Guidelines for
Continuous Subcutaneous Insulin Infusion
(CSII) Pump Therapy ©
Victorian CSII Working Party
Version 1 – July 2009
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: [email protected]
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).
VICTORIAN INSULIN PUMP (CSII) GUIDELINES
INDEX
A.
FLOW
CHART
page
4
UPDATED VERSION PENDING
3
.
PRE
PUMP
INITIATION
page
9
4. ADMISSION
/
COMMENCING
PUMP
page
15
5.
FOLLOW UP
page 23
7.
REFERENCES
page
26
6.
GLOSSARY
page 25
2.
ASSESSMENT
page
7
1.
ENQUIRY page
5
B. APPENDIX
page
28
A. FLOW CHART
Available resources for patient Available resources For CDNE
• Patient/staff ongoing contact • Dose adjustment
• Confirm review appts: Endo / CDNE / Dieititan
• Letter from CDNE to referring Endo & cc to patient’s GP 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
Insulin Pump Enquiry • Referral source
• Referral letter
Patient to
• Advise wish to proceed • Decide which pump • Be advised of potential
start dates
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
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 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 Endocrinologist responsibilities
• Determine basal/bolus rates • Agreement re /target BGL • Contact CDNE
• Pre pump insulin doses • Advise patient
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
Follow-up Appointments
• Understanding
• Decision making
• Documentation
• Results
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
□ DiabetesNetwww.diabetesnet.com
• Pump Supplier brochures and websites
□ Insulin Pump Information Booklet 2007 from DA Vic [email protected] □ 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 4th
edition Torrey Pines Press, San Diego 2006
□ The ABC of Insulin Pump Therapy (or.. is that you beeping?), Prof Ulrike Thurm 2nd Ed, 2008
□ Guide for Insulin Pump Therapy. Authors Cheryl Steele, Emma White, Megan Buszard. 3rd 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
□ Understanding Diabetes: A handbook for people who are living with diabetes. H Peter Chase. 11th 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: [email protected]
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
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.
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
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.
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
□ 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
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
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: [email protected] 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
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.
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.
Basic Pump Operation Checklist
How to insert batteriesHow 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
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
Treating High Blood Glucose (Hyperglycaemia)
Quick Reference Guide
Causes
□ 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
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
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 Dizziness Sweating Pale
Tired 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.
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.
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.
5. FOLLOW UP
In most cases the patient is discharged after a 4 – 6 hr admission with instructions for follow-up. 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. SpecialistPhysician / CDNE
□
Discuss preferred method of communication e.g. e-mail / fax / phone□
Ensure arrangements are in place for after hours coverContact 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
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
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
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
□ DiabetesNetwww.diabetesnet.com
• Pump Supplier brochures and websites
□ Insulin Pump Information Booklet 2007 from DA Vic [email protected] □ 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 4th
edition Torrey Pines Press, San Diego 2006
□ The ABC of Insulin Pump Therapy (or.. is that you beeping?), Prof Ulrike Thurm, 2nd edition, 2008
□ Guide for Insulin Pump Therapy. Authors Cheryl Steele, Emma White, Megan Buszard. 3rd 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.• 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: [email protected] and Web site: http://wchs.health.wa.gov.au
Web resources:
• www.calorieking.com.au
• www.food.com.au
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
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%)
Wt: Ht: BMI:
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
