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Optimization Training for Insulin Pumps

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Every opportunity should be taken during office visits to evaluate the learner’s current knowledge and build on their experience.

Reviewed by: the ADCES Professional Practice Committee

Acknowledgements: Carla Cox, PhD, RD, CDE, CPT; Karen M. Bolderman, RD, LDN, CDE; Gary Scheiner, MS, CDE; Claire M. Blum, MS Ed, RN, CDE; Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE; Janet Mertz, MS, RD, LD, CDE. Revisions: January 2018: Diana Isaacs, PharmD, BCPS, BC-ADM, CDE, Diane Battaglia, RN, CDE, Carla Cox, PhD, RD, CDE, CPT. Revisions: March 2021: Carla Cox, PhD, RDN, CDCES, CPT

The foundation for use of an insulin pump begins during the initial training session(s). Learning continues as insulin delivery is initiated and connections are made between prior knowledge and present experience. Because there are few, if any, life experiences that compare to the mechanical use or utility of an insulin pump, multiple learning sessions are often necessary to master basic skills.

Twenty-four-hour coverage should be provided and may extend for months or years due to potential problems which can arise due to occlusions, pump malfunctions and illness. Experience in the use of long-acting insulin, insulin-to-carbohydrate ratio(s), and correction factor(s) must be expanded to promote understanding of how rapid-acting insulin works when delivered via an insulin pump.

The use of CGM and integrated systems makes foundational learning even more imperative. There is the potential for a greater risk that the learner may “stack” insulin, overtreat hypoglycemia, or make inappropriate changes in pump settings in response to the continuous availability of glucose data. Safe practice requires that the learner understands the concept of active insulin, the use of advanced prandial delivery options, and effective management strategies during periods of activity, inactivity, stress, travel or illness. (See Safe Practices).

Teachable moments occur during the follow-up calls and visits for fine-tuning of basal and bolus settings. The specialist must continually assess the individual’s comprehension and follow-up until the person is able to demonstrate comfort and competence in the use of their pump and its features.

The PWD must be taught how to:

  • Properly insert and remove the specific type of infusion set used, with emphasis on site rotation
  • Adjust insulin delivery to accommodate physical activity, inactivity, sick days and stress.
  • Safely untether (if appropriate) their infusion set tubing for special events.
  • Implement a backup plan in case of equipment failure.
  • Protect themselves and their pump, infusion set, sensor and transmitter if applicable during certain physical activities and when undergoing some medical tests, such as a CAT scan, MRI, or X-ray, and airport scanning equipment.
  • Upload data for review by their healthcare team at regular intervals.
  • Prepare for and pack necessary supplies for travel within the United States as well as out of the country.
  • Contact technical support and medical personnel when necessary.

The individual should expect to stay in daily contact with the diabetes care and education specialist during the first two to three days and at designated intervals during the weeks following the initiation of insulin pump therapy, to report and review glucose levels and titration of basal and bolus settings. Individual response to insulin delivery via an insulin pump can vary significantly from that of MDI. The specialist must know how to make appropriate adjustments in basal and bolus settings during this time to prevent hypo- and/or hyperglycemia, and determine settings that match the person’s circadian rhythms and patterns of daily living.

Detailed attention should be given to infusion site management. Issues with site reactions, infusion set tolerance and compatibility, and site adherence should be assessed at the time of the first site change and during follow-up visits. The specialist should never assume that the new or seasoned insulin pump wearer has achieved optimal mastery of skills. Every opportunity should be taken during office visits to evaluate the learner’s current knowledge and build on their experience towards mastery of blood glucose management skills.

References:

1. Bergenstal R, Tamorlane W, Ahmann A et al. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010:363:311-320. 2. Bally L, Hood T and Hovorka R. Closed-loop for type 1 diabetes-an introduction and appraisal for the generalist. BMC Medicine. 2-17:15:14. Accessed 8/26/2017/ 3. Heinemann L, Fleming G, Petrie J et al. Insulin Pump Risks and Benefits: A Clinical Appraisal of Pump Safety Standards, Adverse Event Reporting, and Research Needs A Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015;38:716–722. 4. Grunberger G, Abelseth J, Bailey T, et al. (2014) Consensus Statement by the American Association of Clinical Endocrinologists/American College of Endocrinology Insulin Pump Management Task Force. Endocrine Practice: 2014:20(5) 463-489. 5. Decision Memo for Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092R) available: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=109&. Accessed 9/6/2017 6. Beck J, Greenwood D, Blanton L et al. 2017 National Standards for Diabetes Self-Management Education and Support. https://doi.org/10.2337/dci17-0025. Accessed 9/9/2017. 7. Walsh J, Roberts R. Pumping Insulin: Everything for Success on an Insulin Pump and CGM. 6th Edition. Torrey Pines Press, 2016 8. McCrea, D. A Primer on Insulin Pump Therapy for Health Care Providers. Nurs Clin N Am 52 (2017) 553–564. 9. Bolderman K. “Pump Start-Up” in Putting Your Patients on the Pump. Alexandria VA: American Diabetes Association 2013. 10. Standards of Medical Care in Diabetes--2017. Diabetes Care. 2017;40 Suppl 1:S48-57. 11. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17 Suppl 2:1-53. 12. Clayton-Jeter H. Contributing Factors to Insulin Pump Errors in Children, Adolescents and Adults Available: http://www.fda.gov/forhealthprofessionals/articlesofinterest/ucm295562.htm. Accessed February 13, 2014. 13. Aldasouqi S and Reed A. Pitfalls of insulin pump clocks: technical glitches that may potentially affect medical care in patient with diabetes. J Diabetes Sci Technol 2014;8(6):1215-1220. 14. Evert AB, Insulin pump therapy troubleshooting for optimal performance. Empower. 2015;7(4):23-24 15. Guilhem I, Leguerrier AM, Lecordier F, et al. Technical risks with subcutaneous insulin infusion. Diabetes Metab. 2006;32(3):279-284. 16. Maahs D, Horton L and Chase H. The use of insulin pumps in youth with type 1 diabetes. Diabetes Technol Ther 2010;12(suppl1):S59-65. 17. Cornish A, Chase HP. Navigating airport security with an insulin pump and/or sensor. Diabetes Technol Ther. 2012;14(11):984-985. 18. American Diabetes Association. Fact Sheet – Air Travel and Diabetes Available: http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/publicaccommodations/air-traveland-diabetes/what-can-i-bring-with-me.html?referrer=https://www.google.com/. Accessed 9/10/2017 19. Diabetes care in the school and day care setting. Diabetes Care. 2014;37 Suppl 1:S91-96. 20. McCrea D. Management of the hospitalized diabetes patient with an insulin pump. Crit Care Nurs Clin North Am. 2013;25(1):111-121. 21. Boyle ME, Seifert KM, Beer KA, et al. Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. J Diabetes Sci Technol. 2012;6(1):184- 190. 22. Buchko BL, Artz B, Dayhoff S, et al. Improving care of patients with insulin pumps during hospitalization: translating the evidence. J Nurs Care Qual. 2012;27(4):333-340. 23. Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges and Opportunities. Diabetes Technol Ther. 2016;18(Suppl2):S2-3-S2-13. 24. https://www.diabeteseducator.org/practice/practice-documents/practice-papers © Copyright © 2021 Association of Diabetes Care & Education Specialists. All rights reserved Reproduction or republication strictly prohibited without prior written permission 13 25. Bergenstal RM1, Tamborlane WV, Ahmann A, et al STAR 3 Study Group. Sensor-augmented pump therapy for A1C reduction (START 3) Study: results from the 6 month continuation phase. Diabetes Care. 2011;34(11):2403-5. 26. Abraham MB1,2, Nicholas JA1,3, Smith GJ3 et al; PLGM Study Group. Reduction in Hypoglycemia With the Predictive Low-Glucose Management System: A Long-Term Randomized Controlled Trial in Adolescents With Type 1 Diabetes. Diabetes Care. 2017;Nov 30. pii: dc171604. doi: 10.2337/dc17- 1604. [Epub ahead of print] 27. Forlenza G, Raghinaru D, Cameron F, et al. Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents. Pediatric Diabetes. 2017;1-9. 28. Breton M, Chernavvsky D, Forlenza G et al. Closed-loop control during intense prolonged outdoor exercise in adolescents with type 1 diabetes: the artificial pancreas ski study. Diabetes Care. 2017:40(12):1644-50. 12. 29. Tauschmann M, Thabit H, Bally L, et al. Closed-loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre 12-week randomised trial. Lancet. 2018:13:92. 30. OpenAPS.Outcomes. Downloaded 3/2/2021. 31. Standards of Medical Care in Diabetes-2021Diabetes Care. 2021;44 Suppl 1:S89 32. Danne T, Nimri R, Battelino R et al. International consensus of use of continuous glucose monitoring. Diabetes Care. 2017:40(12):1631-1640. 33. Chase P and Messner L. Understanding insulin pumps, continuous glucose monitors and the artificial pancreas (3rd ed). 2016. Children’s Diabetes Foundation at Denver, Colorado. 34. Wallia A, Umpierrez G, Rushakoff R et al. Consensus statement on inpatient use of continuous glucose monitoring. J. Diabetes Sci Technol. 2017:11(5);1036-1041. 35. Shapiro A. FDA approval of nonadjunctive use of continuous glucose monitors for insulin dosing: A potential risky decision. JAMA. 2017:318(16);1541-1542. 36. Rinker J, Dickinson J, Litchmanb M et al. Diabetes Educator. 2018:44(3):260-268.


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