Shropshire Children s Diabetes Team Insulin Pump Training Workbook & Care Plan

Shropshire Children s Diabetes Team Insulin Pump Training Workbook & Care Plan

Table of Contents Overview of training for insulin pump starts... 3 On the initiation visit... 4 General pump Information & Understanding terminology... 4 Hyperglycaemia management... 5 Signs and symptoms... 5 Pump related causes:... 5 Other causes:... 6 Action Plan for High Blood Glucose (BG) on an insulin pump... 6 Hypoglycemia management... 8 Assessment... 8 Recognition... 8 Illness management... 10 Sick Day Rules... 10 Call your diabetes team or ward if:-... 11 Exercise & Physical Activity... 11 Time off the Insulin Pump... 12 Emergency planning and equipment... 12 Always carry a supply of emergency equipment:-... 13 Getting ready for a pump start... 14 Patient Consent/Agreement... 16 Starting doses... 17 Diabetes Team Contact Numbers... 18 Resources... 18 Insulin Pump Accessories... 19

Overview of training for insulin pump starts What to expect after you have been considered by the diabetes team eligible for an insulin pump. You will have at least two visits with the diabetes team including Doctor, Nurse and Dietician. In these sessions they will cover: Assessment of current diabetes knowledge Current treatment and document main problems Assess and improve your understanding of diet and carbohydrates Discuss Advantages and disadvantages of pump (Possible disadvantages - need for frequent blood glucose testing, risk of Ketoacidosis, infection and disconnection from pump. Possible advantages - reduction in frequency and severity of hypoglycaemia, lower HbA1C and improved quality of life) Management of Hypoglycaemia on pump Management of Hyperglycaemia on pump Management of illness on a pump The importance of frequent blood glucose testing and guide for when to test What to do if your pump fails to work correctly Discussion of school issues and arrangements for school staff education When you have good understanding of all above we will then demonstrate the important pump features including:- Basic programming -changing batteries, setting date and time Bolus options Basal Rates including temporary rates for sickness and exercise Infusion and cannula site management including insertion and rotation of site When to remove, stopping, suspending and restarting mechanics You will then be given the option of a saline start with the pump connected or disconnected - this can be also offered to parents so they become more familiar with the technology Page 3 of 19

On the initiation visit Your care plan will be reviewed with starting doses documented. You will be given an emergency action plan for switching back to injections Pump started with set basal rates, at least one bolus in hospital for a meal, then daily phone contact initially with diabetes team to adjust rates etc. Home visit by nurse within first week then weekly if required 2 week OPD then monthly, leading to 3 monthly when settled You will be expected to bring detailed documentation to clinic as follows: Pump diary containing Dietary history. Blood glucose results Activity diary General pump Information & Understanding terminology You have been selected to start on an insulin pump by the diabetes team to improve your blood glucose control. The usual benefits of pump treatment are improved blood glucose control, less hypo and hyperglycaemia, increased flexibility and improved quality of life with diabetes. Insulin Pumps are pager size devices which contain a cartridge of rapid acting insulin; they have an internal computer and a precise motor which pushes insulin from the cartridge through infusion tubing into your body. Pumps use only rapid-acting insulin (e.g. Novorapid, Humalog or Apidra) which:- Starts working almost immediately after you inject insulin. Peaks (or works it hardest) about 1-1½ hours after you inject. Stops working around 3-5 hours after you inject. This is referred to as the duration of action. Insulin is delivered using 2 methods:- Basal: a small amount of insulin delivered continually throughout the day and night. Bolus: the extra insulin you deliver when you eat, or to correct high blood glucose (BG). Bolus insulin: You will need to bolus when you eat and when your BG is higher than your target. There are two main types of bolus doses: bolus for carbohydrates and blood glucose correction boluses. Page 4 of 19

Bolus for Carbohydrates: The type of bolus you take when you eat or drink foods with carbohydrate. The dose will be based on your insulin to carbohydrate ratios. Some of the pumps have a calculator which will help you work out how much insulin you need if you program in your blood glucose and the amount of carbohydrate e.g. Bolus Wizard or ezcarb. Correction Bolus: The type of bolus you take when you need to correct a high Blood Glucose. The calculators mentioned above will help to calculate the amount of insulin your body needs to correct a high BG taking into account when you last had insulin. Day to day with Pump involves Inserting infusion set every 2-3 days Checking Blood glucose 4-8 times /day Meals and snacks when you want with boluses of insulin calculated on how much carbohydrate you eat Adjusting insulin for high or low sugars, exercise and sick days Good documentation and links with diabetes team Your Nurse will give you an information pack/workbook for your specific pump Hyperglycaemia management A significant high blood glucose level is anything greater than 14mmol/l Signs and symptoms - there may be no specific signs or symptoms unless the hyperglycaemia is prolonged when there may be a history of frequent passing of urine, thirst, vomiting and drowsiness. Hyperglycaemia on pump therapy may be due to:- Pump related causes: 1. Infusion Set/Cannula: Kept in too long. Inflammation at site. Inserted in hardened area of skin (lipohypertrophy). Reflux of blood / tissue fluids in infusion set. Canula/needle blocked. Canula/needle at insufficient depth/incorrect angle or Canula/needle partially slipped out. Air in tubing: forgot to prime new tube or not connected properly to adaptor. 2. Pump: in STOP mode or pump failure (pump should alarm). 3. Cartridge: empty or leaking (pump should alarm). 4. Battery: alarms have been ignored and battery has expired. Page 5 of 19

Other causes: Forgotten bolus Bolus too low / quantity of carbohydrates misjudged Over correction of a low blood sugar Lack of activity, bed rest Deteriorated insulin (having been exposed to high/low temperatures/direct sunlight) Illness Some medications Hormonal changes (puberty, menstruation) Action Plan for High Blood Glucose (BG) on an insulin pump If your BG is higher than 14mmol/l CHECK RESULT, THEN CHECK FOR KETONES. Troubleshoot your pump, infusion set and site. If you find a logical cause for the high BG, take your normal corrective action. Examples of a logical cause include: you forgot your last meal bolus or your infusion set came out. Your action plan will include taking a bolus and may also include changing your infusion set/site. Below is the advice flow chart if blood glucose is greater than 14mmo/l (> denotes greater than) Page 6 of 19

Blood glucose >14mmo/l Check Ketones Ketones negative or <1.5 Ketones >1.5 Take a correction blood glucose bolus via pump Check blood glucose in 2 hours Look for causes of a high blood glucose Take insulin correction bolus by syringe immediately. Change your infusion set Begin to drink plenty of beverages that are sugarfree; 1 cup every ½ hour If blood glucose is decreasing that is a good sign, but monitor a bit more closely throughout the day If after 2 hours the blood glucose is not decreasing take another correction by syringe Check ketones Ring the diabetes team or ward if Ketones are > 3, you will need to come to the ward for review Recheck BG and Ketones in 1hour Do a site change Continue to monitor to be sure BG decreases If BG Decreasing Continue to monitor BG to ensure continues to decrease and new set is working Ketones are still high Call WARD and come for review Blood glucose not decreasing Ketones are decreasing Take another correction via pump and monitor closely Page 7 of 19

Hypoglycemia management Assessment Hypoglycaemia in a person with diabetes is defined as a plasma blood glucose levels less than 4mmols/l (Drury & Gatling 2005). Causes of hypoglycemia on an insulin pump Basal rate too high Increased physical activity with insufficient reduction of basal rate Miscalculation of meal bolus or correction bolus Too little food or vomiting Pump clock incorrect Alcohol Excessive heat - sun, bath, sauna Recognition Signs & Symptoms of Hypoglycaemia Mild Hypoglycaemia Sweating Dizziness Trembling Tingling lips, tongue, hands or feet Hunger Blurred Vision Difficulty in concentrating Palpitations Headache Moderate Hypoglycaemia Odd Behaviour e.g. rudeness or spontaneous laughter Bad temper or moodiness Appears to be under the influence of alcohol i.e. drunk Aggressive behaviour Confusion Severe Hypoglycaemia Unconsciousness Fitting Page 8 of 19

Management of hypoglycaemia on an insulin pump (CSII) Confirm by checking Blood glucose Immediately give 10-15 g rapid acting carbohydrate e.g. 3 glucose tablets, 50ml Lucozade Energy TM 100ml sugary drink e.g. cola, GlucoGel TM (can be used if uncooperative but able to swallow). If still feeling unwell after 15minutes repeat blood glucose test and if levels are less than 4 mmol/l give a further 10grams rapid acting carbohydrate. Wait a further 15 minutes, then repeat blood glucose test again and if levels are still less than 4 mmols/l, stop the pump and give a further 10 grams of rapid acting carbohydrate. Remember to restart the pump once blood glucose levels have normalized and the person has recovered. Once blood glucose normal it may be necessary to have 5-10g longer acting carbohydrate e.g. biscuit or bread, especially if you feel your basal rates aren t right or you have just given an insulin bolus. There is no need to stop the pump unless it is a severe hypoglycemic episode or if 2 treatments of rapid acting carbohydrate have not raised the blood glucose level above 4mmols/l. If there is an ongoing bolus, it should be cancelled. In the case of severe hypoglycemia with convulsions or unconsciousness: Interrupt the insulin supply - stop the pump Place the person in the recovery position Give glucagon (GlucaGen Hypo Kit) by Intramuscular injection (IM) Call 999 for an ambulance. Remember to restart the, pump within 1hr after blood glucose levels have normalized and the person has recovered, unless there is an obvious pump problem or you feel the person needs admission to hospital. In which case it may be appropriate to change to a basal bolus regime. Try to identify the cause of hypoglycemia and note cause for future reference Consider: Is the basal rate too high? Are the basal rates programmed correctly? Does the insulin to carbohydrate ratio need to change or the insulin sensitivity? Is the carbohydrate estimation correct? Are Bolus doses of insulin overlapping? Does exercise management need to be reviewed? The diabetes team can usually be contacted to make changes to any of the above if necessary. Page 9 of 19

Illness management During infection there is usually an increase in insulin requirements unless the child is vomiting, in which case the basal rate may need to be decreased. Sick Day Rules Follow these rules if you/your child is unwell:- Monitor blood glucose and ketones more often. You may need to test 1-2 hourly during illness but at least 4-6 times each day while you are unwell. You will also need to test blood glucose levels overnight Drink lots of unsweetened fluids e.g. water, reduced sugar drinks Try at least three times a day to eat/drink some food containing carbohydrate and bolus as normal for this e.g.100mls of fruit juice, 200mls of milk or 200mls of soup all contain approximately 10 grams of carbohydrate. If your blood glucose is greater than 14 mmols/l, check blood for ketones:- if no ketones, or less than 1.5mmols/l give a correction dose of insulin and repeat blood glucose in two hours. If glucose levels are still elevated after 2 hours, change infusion set and give another correction bolus via a syringe or injection pen. Continue to monitor blood glucose and ketone levels 2 hourly until normalized. If ketones more than 1.5mmols/l, give a correction bolus of fast acting insulin (Novorapid or Humalog) via an injection pen or syringe, change the infusion set, then restart the pump. Contact children s ward if ketones are more than 3mmols/l. Repeat blood glucose & ketones in 1 hour and if glucose levels are still high give a correction dose via the pump. If ketone levels have not decreased, contact the children s ward. If you are having to do repeated corrections when you are ill, you may need to increase your basal rate as follows:- (If unsure please check with your diabetes team first). Start a temporary basal rate of plus 30% (see pump manual) and continue to monitor blood glucose 2 hourly. If after 2 hours the blood glucose has increased, take a correction bolus & increase the temp basal by further 30%. Do this every 2 hours until blood glucose levels are between 6-12mmols/l. You may need to remain on a temporary basal rate for 24-48hours Once blood glucose levels start to fall under 5mmol, decrease the temporary basal rate by 30%. Recheck blood glucose levels every 2 hours and continue to reduce temporary basal rate by 30% each time there is a fall in blood glucose levels, until glucose levels are within the target range of 6-12mmols/l and you are back to your usual basal rate. Page 10 of 19

Call your diabetes team or ward if:- Your child is vomiting all food and drinks. Illness continues longer than 24 to 48 hours. Your child has a temperature. Ketones are greater than 3mmols/l in the blood. Your BG is less than 4mmol/l or above 14 mmol/l after taking extra boluses. Your child shows signs of ketoacidosis drowsiness, abdominal pain, chest pain, fast breathing, dry cracked lips When you are uncertain what to do with the pump. Exercise & Physical Activity In general blood glucose levels drop when you exercise as your body is working harder and uses up glucose for the extra fuel the muscles need. However, exercise can cause different blood glucose changes in different people. Check blood glucose levels before during and after exercise to learn what your response is. Keep in mind response will vary depending on type of activity, how strenuous it is and duration of activity. Exercise lasting longer than 30minutes will require extra carbohydrate or a decrease in insulin. Discuss which to do with your diabetes team. In general you should adjust the insulin that has greatest effect during the exercise session e.g. 1. Exercise within an hour or two of a bolus, decrease the bolus by half. 2. If exercise is not close to a bolus, change to a temporary basal rate (30-50% reduction) starting 1 hour before exercise and continuing for 2 hours after exercise. 3. You may need to do both. Page 11 of 19

If blood glucose levels are greater than 14 mmols/l before exercise check blood for ketones. If ketones present, take a correction bolus and delay exercise until ketones are zero exercise makes ketones worse. NB. Always carry carbohydrate to treat low blood glucose levels. Many ask if you should disconnect the pump for exercise there is no right or wrong answer. Problems may happen with body heat/perspiration irritating the infusion site check infusion site after exercise. For contact sports you will probably have to remove the pump but do not remove for longer than 1 hour without a plan for insulin replacement. Time off the Insulin Pump Test blood glucose prior to disconnecting If disconnected for less than an hour no need to change basal insulin but give bolus doses if required for food or high blood glucose levels as normal. If disconnected for greater than 1hour need plan to replace basal insulin and bolus doses. Discuss with your diabetes team. Emergency planning and equipment In the rare event of pump failure Remember you should always have a supply of basal insulin and an injection pen or syringe available so you can switch back to a basal bolus regime in an emergency. To calculate dose of long acting insulin to take i.e. Lantus or levemir - Calculate total basal insulin in 24 hours given via pump and add 10%. E.g. 20 units via pump would be 22 units for pen/syringe injection. Continue to bolus rapid acting insulin e.g. Novorapid with either an injection pen or syringe at usual ratio for carbohydrate. Page 12 of 19

Always carry a supply of emergency equipment:- Spare insulin pens or syringes with insulin and needles Glucose and Ketone testing sensors and meter Spare cannula, tubing and reservoir Fast acting glucose and foods to treat a hypo. Telephone numbers for diabetes team and children s ward Page 13 of 19

Getting ready for a pump start 1. Time/Date: ------------------------- Location: -------------------------- 2. Please be prepared! Read the workbook and User Guide. Practice with your pump, not attached to your body, by doing some basic programming. We will practice these skills again on day of your pump start. 3. The night before you start your pump start: If you are using Lantus /Levemir insulin, take units of insulin at (time) the night before your pump start. 4. The morning of your pump start: Take Humalog /Novorapid insulin for your food and any high BG. Do NOT take any long acting or intermediate acting insulin the morning of your pump start. 5. Eat your usual breakfast the morning of your pump start. Remember to cover the carbs with rapid-acting insulin that your doctor has prescribed. 6. Items you will need on the day of your pump start: 1 unopened vial of Humalog or Novorapid insulin. Insulin pump in its box, User Guide, 2 cartridges, 2 infusion sets. Blood glucose meter, lancets and strips. Blood glucose diary. Glucose tablets or another treatment for hypoglycaemia. 7. Other items you need: Ketone test strips Carbohydrate counting book Glucagon Emergency Kit 8. Additional information (to be provided by your healthcare professional): Page 14 of 19

INSULIN PUMP AGREEMENT Shropshire Children s Diabetes Service expects you and your family to follow the recommendations given below, whilst using Insulin Pump Therapy. 1. To attend all clinic appointments. 2. To check blood glucose readings at least 6-8 times daily, record the results and act on high and low readings. 3. To use carbohydrate counting for calculating bolus doses of insulin, which should ideally be taken before each meal 4. To use pump bolus calculator for all insulin boluses. 5. Understand the various basal rates and adjust them appropriately (for sick day, weekends etc.). 6. To follow advice regarding safe use of cannula, skin care and site rotation. 7. Take personal responsibility for care of the pump i.e. insurance and maintenance of pump. 8. Take responsibility for ordering and receiving consumables. 9. To attend all education sessions organised in line with funding agreement 10. The insulin pump should be returned to the Trust promptly if no longer required and in any event must be returned at the request of the Trust at any time. 11. Main carers and family to show commitment to successful pump therapy and engage fully with the diabetes team. Responsibilities of the Paediatric Diabetes Team 1. Ensuring insulin pump education and assessment for child and family and nursery/school, before pump start. 2. Provision of appropriate dietary advice and help with training school personnel. 3. Help with trouble-shooting, including 24 hour telephone support/open access to the ward 4. Ongoing insulin pump education. 5. Arranging for a minimum of 4 follow up visits in a year along with HbA1C measurements, and ensuring patient has 8 other contacts with team /year e.g. telephone contacts, school or education sessions. 6. Provision of continuous glucose monitoring and discussion of results and training where required/appropriate. Patient consent/agreement The Shropshire Paediatric Diabetes team have assessed and have agreed that they are eligible for an insulin pump to improve their diabetes control. Funding for the insulin pump and ongoing consumables has been agreed with the Trust...(Patient) &.(Parent) Have completed the training package and are happy to commence on an insulin pump with continued support and training being provided by the diabetes team Page 15 of 19

The goals/aim of starting on a continuous subcutaneous insulin infusion pump are:- 1 2 3 E.g. Improvement in HbA1c,If acceptable HbA1c at initiation maintenance of this level,improvement in variation of blood glucose levels e.g. reduction in frequency of disabling hypoglycaemia, Improvement in quality of life. I..(Name), father / mother/ guardian of..agree to follow the above recommendations and understand that failing to do so could result in the pump treatment being reviewed or discontinued...(signature)..(date) I..(Name), father / mother/ guardian of..agree to follow the above recommendations and understand that failing to do so could result in the pump treatment being reviewed or discontinued...(signature)..(date) I (Name) agree to follow the above recommendations and understand that failing to do so could result in the pump treatment being reviewed or discontinued. (Patient)..(signature) (date) Witness.(Name and designation)..(signature) (date) Page 16 of 19

Starting doses Basal Rate My starting basal rate is 12am- = u/hr._ = units per hr. = u/hr. = u/hr. = Food Boluses Use the insulin-to-carbohydrate ratio (I:C) to calculate a bolus dose before meals and snacks. My I:C ratio is Bolus 1 unit for every grams of carbohydrate. Formula for Food Boluses: Carbohydrate grams = no. of units to bolus (X = C in the I:C ratio) X Blood Glucose Correction Boluses Use the Insulin Sensitivity Factor (ISF) to calculate a BG bolus when the BG is out of range. My ISF is 1 unit of insulin will drop by BG approximately mmol/l BG Target The target range for my BG is mmol/l I correct out-of-range BG to a target of mmol/l Before meals 2hrs After meals Bedtime During the night Formula for High BG Corrections: Current BG Target BG = units needed to return BG to target ISF Page 17 of 19

Diabetes Team Contact Numbers Consultants Dr McCrea Dr Hinde 01952 641222 ext 4798 working hours 07776133639 mobile 01952 641222 ext 4182 working hours Diabetes Specialist Nurses For Shropshire County PCT & Powys Patient s Beth Hughes and 01743 277696 Amanda Stephenson Nicola Collins For NHS Telford and Wrekin Patient s Carol Metcalfe 01952 641222 ext 4739 Dietitians Lynne Mander 01952 641222 ext 4419 Hannah Joscelyne 01743 261139 Pump companies Animas Medtronic Roche Resources Children with Diabetes www.childrenwithdiabetes.co.uk www.insulin-pumpers.org.uk These are UK websites providing information about the use of pumps in children. Page 18 of 19

Insulin Pump Accessories www.pumppack.com www.pumpwearinc.com www.insulinpumppacksforyou.com These American website offer various holders for insulin pumps, including pouches, belts, T- Shirts with pouches and backpacks for small children. This leaflet was produced in November 2008, Updated January 2014 Page 19 of 19