MidCentral is 'Pumping': Insulin Pump Programme

Slide 1: MidCentral is ‘Pumping’ INSULIN PUMP PROGRAMME Continuous Subcutaneous Insulin Infusion (CSII) Mary Yiannoutsos NZRCPN. MCNA (NZ) Clinical Nurse Specialist Accredited Diabetes Nurse Specialist.

Slide 2: Ye Olde Diabetes  1500 BC – A mysterious disease…. ants are attracted to the urine of those who have it.  100 AD – “not very frequent among men, being a melting down of the flesh and limbs into urine…. The patients never stop making water, the flow is incessant, as if from the opening of aquaducts.

Slide 3:  250 AD – “diabetes” – their word for “siphon” or “ to go through”.  “honey”

Slide 4:  1889 – Scientists realised that removing a dog’s pancreas causes diabetes.  1921 – Insulin, discovered by two Canadian scientists.

Slide 8: Spotlight On Insulin Pump Therapy  Management of Type 1 is complex  Improved glycaemic control → reduced risk of long term complications

Slide 12: Reported Benefits of CSII  Reduced incidence of hypoglycaemia  Improved glycaemic control  Improved lifestyle and meal flexibility  International studies demonstrate high patient satisfaction and low discontinuation rates (<10%)

Slide 13: Disadvantages of CSII  Possible increased risk of diabetic ketoacidosis (DKA)  Site inflammation/infection  Lots of testing  Hard work! (families, child/youth, clinicians)  Cost

Slide 14: Background to the MCH Pump Programme.  Worldwide the incidence of Type 1 diabetes is increasing 3% annually  A recent study in Canterbury (NZ) has shown an estimated 30 young people aged (0-24 yrs) diagnosed each year  98% of young people (0 -25 yrs) with diabetes MidCentral Health District have Type 1 diabetes (170)

Slide 15:  MidCentral District Health Board (MDHB) – Diabetes Service Plan, 2006 Three initiatives:  Employment of a Diabetes Youth Clinical Nurse Specialist  Employment of a Diabetes Dietitian  Purchase of and implementation of Continuous Supply of Infused Insulin (CSII) pump programme — Admin support 0.3 FTE — On Call — Assistance with travel costs

Slide 16:  Appointment of the Diabetes Youth Clinical Nurse Specialist  Establishment of the ‘Pump’ committee  ‘Pump’ tender panel formed  Purchase of the pumps  Pump therapy training for all clinical staff involved in the pump programme  Development of guidelines for ED, after hours G.P service and children's ward. (Waikato, Starship)

Slide 17: Aims of the Programme:  To improve the quality of life (QoL) for children/youth with Type 1 diabetes and their family/whanau  To reduce the impact of unstable diabetes and hypoglycaemia  To reduce the risk of short and long term complications and improve health outcomes

Slide 18: Criteria developed for entry into the programme  Hypoglycaemic unawareness  Difficult to control and / or severe repeated hypoglycaemia  Ongoing sub-optimal control  Planning pregnancy or pregnant  Complications – nephropathy, gastro paresis, retinopathy, autonomic neuropathy  Co-existent medical conditions, e.g. Coeliac disease  Commitment to blood glucose monitoring

Slide 19: The Pump Programme Consists of:  Regular out patients clinics  Carbohydrate counting  Trial of a long acting insulin analogue (Glargine)  CSII is commenced - Younger children admitted to children's ward - Accommodation provided for participants' living out of Palmerston North - Petrol vouchers - On call Nursing and Medical cover

Slide 20:  Families were invited to: → Expression of interest form → An Information sharing evening → Carbohydrate counting workshops  Development of Specialist Nurse Assessment and follow up clinics  ‘ Pumpers’ clinic

Slide 21: Pump Consumables  Cannula: change every 3 days  Infusion line: change weekly  Insulin cartridge: uses only short acting insulin analogues; change cartridge weekly  Approximate cost per annum $2500 of which under the programme $1800 is subsidised.

Slide 22: Learning to ‘Pump’  CHO counting  Basal insulin  Bolus insulin (insulin to CHO ratio)  Correction factors  Insulin on Board / unused insulin rule

Slide 23: Basal vs. Bolus Concept  Basal insulin is the low level of insulin which is needed between meals (especially overnight) to keep blood sugars normal and prevent ketoacidosis.  Bolus insulin is the temporary higher insulin level at meal times, to prevent the blood glucose rising too high.

Slide 24: Basal Insulin  Basal via pump instead of Long acting insulin  More predictable absorption (3% variability)  Small amount of insulin delivered every few minutes by the pump  Patient can adjust basal rate to match subtle changes in insulin requirements (diurnal variation, exercise, weight change, menstruation)

Slide 25: Basal rate at pump commencement  Take 75% of total daily insulin dose (TDD)  Divide this in half (half basal/half bolus)  Divide this answer by 24 to get hourly basal rate  Usually more basal in day than night to start

Slide 26: Basal rate adjustments after commencement  Basal rate adjustments by hourly blood glucose readings over a 6 hour period while fasting  24 hour period divided into 4 time frames (overnight, breakfast, lunch and dinner)  Basal rate is correct if blood glucose level does not increase more than 2.2 mmol/l during the evaluation  No alcohol or exercise during evaluation

Slide 27: Meal Bolus  Bolus….instead of Short acting insulin  Meal bolus is calculated from amount of carbohydrate (CHO) consumed  Divide 500 by pump TTD = insulin to CHO ratio e.g. 500/48 = 1 unit : 10.4 g of CHO  Start with all meal ratios the same; change ratios later as children usually require more insulin for breakfast carbohydrate intake

Slide 28: Meal Bolus  Check if meal bolus is sufficient by doing 2 hour postprandial blood glucose:  < 10 mmol/l young children  < 8 mmol/l for healthy (non pregnant) adults

Slide 29: Correction bolus  Work out the insulin sensitivity factor (ISF)  100 divided by total daily dose (TDD) = ISF  Eg.100 divided 40 = 2.5 i.e. 1 unit of insulin will drop the blood glucose by 2.5 mmol/l

Slide 30: Correction Bolus cont.  Always check for ketones if blood glucose level >15 mmol/l  If ketones absent, take correction bolus  If before a meal, take bolus, wait 30 mins, then have usual meal bolus and eat as usual.  Check blood glucose level 1, 2 and 3 hours after meal  If between meals take correction bolus and check blood glucose level hourly (usually do not correct within 2-3 hrs of any other bolus).

Slide 31: Correction Bolus cont.  If ketones are positive, take 1.5 x correction dose (or 10% of TDD) every hour BY INJECTION until blood glucose <10 mmol/l.  Check blood glucose hourly  If no improvements after 3 corrections or if urine ketones moderate-high, seek urgent medical help.

Slide 32: INSULIN ON BOARD/UNUSED INSULIN RULE  This works out how much of a previous bolus is still left.  We assume Novorapid has a 4 hour action.  30% is used in first hour i.e. 70% still on board  Another 30% is used in the 2nd hour (40% on board)  A further 30% is used in the 3rd hour (10% on board)

Slide 33: Summary of Initiation of Pump therapy  Selection into the programme  Long lead up / preparation time  Education on Pump therapy skills  CHO counting  Site changes  Follow up clinics  School visits

Slide 34: Where are we at….  CSII therapy takes commitment  Patients must be motivated  Gain skills and knowledge and confidence

Slide 35:  Data is being collected  The Health care team – skills, experience and resources to provide expert advice and assistance.  February 2007 saw the first pump start under this programme by November 2007 will see 10 children/youth 0-25yr commenced on pump therapy

Slide 36: HBA1c Pre Pump Start Post Pump Start J. M. 6.1 % 6.5 % S. M. 8.3 % 7.0 % P. N. 9.7 % 8.3 % K. M. 10.5% 8.8 % B. S. 9.0 % 8.1 %

Slide 37: Results Comparison between HbA1c Initial and Final Results 11.0% 10.0% 9.0% Initial HbA1c HbA1c % 8.0% Final HbA1c 7.0% 6.0% 5.0% 1 2 3 4 5 6 7 8 9 10 11 12 Participant ID

Slide 38: Struggles  Limited prior experiences outside of a tertiary centres that offer a complex programme such as this aimed specifically at child/youth  Relatively new technology in the public sector  No access to psychological support  No specific funding for paediatrician or physician time  No project management funded  Busy clinicians working their way through the process

Slide 39: Critical Success Factors  Extensive team training and ongoing education  Dedicated nursing resource  Dedicated admin resource  After hours nursing cover funded  Highly functional multidisciplinary team  Inter-departmental service links and goodwill

Slide 40: Quality of life and flexibility in lifestyle  “Ill be able to lead a pretty normal life”  “Just think I can go out now and I don’t have to worry about having to find a toilet to draw up my insulin shot”  “gone are the five times a day injections”

Slide 41: Summary  CSII therapy takes commitment and enthusiasm by participants, family/whanau and caregivers.  A dedicated MDT approach  Continued DHB support to assist with costs of consumables  Further evaluation of the programme is planned including prospective formalised QoL evaluation using the PedsQoL.  CSII has produced a mean reduction of HBA1c, reduced frequency of hypoglycaemia and improved QoL in our study participants' to date.

Slide 42: Acknowledgements  Dr Paul Dixon  Dr Nicky Pereira  Dr David Smith  Dr Warwick Hunter  Helen Snell (NP)  Pauline Giles (CNS)  Lois Nikolajenko (CNS)  Mary Yiannoutsos (CNS)  Rosemairi Knowles (Dietitan)  Judy Kitchen (Secretarial Support)  MidCentral District Health Board  Starship Children’s Hospital  Waikato Diabetes Service  Children/youth & Families.

Slide 44:  Bevan, D., Scott, R., Darlow, B., Raizis, A., & Willis J. (2006). Type 1 diabetes:research hopes and their New Zealand implications. The New Zealand Medical Journal, 119 (1228).  National Institiute of Helath and Clinical Excellence: Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (review of technology appraisal guidance 57), (2008), 1-31  Reda, E., Van Reitzestein, A., & Dunn, P. (2007). Metabolic Control with insulin pump therapy: the Waikato experience. The New Zealand Medical Journal, 120 (1248).  Wu, D., Kendall, D., Lunt, H., Willis, J., Darlow, B., & Frampton, C. (2005) Prevalence of Type 1 diabetes in New Zealand aged 0–24 years. The New Zealand Medical Journal, 118 (1218).