorman et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
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and indicate if changes were made.
Background
e intensive management of Type 1 diabetes melli-
tus (T1DM) in children requires insulin regimes that
are dose adjusted based on the carbohydrate content of
a meal and the patient’s blood glucose (Silverstein etal.
2005). Implementing this requires knowledge about the
carbohydrate content of foods, and subsequently the abil-
ity to calculate the correct insulin dose. is a fundamen-
tal task carried out several times daily by patients with
T1DM who are on intensive insulin regimes. Paediatric
patients and their families are taught the principles of
this during T1DM education and re-education sessions
by their T1DM multi-disciplinary team (MDT).
e implications of poor glycaemic control are well
known. Good control in children is imperative to main-
tain normal physical growth (Silverstein etal. 2005), to
avoid acute complications of ketoacidosis and hypogly-
caemia, as well as combating against chronic microvas-
cular and macrovascular complications (Nathan 2014;
Brink 2001; Olsen et al. 2000). e unique challenges
faced when managing T1DM in children are also recog-
nised in the literature, including increasing diagnoses in
younger children (Edwards 2014; Streisand and Mona-
ghan 2014), evolving needs as patients grow and develop,
and continual support and education required across
different environments including at home and at school
(Edwards 2014; Borus and Laffel 2010).
Hospital admissions are an excellent an opportunity
to identify poor control and reinforce carbohydrate and
insulin principles to patients and parents, if the staff at
ward level are competent in these principles. e aim of
this study was to assess the level of knowledge of these
carbohydrate and insulin calculations by paediatric ward
staff members who are not part of the T1DM MDT, and
thereby identify how well we are using this opportunities
to re-educate our patients.
Methods
We assessed the knowledge of the ward staff at e Chil-
dren’s Ark, University Hospital, Limerick (UHL), regard-
ing carbohydrate content of food, carbohydrate counting
and insulin dose calculations using the validated PedCar-
bQuiz (PCQ) questionnaire. e PCQ was designed and
tested in the Department of Paediatrics, Rainbow Babies
Open Access
*Correspondence: clodagh.ogorman@ul.ie
4 Department of Paediatrics, Graduate Entry Medical School, University
of Limerick, Limerick, Ireland
Full list of author information is available at the end of the article
Page 2 of 4
O’Gorman et al. SpringerPlus (2015) 4:727
and Children’s Hospital, Case Western Reserve Univer-
sity, Cleveland, Ohio, a tertiary paediatric diabetes clinic
(Koontz etal. 2010). While it is designed for a US pae-
diatric diabetes cohort, we have modified it for an Irish
population and used it in a previous study in an Irish
paediatric diabetes cohort (submitted data). e ques-
tionnaire evaluated the staff members’ understanding
of the carbohydrate content of commonly eaten foods,
the ability to read nutritional labels, and the calculation
of proper insulin dosage. A report is generated which
estimates skills in three domains: calculating carbohy-
drate content; insulin dose calculations; and overall skills
(Koontz etal. 2010).
Modification of this questionnaire for an Irish popu-
lation included: (1). Replacing certain typically Ameri-
can or Canadian food groups with more typical Irish
foods, e.g. corn dogs with sausages; and (2). Conver-
sion of the blood sugar readings within the PCQ from
American (mg/dL) to Irish units (mmol/L). e PCQ was
then offered to 70 members of paediatric ward staff (45
nurses and 25 doctors) who were rostered to work over
a 2 weeks period. Questionnaires were filled out and
returned anonymously to a collection box located on
the ward. e grade of staff was highlighted on returned
studies, but no other identifiable information was col-
lected. Members of the T1DM MDT were excluded from
participating in this study.
Results were calculated using the marking scheme
devised in the original questionnaire. e survey con-
tained seven sections. ese included carbohydrate rec-
ognition, carbohydrate counting of individual items,
carbohydrate calculation of an entire meal, nutritional
label reading, use of an insulin sliding scale, use of insu-
lin to carbohydrate ratios, and calculation of whole meal
insulin dose using all of the above knowledge domains.
Local institutional ethical approval for this study was
granted.
Results
48 out of 70 eligible staff responded (rate 68%), including
34/45 (76%) nurses and 14/25 (56%) doctors. e overall
knowledge of staff was good. e average mark obtained
for correctly identifying foods containing carbohydrate
was 75.5 %, and the majority of staff members scored
highly at nutritional label reading (average department
total score 94 %), use of insulin sliding scale (average
department total score 90%) and use of insulin carbohy-
drate ratios (average department total score 94%).
However, scores were lower for the ability to count
the amount of carbohydrates in individual items (aver-
age department score 29 %), and the amount of car-
bohydrates per meal (average department score 26 %).
Carbohydrate counting for a meal is an integral require-
ment for calculating insulin doses, and thus this led to
poor scores for calculating insulin doses for meals (aver-
age department score 38%).
All staff members achieved a higher score in the insu-
lin dosing domain compared to the carbohydrate count-
ing domain. Consultants demonstrated a greater amount
of knowledge on average in comparison to the other staff
members. [See Tables1 and 2 for summaries of scores for
nurses (registered general nurses and clinical nurse man-
agers), and doctors (non-consultant hospital doctors and
consultants) separately.]
Discussion
Our study demonstrated greater knowledge among all
staff members of insulin dosing in comparison to carbo-
hydrate counting. is is consistent with current ward
practice, with patients estimating the carbohydrate con-
tent of meals, and the nursing and medical staff double-
checking the patient’s calculation of insulin required
based this estimate.
e average total score for the department as a whole
was 68.5%. In another study using the PCQ questionnaire
(unpublished), patients with T1DM attending our paedi-
atric clinic had an average total score of 68.9%± 15.8,
which is comparable to the score for staff in this study.
e total average patient carbohydrate score was
68.7%±16.3 versus 55.7% among staff members. is
highlights the discrepancies in our knowledge to advise
our patient’s on their diet, and on carbohydrate intake.
Furthermore the total average PCQ score in the original
American study was 87.9%± 9.7 (Koontz etal. 2010).
Our total average score is significantly less than this. Of
note all patients in the American study were taught car-
bohydrate and insulin skills by a dietician. ere were no
dieticians included in our study group, and at the time
this study was conducted, there was no dietitian for pae-
diatric diabetes patients working in our unit. It is possible
that staff knowledge of carbohydrates would improve if a
dietitian was working on the ward, providing dedicated
education to children and families but also some educa-
tion, either formal or informal, to other staff members.
Despite this, it cannot be ignored that staff knowledge is
lacking, and that we may be missing valuable opportuni-
ties to reinforce carbohydrate counting techniques dur-
ing inpatient stays.
Overall, consultant doctors scored the highest, fol-
lowed by RGNs and CNMs, with non-consultant hospital
doctors scoring the lowest. While it is important that all
staff have knowledge of carbohydrate content of foods,
it is arguably a more important skill for hospital nurses
than for hospital doctors, as it is usually nurses who
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O’Gorman et al. SpringerPlus (2015) 4:727
have more direct patient contact during hospital admis-
sions. Notwithstanding, it is clear from the results of this
study, that staff on our general paediatrics ward are not
equipped to provide constructive ongoing help or educa-
tion to patients when trying to count carbohydrates and
then calculate relevant insulin doses. It is not likely that
every staff member could aim to be an expert carbohy-
drate counter but it is possible to aim to improve every-
one’s baseline level of knowledge and to aim to have some
staff members who are experts in this domain, who might
then act as champions for carbohydrate counting and
insulin dosing accurately.
One of the limitations of this study is that PCQ was
developed for a US population—some food types
included in the original validated questionnaire are
not consumed regularly in Ireland. We modified the
questionnaire to better suit our study population, and
although it has been used in a previous paediatric study
in the department, it has not been fully validated. A
further limitation is the response rate to the study. A
response of 68% does not reflect knowledge of depart-
ment as a whole. For re-auditing in the future, we will
emphasise that each questionnaire is anonymised, and
the importance of the results for improved clinical prac-
tice on the ward.
is study has highlighted the need for education
of staff members in the department, particularly with
regards to exact carbohydrate content of food. is may
be achievable following the appointment of a special-
ist paediatric diabetes dietitian. We propose education
in the format of departmental lectures, a practical tuto-
rial session with emphasis on carbohydrate counting and
subsequent insulin dosing, and ongoing awareness and
education with picture guides as aide-memoires on the
wards. A further option would be for the catering service
to standardise carbohydrate content of food served to
children with T1DM during in-patient admissions.
Table 1 Summary ofscores ineach domain according tosta grade
Registered general
nurse (RGN) (N=30) Clinical nurse man-
ager (CNM) (N=4) Consultant doctors
(N=4) Non-Consultant hos-
pital doctors (NCHD)
(N=10)
Department total
(N=48)
Carbohydrate recogni-
tion
(%)
69 74 85 74 75.5
Carbohydrate counting
(individual item)
(%)
35 21 41 18 29
Carbohydrate counting
(entire meal)
(%)
29 38 23 14 26
Nutritional label read-
ing
(%)
92 96 100 88 94
Use of insulin sliding
scale
(%)
85 89 98 88 90
Use of insulin to carbo-
hydrate ratios
(%)
95 100 100 80 94
Calculation of whole
meal insulin dose
(%)
43 30 45 35 38
Table 2 Summary of average total score, average carbo-
hydrate score andaverage insulin score according tosta
grade
Average
total score
(%)
Average carbohy-
drate score
(%)
Average
insulin score
(%)
Registered general
nurse (RGN)
(N = 30)
69 55 74
Clinical nurse
manager (CNM)
(N = 4)
66 57 73
Consultant doctor
(N = 4) 74 62 87
Non-consultant
hospital doctor
(NCHD) (N = 10)
65 49 67
Total 68.5 55.7 75.2
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O’Gorman et al. SpringerPlus (2015) 4:727
Conclusion
e key finding from our study was a significant dis-
crepancy in staff members’ knowledge of carbohydrate
counting and insulin-dosing in T1DM on a general pae-
diatric regional hospital ward. is will have a direct
impact on the management of paediatric patients under
the department’s care. We are well aware of the long term
implications of poor diabetic control, and the particu-
lar challenges facing management of T1DM in children,
and yet we are not utilising inpatient hospital admissions
as an opportunity for re-education for the patient with
T1DM. Staff education is required, as well as stronger
paediatric dietetic presence. Following re-education of
staff members we propose repeating this study.
Authors’ contributions
JOG interpreted the data and drafted the manuscript. OOL participated in
study design and data collection. NF and AQ contributed to data collection, as
well as drafting the revised version of the PedCarbQuiz questionnaire which
was used in this study. COG conceived and coordinated the study, and helped
draft and review the final manuscript. All authors read and approved the final
manuscript.
Author details
1 The Children’s Ark, University Hospital Limerick, Limerick, Ireland. 2 National
Children’s Research Centre, Dublin, Ireland. 3 Centre for Interventions in Infec-
tion, Inflammation & Immunity (4i), Graduate Entry Medical School, Limerick,
Ireland. 4 Department of Paediatrics, Graduate Entry Medical School, University
of Limerick, Limerick, Ireland.
Competing interests
The authors declare that they have no competing interests.
Received: 23 June 2015 Accepted: 26 October 2015
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