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The suggestions and information contained in this publication are generally consistent with the Clinical Practice Recommendations and other policies of the American Diabetes Association, but they do not represent the policy or position of the Association or any of its boards or committees. Reasonable steps have been taken to ensure the accuracy of the information presented. However, the American Diabetes Association cannot ensure the safety or efficacy of any product or service described in this publication. Individuals are advised to consult a physician or other appropriate health care professional before undertaking any diet or exercise program or taking any medication referred to in this publication. Professionals must use and apply their own professional judgment, experience, and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise, or medication. The American Diabetes Association—its officers, directors, employees, volunteers, and members—assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the suggestions or information in this publication.
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DOI: 10.2337/9781580404976
Library of Congress Cataloging-in-Publication Data
Putting your patients on the pump / Karen M. Bolderman, editor. -- 2nd ed.
p. ; cm.
Rev. ed. of: Putting your patients on the pump / Karen M. Bolderman. c2002.
Includes bibliographical references and index.
ISBN 978-1-58040-497-6 (alk. paper)
I. Bolderman, Karen M., 1954- II. Bolderman, Karen M., 1954- Putting your patients on the pump. III. American Diabetes Association.
[DNLM: 1. Diabetes Mellitus, Type 1--drug therapy. 2. Insulin Infusion Systems. 3. Insulin--therapeutic use. 4. Patient Education as Topic. WK 820]
616.4’62061--dc23
2012049593.
eISBN: 978-1-58040-537-9
Table of Contents
Chapter 1: Insulin Pump Therapy Advantages and Disadvantages
Chapter 2: Pump and Infusion Set Options and Selection (with Susan L. Barlow, RD, CDE)
Insulin Pump Options and Selection
Infusion Set and Tubing Options
Customer Service and Other Practical Considerations
Chapter 3: Pump Candidate Basics
Profile of an Appropriate Candidate
Steps for Helping the Patient Determine and Achieve Readiness
Chapter 4: Getting the Patient Ready
Lifestyle Issues and Wearing the Pump
Ordering the Pump and Supplies
Chapter 5: Pump Start-Up (Nicholas B. Argento, MD and Karen M. Bolderman, RD, LDN, CDE)
Pump Start Basics: Patient and Prescriber Responsibilities
Pump Start Guidelines for the Patient
Pump Start Guidelines for the Clinician
Determining Target Blood Glucose Values
Determining Starting Basal Rate
Calculating Insulin-to-Carbohydrate Ratios
Calculating the Correction Factor
Calculating a Meal Bolus
Identifying, Managing, and Preventing Hyperglycemia
Identifying, Managing, and Preventing Hypoglycemia
Follow-up Instructions
Additional Considerations
Chapter 6: Pump Therapy Management (Keeping Patients on the Pump)
Record Keeping
Using Pump Data
Using Blood Glucose Meter Data
Using Continuous Glucose Monitor Data
Basal Rate Adjustment
Additional Basal Rates and Establishing Basal Patterns
Temporary Basal Rates
Insulin-to-Carbohydrate Ratio Adjustment
Correction (Sensitivity) Factor Adjustment
Infusion Site and Tubing Concerns
Emergency Supplies
Troubleshooting
Chapter 7: Other Considerations in Pump Therapy Management
Use of Duration of Insulin Action “Insulin on Board” or “Active Insulin” Feature
Dining Out and Special Meals: Bolus Options
Alcohol
Exercise and Physical Activity (Gary Scheiner, MS, CDE )
Intimacy/Sexual Activity
Managing Sick Days and Medical Procedures (with Nicholas B. Argento, MD)
Stress (Nicholas B. Argento, MD)
Travel (with Nicholas B. Argento, MD)
Weight Change (Nicholas B. Argento, MD)
Menses, Peri-menopause, and Menopause (Nicholas B. Argento, MD)
Pregnancy (Nicholas B. Argento, MD)
Pediatrics: Infants, Toddlers, Children, Teenagers
Type 2 and Type 1.5 (LADA) Diabetes
Older Adults and Special Needs Patients
Chapter 8: Forms and Resources
Healthcare Professional Guidelines, Checklists, and Forms
Patient Guidelines, Checklists, and Forms (with Nicholas B. Argento, MD)
Insulin Pump Therapy Resources (with Susan L. Barlow, RD, CDE)
Chapter 9: Tips from Pump Experts and Case Studies
Tips for Healthcare Professionals from Healthcare Professionals
Pump Tips for Patients from Patients (with Susan L. Barlow, RD, CDE)
Case Studies/Success Stories
I wanted to be a teacher for as long as I can remember. When I developed diabetes in 1965, my parents, physicians, and teachers encouraged me to learn all that I could about diabetes and to fit diabetes into my life—not build my life around diabetes. Years later, insulin pump therapy made my life with diabetes much easier, and I wanted others to benefit from my experience.
The second edition of Putting Your Patients on the Pump would not have been possible without the invaluable contributions of Nicholas B. Argento, MD; Susan L. Barlow, RD, CDE; and Gary Scheiner, MS, CDE. I envisioned this updated version to be a compilation of practical experience and guidance from fellow healthcare professionals who work with pump patients, while living successfully with type 1 diabetes managed with an insulin pump. And that’s exactly what I got. Each contributor provided personal and professional information that will benefit healthcare professionals and patients alike. Together with my own personal and professional experience: Dr. Argento’s enthusiasm and inclusion of the most current information available, Sue Barlow’s expertise and sense of humor, and Gary Scheiner’s experience and insightful knowledge, blended together to create a resource to help the novice insulin pump healthcare professional develop confidence implementing pump therapy.
Many people have had an impact on my career as a diabetes educator as well as on my life with diabetes. I am indebted to James (Jim) Mersey, MD, FACP, FACE, Chief of Endocrinology at Greater Baltimore Medical Center (GBMC) and Medical Director of the Geckle Diabetes and Nutrition Center at GBMC, for providing me with unique and rewarding career opportunities and for teaching me the finer points of diabetes management. Jim’s diabetes knowledge, kindness, skillful care for patients, and wisdom are infinite. I am honored that he agreed to write the Foreword to this book.
Maureen D. Passaro, MD, is credited with the idea of the “future” chapter. I also owe much to my former personal physician, G. William Benedict, MD (d, 2006) for his guidance and patience in putting me on my first pump many years ago. And to the select group of the many other patients and physicians who influenced my decision to begin pump therapy and help others make the same decision, I would also like to acknowledge: Riccardo Calafiore, MD; Richard E. Berger, MD, FACP, FACE; and John P. Comstock, MD. I am also thankful to Frank Weller (d, 1997); Scott Fischell; Cindy Shump, RN, MS, MSN, CRNP, CDE; Amy Mersey, RN; Zoe (Heineman) Myers, MA; James A. Dicke, MD; Joanna B. Tyzack, MD; Fran R. Cogen, MD, CDE; Ruth S. Horowitz, MD; and Philip A. Levin, MD, for their dedication and contributions to the field of diabetes and insulin pump therapy.
A special thank you goes out to the reviewers Davida Kruger, MSN, APRN, CDE; Joan Hill, RD, CDE; and Dr. James H. Mersey for kindly providing their time and expertise.
I want to thank the American Diabetes Association for providing me with the opportunity to write the second edition of this book. I am especially indebted to Victor Van Beuren, Acquisitions Editor, for his patience, wisdom, and unending support, and book editor Rebekah Renshaw for her dedicated editorial work and insight.
I extend gratitude also to my loving, very smart, and very patient husband Tom and my extraordinary parents. Additionally, I thank my dear siblings and their spouses, nephews, and nieces for their constant support and encouragement. Thanks also to my professional colleagues through my years as a pump therapy diabetes educator. I am indebted to the countless pump patients with whom I have had the privilege and pleasure to work with and learn from. Their contribution to my knowledge of diabetes has been of untold value, for which I am most grateful.
Karen M. Bolderman, RD, LDN, CDE
I have been an endocrinologist involved in the management of diabetes for the past 35 years. I began before glucose meters existed. In 1977 when I started the Diabetes Clinic at The Johns Hopkins University School of Medicine, Ames gave me the first Dextrometer to use. It took several minutes to get a reading on a dial the size of a bathroom scale, but this device signified a huge step forward in diabetes monitoring. When insulin pumps became clinically available, I actively championed their use, although the early ones were the size of an Uzi.
Over the years, pump technology has progressed at a steady pace, with the addition of new ways to deliver insulin, better integration with meters either as built in or by infrared communication, and with use of continuous glucose sensors. All of this brings the hope of a true closed-loop system.
In spite of these improvements in technology, selecting patients for pumps and starting patients on pumps still requires a great deal of education, training, and time, along with knowledge on the part of the healthcare provider.
I have known Karen Bolderman since she began working for me as a diabetes educator 30 years ago. After several years, Karen and I began working together again at the Geckle Diabetes and Nutrition Center at Greater Baltimore Medical Center, where we are working to integrate diabetes care in and out of the hospital.
For us this is déjà vu all over again. We work together to teach patients about pumps, get them started, and manage their diabetes post initiation. With Karen’s knowledge and personal experience, starting and training patients on pumps, managing patients in the hospital, and following patients on pumps makes my life much easier. I look forward to a continued partnership with Karen in our attempts to improve diabetes care.
Karen has done a marvelous job with the details of insulin pumps in this edition of Putting Your Patient on the Pump. This book will make everyone’s job of utilizing insulin pumps more understandable and practicable.
Read ahead and enjoy.
James H. Mersey, MD Director, Endocrinology and Metabolism, Medical Director, Geckle Diabetes and Nutrition Center Greater Baltimore Medical Center Assistant Professor of Medicine, The Johns Hopkins University School of Medicine Clinical Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Insulin pump therapy gives people with diabetes the freedom to enjoy life, despite their chronic condition. The value and importance of having freedom are obvious from the impact this innovative technology has made in the past several decades. The insulin pump is now a common, integral component of diabetes management. Technological improvements and advances have made the insulin pump a desirable and useful tool in the management of diabetes.
As long-term insulin pump wearers with type 1 diabetes and healthcare professionals who have learned much from our colleagues and countless other “pumpers,” the contributors to the second edition of Putting Your Patients on the Pump have a unique perspective and understanding of what constitutes practical, useful information. Collectively, the four of us have lived with type 1 diabetes for over 165 years. Most of these years have been spent with an insulin pump. It is our hope that this book will help healthcare professionals with expertise in diabetes care and education successfully start and maintain diabetes patients on insulin pump therapy. We believe that even experienced clinicians will find the information, tips, and resources helpful.
We hope this book provides user-friendly information from our combined practical experience and supports the extra efforts diabetes healthcare professionals must make to help their patients achieve success using an insulin pump.
Karen M. Bolderman, RD, LDN, CDE
