Guidelines for Continuous Subcutaneous Insulin Infusion (CSII) Pump Therapy Victorian CSII Working Party Version 1 July 2009 1
ABOUT THE GUIDELINES Rationale Continuous Subcutaneous Insulin Infusion (CSII) therapy, also known as insulin pump therapy, is now available, partly subsidized, to paediatric and adult Australians with Type 1 diabetes. People with insulin requiring Type 2 diabetes may also choose insulin pump therapy but must meet the financial requirements themselves. CSII therapy was initially and as of 2009 is still predominantly available via diabetes clinics in major metropolitan teaching hospitals. Many diabetes clinics throughout Australia wish to provide their patients with access to this treatment modality. So as to facilitate the establishment of additional clinics, reducing reduplication of effort, the Victorian CSII group has provided the following guidelines. No particular pump is endorsed by the group. Pumps and suppliers are listed alphabetically. Available pumps, websites and other resources were current as of guideline publication. Contributors The following Health Care Professionals contributed to this document: President: Cheryl Steele, CDNE,Western Health, Footscray Meagan Buszard, CDNE, Southern Health, Monash Medical Centre, Clayton Prof. Peter Colman, Royal Melbourne Hospital, Parkville Rebecca Gebert,CDNE, Royal Children s Hospital, Parkville Assoc. Prof. Alicia Jenkins, The University of Melbourne, St Vincent s Hospital, Fitzroy Lorraine Marom, CDNE, Southern Health, Dandenong Hospital, Dandenong Dr. David O Neal, The University of Melbourne, St Vincent s Hospital, Fitzroy Kerryn Roem, APD, Fitzroy Victoria Stevenson, CDNE, Austin Health, Heidelberg Sue Wyatt CDNE, Alfred Hospital, Prahran Vic CSII Group Contact Cheryl Steele: email address: Cheryl.Steele@wh.org.au Acknowledgements Meetings, guidelines and presentation at the 2008 ADS meeting were without funding or sponsorship. CD and paper production costs were sponsored by the NHMRC CCRE Clinical Science in Diabetes (PI James Best, The University of Melbourne). 2
VICTORIAN INSULIN PUMP (CSII) GUIDELINES INDEX A. FLOW CHART page 4 1. ENQUIRY page 5 2. ASSESSMENT page 7 3. PRE PUMP INITIATION page 9 4. ADMISSION / COMMENCING PUMP page 15 5. FOLLOW UP page 23 6. GLOSSARY page 25 7. REFERENCES page 26 B. APPENDIX UPDATED VERSION PENDING page 28 3
A. FLOW CHART Available resources For CDNE Insulin Pump Enquiry Referral source Referral letter Available resources for patient Patient Assessment Usual education assessment Suitability of patient for a pump Private health fund status Show pumps & cannulae Discuss process of commencing a pump Blood glucose/ketone meter Patient to Advise wish to proceed Decide which pump Be advised of potential start dates Dietitian Healthy eating review CHO counting Alcohol/Fat/Fibre Gastroparesis Co-morbidities e.g. coeliac disease Pre-Pump Initiation Patient commencing pump CDNE to advise/ arrange Dietitian appt. Ensure patient can CHO count CDNE orders pump Hospital process Pump company process Pre pump education Decide number of pump teaching sessions eg 3 admissions Available dates Book & confirm venue for pump start Endocrinologist responsibilities Determine basal/bolus rates Agreement re /target BGL Contact CDNE Pre pump insulin doses Advise patient CDNE pre pump detailed advice for patient Pump start date Sick days/hypos/site infection/other What to bring Who to bring Possible collection of pump by patient pre education Pump insurance Pre pump insulin doses Admission/Pump Commencement Documentation to include evidence of medical visitation/involvement and insulin doses Initial and safe education to operate pump Pump check list Spread sheet record chart R/v sick day / ketone / hypo management 24 hr contact: Endo / CDNE & Pump company tel. numbers Arrangements for regular contact Patient/staff ongoing contact Dose adjustment Confirm review appts: Endo / CDNE / Dieititan Letter from CDNE to referring Endo & cc to patient s GP Follow-up Appointments Understanding Decision making Documentation Results Other pump features Special circumstances 4
1. ENQUIRY Enquiry to a pump service may be initiated by a prospective patient or carer or by a Health Care Professional. Initial Information Basic information on the benefits and risks of insulin pump therapy is available from many different sources. There are resources that have been developed by the insulin pump suppliers; some of this information is about pump therapy in general whilst some is specific to the pump supplied by a particular manufacturer. Some resources are also aimed at the prospective user whilst other information is targeted toward the Health Professional. Resources listed below are a sample of the types of material available and a useful starting point. Specific information developed by individual hospitals or institutions Web sites, including: American Diabetes Association www.diabetes.org Australian Diabetes Educators Association lists Pump Centres of Excellence www.adea.com.au Diabetes Australia www.diabetesaustralia.com.au Each DA member state also has information on their individual websites follow the links. For Victoria it is www.dav.org.au Diabetes Health www.diabeteshealth.com Reality Check www.realitycheck.org.au DiabetesNet www.diabetesnet.com Pump Supplier brochures and websites Insulin Pump Information Booklet 2007 from DA Vic mail@dav.org.au Animas Australasian Medical & Scientific www.animascorp.com Dana11S Diabetes Australia-NSW www.diabetesnsw.org.au Medtronic www.medtronic-diabetes.com.au Roche Accuchek Spirit www.accu-chek.com.au Books Pumping Insulin, John Walsh and Ruth Roberts 4 th edition Torrey Pines Press, San Diego 2006 The ABC of Insulin Pump Therapy (or.. is that you beeping?), Prof Ulrike Thurm 2 nd Ed, 2008 Guide for Insulin Pump Therapy. Authors Cheryl Steele, Emma White, Megan Buszard. 3 rd edition 2008. Available www.abbottdiabetescare.com.au Insulin Pump information booklet. April 2006. Diabetes Australia Victoria www.dav.org.au Smart Pumping. Howard Wolpert, Editor, American Diabetes Association, 2002 5
Understanding Diabetes: A handbook for people who are living with diabetes. H Peter Chase. 11 th edition. 2006. Pump specific journals suitable for ongoing Health Care Professional Education Infusystems Publications. http://www.publiscripts.com Diabetes Technology and Therapeutics Mary Ann Liebert, Inc. publishers Phone: 914-740-2100, Fax: (914) 740-2101 Email: info@liebertpub.com Making a referral The referral for assessment and initiation of insulin pump therapy needs to contain: Patient details to create a hospital number Reasons for referral History of patient s diabetes including type of diabetes, complication status, current level of control (HbA1c), and hypoglycaemic awareness. (NB. NDSS concession for pump consumables are only available for type 1 or gestational diabetes or for pregnant women with type 2 diabetes. For the latter group post-pregnancy reassessment is required by NDSS.) Patient s current insulin regimen and method of testing blood glucose levels Patient s private health cover details or alternate means of obtaining a pump Details of treating Endocrinologist / Physician, Credentialled Diabetes Nurse Educator (CDNE), Dietitian and General Practitioner (GP). 6
2. ASSESSMENT It is recommended that the initial assessment be performed by a team consisting of a physician, CDNE or diabetes nurse practitioner, dietitian and, if deemed appropriate, a psychologist. The assessment can be subdivided into a) general clinical assessment; b) general diabetes education status; c) health fund or alternate funding source; d) initial determination regarding patient suitability for CSII therapy; and e) actions to be taken if the patient is regarded as suitable for CSII therapy. a) Clinical Assessment. An overall assessment of the patient with regard to: 1/ The confirmation of diagnosis of Type 1 diabetes or gestational diabetes. 2/ Glycaemic control.* Total daily insulin requirements to achieve the desired glycaemia are to be determined as this will be required in calculating insulin doses when initiating pump therapy and determining the capacity of the insulin reservoir in the pump. This should be rechecked immediately prior to starting CSII therapy as insulin requirements may change greatly over short periods of time. 3/ Review of complication status and management. * Particularly those that will impact on ability to use pump (visual acuity, manual dexterity) and insulin dosing (renal impairment) 4/ Other co-morbidities and lifestyle factors that may impact management. *Includes obtaining and reviewing pathology results e.g. HbA1c, renal function b) General Diabetes Education Assessment The patient s general diabetes education is to be assessed. This is to include: Accuracy and reliability of home blood glucose and blood ketone testing Understanding of dietary issues in diabetes Understanding of and potential to learn carbohydrate counting Understanding of diabetes and insulin (analogues) and their profile of action Hypoglycaemia (including glucagon use for severe hypoglycaemia), hyperglycaemia, DKA, and sick day management Up-date session to check meter, understanding of diabetes, meaning of basal / bolus, terms used in pump therapy (e.g. basal, bolus, insulin carb. ratio and correction factor), and effects of alcohol and exercise on glucose levels c) Confirm the private health insurance fund status or alternate funding source. d) Initial Determination Regarding Patient Suitability for CSII Therapy. Based upon the information obtained following the clinical assessment the patient s suitability for pump therapy is assessed according to a number of patient selection criteria. 7
Patient confirmed as having Type I diabetes or diabetes in pregnancy. (For Type 1 diabetes this may include measurement of fasting C-peptide and (pre-exogneous insulin) insulin levels and anti-islet antibodies, including anti-gad and anti-ia2 antibodies) Lifestyle allows for wearing of a pump Lifestyle choices to facilitate adequate time for initial stabilization and education Patient requires less than 300 Units of (100 IU) insulin per 2-3 days Consistent home blood glucose (BG) monitoring and recording or is willing to increase monitoring (and subsequently demonstrates has done so) Ability to measure blood or urine ketone levels, or agreeable to learning to do so Basic numeracy Willing and able to learn how to carbohydrate count and to calculate doses of insulin Willing to communicate on a regular basis with the team Able to comply with treatment plans or scheduled visits Absence of any severe or unstable psychiatric condition: eating disorder, psychosis, depression. It is noted that the presence of an eating disorder or depression does not preclude insulin pump use Reasonable level of motivation and able to accept responsibility for care of diabetes No significant visual impairment No major restriction in manual dexterity, or lack of required assistance Adequate condition of subcutaneous tissue and skin Satisfactory hygiene Funds available to purchase pump and consumables (N.B. NDSS will not provide consumables for non-pregnant Type 2 diabetes patients using CSII therapy) e) Actions To Be Taken If Patient Is Deemed Suitable For CSII. 1/ Discuss broad outlines, including advantages and disadvantages of pump therapy. Ensure that patient has realistic expectations e.g. carbohydrate counting and glucose monitoring. 2/ Show pumps and consumables. Demonstrate the range of pumps available and the types and sizes of (pump specific) reservoirs and cannulae supplied through NDSS. Ensure the patient understands the features of each pump and the practical applications of each type of cannulae. Direct the patient to the appropriate web site of each pump manufacturer. Direct patient to web-based and printed sources of information on pump therapy (listed in section 1). 3/ Referral to dietitian for carbohydrate counting training or for review and advanced training. It is preferable but not essential if patient has already taken part in a program such as DAFNE. Note patients declared as about to start CSII therapy are not eligible for DAFNE. 4/ Discuss process / timelines for commencing pump therapy and for achieving the goals. 5/ Organise follow-up contact / appointment when patient has come to a decision as to whether he/ she wishes to proceed. 6/ Once the patient has decided to proceed, determine the brand and model of pump selected. Choose appropriate reservoir size based on total daily insulin dose. 8
3. PRE PUMP INITIATION Once a patient is assessed as suitable and indicates a desire to progress to CSII therapy various team members have complementary roles. Excellent communication between team members is required. The suggested roles of the CDNE, Specialist Physician and Dietitian are now outlined. CDNE ROLE The CDNE will co-ordinate the education needed prior to commencement of pump therapy, the pump purchase, and the admission for pump commencement. The CDNE will: Determine a suitable date for admission Ensure the venue for initiation is booked Notify the admissions office of the booking Notify all members of the team of the admission details Ensure the patient has an appointment with the dietitian Initiate the request for a purchase order for the pump Determine the number of visits needed for education prior to the initiation of pump therapy, provide such education, and assess its uptake Ordering the Pump After ensuring that the patient has valid Private Health Insurance a requisition is raised for the required insulin pump, by the hospital. If the patient does not have Private Health Insurance the patient must order and pre-pay for the pump directly from the company. When raising the requisition (purchase) order for the pump the buyer will require: a) the patient s hospital ID number, b) the date of admission and c) the admitting doctor s details. It is a requirement of most hospitals that a senior member of staff counter sign the purchase requisition for items valued over a certain amount, so it is advisable to know what your hospital s requirements are. Each pump supplier has a patient information sheet that needs to be completed and sent (usually faxed) to the pump supplier. This allows the supplier to register the pump to the patient for warranty purposes. Manufacturers must also be able to trace users of the device in case of recall by the Therapeutic Goods Administration (TGA). It is not compulsory to supply the patient s Private Health Insurance details to the pump suppliers, although they do request that information on the sheet for their own data collection. Most suppliers prefer at least seven working days notice to deliver pumps. Allow 7-10 days for delivery of pump consumables. 9
Pre-Pump Education The number of visits required by a patient for education prior to commencing pump therapy will be determined by patient need and the staffing resources available to the training facility. The education must include information on: Hypoglycaemia Hyperglycaemia and DKA Sick day management, including ketone testing Care of the insulin infusion site Ordering Consumables for the pump Insulin Pump Consumables (IPCs) are subsidised through the NDSS. The insulin pump assessment form must be completed and signed by a CDNE or Specialist Physician prior to the patient being able to place an order. The criteria for access to subsidised consumables are listed on the form (available from the Diabetes Australia website). Allow 7-10 days for delivery, both initially and for supply renewal. It is recommended to only order one box initially to ensure the selected product meets patient needs. The patient needs advice about the most appropriate type of cannula for their requirements. Is an insertion device necessary? Angle of cannula - 90 v 45 Length of cannula shorter for children and lean adults. Type of connection luer lock or proprietary The patient needs to place the order with Diabetes Australia in a timely fashion to ensure delivery of their items prior to the date of admission. Assessment forms and insulin pump consumables order forms are available for downloading from the Diabetes Australia website (diabetesaustralia.com.au or via ndss.com.au) Private Health Insurance companies generally do not provide cover for insulin pump consumables. What to bring on the day The patient should be advised to bring the following with them on the day of initiation: Medicare Card and Private Health Insurance details Consumables for the pump Insulin analogue (Novorapid, Humalog or Apidra) to be used in the pump History of recent blood glucose monitoring Blood glucose monitor Hypoglycaemia treatment food 10
A snack and / or meal of known carbohydrate count Alcohol wipes A significant other for support if possible Note taking material if desired SPECIALIST PHYSICIAN S ROLE The Specialist Physician should be closely involved in CSII initiation. The Specialist Physician, usually in communication with the CDNE, is responsible for: Determining the initial basal and bolus doses based on the daily insulin requirements prior to pump therapy Determining and reviewing the insulin action time Setting the target blood glucose levels in consultation with the patient, having regard for patient s history of hypoglycaemic events including the presence of hypoglycaemia unawareness Providing advice on insulin doses on the day prior to initiation of pump therapy e.g. reduction in basal insulin the night before admission and / or omission of morning basal insulin Providing the patient with contact details for ongoing titration on doses Maintaining contact with the CDNE Communication with the referring doctor if different from the member in the team commencing pump therapy to establish when the patient will return to the care of their treating Specialist Physician Communication with the General Practitioner and any other health care professionals involved in the patient s care Adequate written documentation 11
DIETITIAN ROLE Dietitian Consultations Consultation with an accredited and carbohydrate counting experienced dietitian should be included in the education program for commencing pump therapy so that all patients learn to carbohydrate count. Carbohydrate counting is an essential skill in insulin pump therapy as the amount of carbohydrate eaten at any one time will determine the amount of insulin given as a meal or snack bolus. Every patient needs to be proficient in counting carbohydrates prior to commencing pump therapy. If a patient is not proficient in any area of carbohydrate counting then it is strongly recommended that they not start a pump. The patient will need further review sessions with the dietitian until such time as they have acquired the necessary skills. It is preferable that the patient be seen at least once, and preferably twice prior to commencing pump therapy. A follow-up visit post pump commencement is also recommended. The GP may provide an Enhanced Primary Care (EPC) Plan to subsidise dietitian consultations. Dietitian Pre-Pump Education The patient should have at least one visit to the dietitian a month prior to starting a pump to learn or review carbohydrate counting. The more time a patient has to learn carbohydrate counting the more adept they will be in this often challenging skill. The initial session should go through the basics of carbohydrate counting: Methods of counting carbohydrates There are two main methods of teaching carbohydrate counting, both of which require basic maths skills by the patient: o Total grams patients are taught to calculate the carbohydrate in foods, and then add together all the carbohydrates in the meal (or snack) they intend to eat. They then enter this amount into the pump. Patients therefore need to be able to accurately assess the weight of foods and calculate their carbohydrate content. This is the preferred method of counting carbohydrates as most pumps require the total amount of carbohydrate to be entered into the pump s insulin bolus calculator. o The exchange method patients are taught that 1 exchange equals 15 grams (gms) of carbohydrate. Patients are provided with food lists containing measured amounts of food to give 15gms of carbohydrate. The numbers on the lists are generally rounded down and, this method is considered not to be as accurate as using the total grams method. As most pumps require the total amount of carbohydrate to be entered, patients need to multiply the number of exchanges by 15 and enter this amount into the pump. While it is the less favoured method, it maybe useful if patients are already familiar with it. Required skills for counting carbohydrates In order to count carbohydrates the patient needs to: Know which foods contain carbohydrate and therefore need to be counted Know how much of the food is being eaten (this will require measurement of food 12
amounts with e.g. kitchen scales and measuring cups until familiar with quantities) Determine the amount of carbohydrate in the food Have adequate numeracy skills Be able to read and understand labels on food products Be able to analyse recipes and work out their carbohydrate content Be able to use carbohydrate counters Be able to estimate carbohydrate content of meals when eating out Resources: The following book and web-based resources contain information on the amount of carbohydrate in Australian foods. These are useful to help patients estimate the carbohydrate in the food they eat. Books include: The Australian Women s Weekly Fat and Kj counter. ACP Publishing Pty Ltd 2003. ISBN 1 86396293x The Fat, Fibre and Carbohydrate Counter. The essential guide to healthy eating. Murdoch books 2008. ISBN 1 74045250x Allan Borushek s Pocket Calorie and Fat Counter Family Health Publications (updated annually). ISBN 9780947091170 The Traffic Light Guide to food (2005) By Diabetes Education and Assessment program Royal North Shore Hospital, Sydney Available from Royal North Shore Hospital Diabetes Centre; ph: 02 9926 7229 or Diabetes Australia NSW; ph: 1300 136588 Food for Pumpers Compiled by: Alison Climie and Andrea Clarey, Department of Diabetes and Endocrinology Acknowledgements to: Prof Tim Jones, Jolie Gonzales and Joanne Gonzales Produced by the Women's and Children's Health Service September 2004 WCHS 0156 Available from: Email: alison.climie@health.wa.gov.au and Web site: http://wchs.health.wa.gov.au Web resources: www.calorieking.com.au www.food.com.au Food diaries Getting the patient to keep a food record with the food, the amount eaten and the carbohydrate value is invaluable. Bringing this record back to review sessions will facilitate assessment and advancement of their carbohydrate counting skills. Review sessions All patients require at least one follow up session with the dietitian. The dietitian needs to assess the carbohydrate counting skills of the patient and discuss this with the CDNE and other team members as required. Assessing the patients food records will help determine 13
how well the patient is carbohydrate counting. The dietitian in collaboration with the CDNE and / or doctor may also discuss alternate insulin bolus choices to optimise post-prandial glycaemia. Issues may include types of food and the type of insulin bolus. 14
4. ADMISSION / COMMENCING PUMP Patients are normally admitted as a day patient to facilitate initiation. An inpatient admission allows for the rebate of the cost of the pump from the patient s Private Health Fund. Currently pumps are rebated at 100% provided that the patient is admitted as a private patient when the device is initiated. Diabetes education is not a valid reason for a patient admission. The patient needs to be admitted for medical assessment, including risk of hypoglycaemia, and observed to ensure stable glycaemia prior to discharge. Some facilities may choose to use a representative from the pump supplier to assist with teaching the button pushing component of the pump initiation. The following checklists cover the usual first and second phase of pump education, which commences whilst an in-patient. As there is much to learn, all patients require re-enforcement and assessment of understanding of education. Ongoing education and support is essential (see Section 5). As per the checklist on the following page, recommendations regarding admission documentation and guidelines relating to hyperglycaemia and hypoglycaemia management are provided. 15
Basic Pump Operation Checklist How to insert batteries How to set the time/date How to program basal rates How to program boluses How to set auto-off alarm How to fill the reservoir and place it in the pump How to attach the infusion set to the reservoir Selection of the insertion site How to prepare the insertion site and avoid infections How to insert the cannula How to stop / suspend the pump or start the pump. It is preferable that a significant other be trained to assist the patient if the need arises. How to identify alerts / alarms and what to do How to review pump memory for current basal rates and boluses given How to wear the pump Where to obtain pump supplies Lifestyle issues e.g. showering, sleeping, intimacy, sport Contact list for the pump company help line, CDNE, endocrinologist and dietitian How to program an Insulin/CHO ratio How to program the Correction Factor (Insulin Sensitivity Factor [ISF]) How to program Insulin Duration How to program mmol/l How to program target BGL Follow-up visits within 3 days of initiation should include education regarding: Change of cartridge and of line When to use and how to program temporary basal rates How to test and set basal rates How to test and set Insulin / carbohydrate (CHO) ratios How to use extended or square wave boluses and combination or dual wave boluses How to test the Correction Factor (Insulin Sensitivity Factor [ISF]) How to handle high blood glucose levels (BGLs) on the pump How to handle low BGLs on the pump Lifestyle issues e.g. exercise and intimacy Troubleshooting the pump Skin problems Special circumstances e.g. shift-work, gastroparesis, hypoglycaemic unawareness, MRI or X- Ray, fasting for medical procedures/surgery, travel overseas and Ensure all questions and concerns are addressed 16
NB. Not all patients want or need to use all of the extended features in an insulin pump. The health professional needs to ensure that the patient is confident and competent in the basic principles and use of their insulin pump. Information should be provided at a pace that the patient is comfortable with. Ongoing review and revision of topics covered is critical to the success of insulin pump therapy and positive patient outcomes. Documentation of Admission The admission should be documented in the appropriate part of the patient s file. Documentation must include evidence of medical and dietitian consultation / involvement and insulin doses CDNE must ensure adequate documentation from the medical practitioner. Documentation should include the type of insulin, basal rates, insulin/cho ratio, correction factor, target BGL and duration of insulin action CDNE should document that the patient has commenced a basal rate and delivered a bolus dose of insulin via the pump during the admission. This is a requirement of the medical records coder. CDNE should document education provided and patient s competence and safety for discharge. Notes should include details of next appointment. NB. Please refer to Endocrinologist responsibilities 17
Treating High Blood Glucose (Hyperglycaemia) Causes Quick Reference Guide Excessive exercise without sufficient insulin Increased stress Concurrent Illness Underestimated carbohydrates & bolus Omission of bolus Incorrect bolus type for fatty food Inadequate basal rate Pump cartridge empty Incorrect technique when priming the pump and changing the infusion set Too long between infusion set changes Infusion set or site failure Infected infusion site Temporary basal rate decreased too much or run for too long a period Suspended pump Failure to acknowledge auto-off alarm Failure to reconnect pump Pump failure Drugs e.g. corticosteroids Immediate Action Check Blood Glucose Level (BGL) BGL > 10.0 mmol/l (but under 12.0 mmol/l) Give correction bolus (if 2 hours from last meal bolus) Retest BGL in 1 hour NOTE: Only give another correction bolus after 2 hours or when the bolus calculator in the pump allows extra insulin to be administered BGL > 12.0 mmol/l and if the patient feels unwell Check for ketones in blood (positive > 0.6 mmol/l ) If no access to blood ketone testing then check urine ketones (positive > trace) Give correction bolus (if positive ketones consider giving an additional 50% correction bolus) Perform assessment of current condition and consider if referral to Emergency Department is warranted Encourage 2 glasses of water over an hour Retest BGL in 1 hour 18
If two unexplained BGL > 12.0 mmol/l Give rapid acting insulin (Apidra, Humalog or Novorapid ) via pen or syringe Suggested dose: Previous days total insulin / 6 units to be given) Perform line change Continue to give insulin by pen or syringe every 4 hours until glucose <12.0 mmol/l if unable to perform line change If blood glucose levels greater >12 mmol/l with persistent ketones for more than 2 hours patient should be advised to contact health professional or attend emergency department 19
Treating Low Blood Glucose (Hypoglycaemia) Quick Reference Guide (for mild, moderate and severe hypoglycaemia) Causes Bolused too much insulin e.g. incorrect Insulin / CHO ratio or inaccurate CHO calculation Over - exercise or unusually high activity level without temporary basal rate adjustment Basal rate too high or inappropriate temporary basal rate set Excessive alcohol especially without carbohydrate snack Recreational drugs e.g. narcotics Blood Glucose Level (BGL) < 3.5 but > 2.0 mmol/l (MILD to MODERATE HYPOGLYCAEMIA) Signs & Symptoms Headache Sweating Tired Dizziness Pale Shakiness Treatment Have one serve (15 gms) of rapid acting carbohydrate (CHO) 5 7 jelly beans ½ glass of regular lemonade (not diet) ½ glass Lucozade 3 BD 5gm glucose tablets or 1 (15g) tube of Glucogel 3 level teaspoons sugar dissolved in water Retest BGL in 10-15 minutes If BGL still < 3.5 mmol/l repeat the above (1 serve rapid acting CHO) followed by 1 serve (15 gms) of low GI carbohydrate 1 slice of bread 1 glass of milk 1 piece of fruit Post-recovery: Review cause of hypoglycaemia. Provide education to reduce risk of further hypoglycaemic events. 20
BGL < 2.0 mmol/l (SEVERE HYPOGLYCAEMIA) Signs & Symptoms As above plus Poor coordination Difficulty concentrating Drowsiness Mood swings Uncharacteristic aggressive behaviour SUSPEND or STOP the insulin pump Give 1 serve (15 gms) of rapid acting carbohydrate (CHO) ½ glass regular lemonade (not diet) ½ glass Lucozade 3 BD 5 gm glucose tablets Tube of Glucogel 3 level teaspoons sugar dissolved in water Retest BGL in 10 15 minutes If BGL still < 3.5 mmol/l repeat the above (1 serve rapid acting CHO) followed by 1 serve of low GI carbohydrate (15 gms) 1 slice of bread 1 glass of milk 1 piece of fruit Retest BGL in 30 minutes Only restart the pump when BGL > 3.5 mmol/l Post-recovery: Review cause of hypoglycaemia. Provide education to reduce risk of further hypoglycaemic events. 21
HYPOGYLCAEMIA with LOSS of CONSCIOUSNESS Signs & Symptoms Drunk-like behaviour, coma or seizure Ensure clear airway and place patient in coma position SUSPEND or STOP insulin pump Perform BGL & give I.M. or S.C. Glucagon as prescribed Call ambulance 000 Remain with person until ambulance arrives Retest BGL every 15 minutes When conscious follow protocol for mild to moderate hypoglycaemia Notify treating endocrinologist Post-recovery: Review cause of hypoglycaemia. Provide education to reduce risk of further hypoglycaemic events. Note: Patients who have just had a severe episode of hypoglycaemia are at increased risk of further severe hypoglycaemia. 22
5. FOLLOW UP In most cases the patient is discharged after a 4 6 hr admission with instructions for followup. Some centres may choose to admit patients overnight in special circumstances e.g. rural centres where patients travel long distances, patient has hypoglycaemia unawareness and lives alone. The patient will usually attend their first follow-up visit within 24 48 hours post initiation. At this follow-up visit the following is attended: Change of cartridge/line Review BGL and insulin dosing Ensure all questions and concerns are addressed Subsequent visits may cover the following: When to use and how to program temporary basal rates How to test and set basal rates How to test and set Insulin/CHO ratios How to use extended or square wave boluses and combination or dual wave boluses How to test the Correction Factor (Insulin Sensitivity Factor [ISF]) How to address low BGLs How to address high BGLs Skin problems Lifestyle issues Troubleshooting the pump i.e. alerts and alarms Special circumstances e.g. gastroparesis, hypoglycaemic unawareness MRI or X-Ray, fasting for medical procedures / surgery, travel interstate or overseas Letter to Referring Doctor A letter detailing the admission and follow-up should be sent to the referring doctor. A template is in the Appendix. Reviewing Rates and Adjustment Basal rates need to be titrated regularly in the first 2 weeks of CSII use, then as required. Confirm with patient who will be responsible for dose titration i.e. Specialist Physician / CDNE Discuss preferred method of communication e.g. e-mail / fax / phone Ensure arrangements are in place for after hours cover Contact Telephone Numbers: Ensure patient has contact numbers for the team and knows who and when to call. Ensure patient has emergency contact number for the help line for the pump supplier 23
Dates Of Next Appointments Ensure appointments have been arranged with the Specialist Physician, CDNE, and Dietitian. Initially, allow a 45-60 minute appointment Patients should have continued follow-up with a CDNE at 3 6 monthly intervals as well as their Specialist Physician 24
6. GLOSSARY Alternate Basal Profiles using more than one basal profile to allow for days with different insulin requirements Basal Rate- Background insulin delivered over 24 hrs BGL - blood glucose level Cannula - a small plastic tube inserted into the subcutaneous layer to deliver insulin CHO - carbohydrate containing food CSII - Continuous Subcutaneous Insulin Infusion Combination / Dual Wave Bolus - Dose of meal time insulin delivered as a proportion immediately and the remainder over an extended period Extended / Square Wave Bolus - Dose of insulin delivered over an extended period of time Insulin Action Time - duration of insulin action Insulin / CHO Ratio - Amount of carbohydrate in food covered by 1 unit of insulin Insulin Sensitivity / Correction Factor- Drop in blood glucose expected from 1 unit of insulin over a 2 hour period Infusion Line- length of tubing between pump and cannula Prime - insulin used to fill the tubing or cannula Reservoir - Syringe used to hold insulin in the pump Rule of 500 - An algorithm developed to calculate insulin to carbohydrate ratio Rule of 100 - An algorithm developed to calculate the insulin sensitivity or correction factor Smart pump - Smart insulin pumps that incorporate an internal calculator that calculates the amount of insulin required for a bolus dose. The patient can over-ride the suggested dose if required. TDD - total daily dose of insulin Temporary Basal Rate - An increase or decrease in the basal rate for a specific period of time. 25
7. REFERENCES References re pump settings Davidson P.C. Bolus and supplemental Insulin. In: Fredrickson L, ed. The Insulin Pump Therapy Book: Insights from experts. Sylmar, CA. Minimed Technologies: 1995: 59-71. BW Bode, T Gross, MD Ghegan, PC Davidson. Factors affecting the reduction of starting insulin dose in CSII. Diabetes:1999 vol:48.suppl. 1 p:264 General pump related references Web sites, including: American Diabetes Association www.diabetes.org Australian Diabetes Educators Association lists Pump Centres of Excellence www.adea.com.au Diabetes Australia www.diabetesaustralia.com.au Each DA member state also has information on their individual websites follow the links. For Victoria it is www.dav.org.au Diabetes Health www.diabeteshealth.com Reality Check www.realitycheck.org.au DiabetesNet www.diabetesnet.com Pump Supplier brochures and websites Insulin Pump Information Booklet 2007 from DA Vic mail@dav.org.au Animas Australasian Medical & Scientific www.animascorp.com Dana11S Diabetes Australia-NSW www.diabetesnsw.org.au Medtronic www.medtronic-diabetes.com.au Roche Accuchek Spirit www.accu-chek.com.au Books Pumping Insulin, John Walsh and Ruth Roberts 4 th edition Torrey Pines Press, San Diego 2006 The ABC of Insulin Pump Therapy (or.. is that you beeping?), Prof Ulrike Thurm, 2 nd edition, 2008 Guide for Insulin Pump Therapy. Authors Cheryl Steele, Emma White, Megan Buszard. 3 rd edition 2008. Available www.abbottdiabetescare.com.au Insulin Pump information booklet. April 2006. Diabetes Australia Victoria www.dav.org.au Smart Pumping. Howard Wolpert, Editor, American Diabetes Association, 2002 Diet related references The Australian Women s Weekly Fat and Kj counter. ACP Publishing Pty Ltd 2003. ISBN 1 86396293x 26
The Fat, Fibre and Carbohydrate Counter. The essential guide to healthy eating. Murdoch books 2008. ISBN 1 74045250x Allan Borushek s Pocket Calorie and Fat Counter Family Health Publications (updated annually). ISBN 9780947091170 The Traffic Light Guide to food (2005) By Diabetes Education and Assessment program Royal North Shore Hospital, Sydney Available from Royal North Shore Hospital Diabetes Centre; ph: 02 9926 7229 or Diabetes Australia NSW; ph: 1300 136588 Food For Pumpers Compiled by: Alison Climie and Andrea Clarey, Department of Diabetes and Endocrinology Acknowledgements to: Prof Tim Jones, Jolie Gonzales and Joanne Gonzales Produced by the Women's and Children's Health Service September 2004 WCHS 0156 Available from: Email: alison.climie@health.wa.gov.au and Web site: http://wchs.health.wa.gov.au Web resources: www.calorieking.com.au www.food.com.au 27
B. APPENDIX Sample of letter to referring Health Professional: HOSPITAL LETTERHEAD Address and all relevant contacts phone, fax, email, website. Staff and their role Date:.. Dr Dear Re:.. UR. Thank you for your letter and referral of ----------------------------- to me to commence insulin pump therapy. Date and type of diagnosis HbA1c and date Patient goals for pump therapy: An initial education assessment was completed Wt: Ht: BMI: Patient has seen a dietitian / will be seeing a dietitian Pre pump insulin regimen: Glucose meter Pre pump BGL s Knowledge of carbohydrate counting Name of insulin pump: Date Commenced Company Rep. in attendance Y N Standard pump algorithm used Y N Partner / Parent in attendance Y N (reduction of total daily dose by 30%) 28
Pump consumables arranged Initial pump BG target set at: Basal rate Bolus: carbohydrate Insulin sensitivity Insulin Action Time (hours set at) Blood glucose testing advised Blood Ketones 24hr telephone contact numbers Follow up telephone calls arranged Y N. Insulin pump checklist attached/hospital file Y N Review appointment with the Endocrinologist and Diabetes Educator have been arranged for Yours sincerely, Name Position cc:.. 29
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