Читать книгу Putting Your Patients on the Pump - Karen M. Bolderman - Страница 5

Chapter 3 Pump Candidate Basics

Profile of an Appropriate Candidate

Is Your Patient Ready, Willing, and Able?

Many patients are naturals for pump therapy, but it is not for everyone. Some patients need to overcome specific obstacles before the pump will be an asset to their healthcare. Others just do not have the interest or abilities to master pump therapy. Discovering the character and source of motivation through careful screening of the patient is the key to ensuring success in pump therapy.

You must evaluate the physical and psychological readiness of each pump candidate to take on the responsibilities and challenges of pump therapy. The person with diabetes and his or her family need to buy into pump therapy. Input from the patient’s family and other members of the healthcare team will help you discern the patient’s clinical and lifestyle indications for insulin pump therapy (Table 1).

TABLE 1. Indications for Pump Therapy

Clinical Indications

High glucose variability

Elevated A1C

Nocturnal hypoglycemia

Hypoglycemia unawareness

Recurrent hyperglycemia

Preconception

Pregnancy

Extreme insulin sensitivity

Gastroparesis

Early neuropathy or nephropathy, when improvement in glucose control can reduce acceleration of complications

Renal transplantation

Lifestyle Indications

Erratic schedule

Varied work shifts

Frequent travel (probably accompanied by frequent dining out)

Desire for flexibility

A Good Prospect: Ready, Willing, and Able

• Is motivated. Pump therapy requires readiness, preparedness, and a time investment for weeks or months in advance and during the initiation of pump therapy.

• Has realistic expectations. The patient who expresses interest and desire for pump therapy must understand that the pump will not “fix” blood glucose variations automatically, nor will pump therapy grant freedom from frequent SMBG. Pump therapy does not guarantee “good control,” but it can help achieve and maintain improved glucose control with effort from the pump wearer. Children who use the pump must have parents and caretakers with a thorough understanding of what pump therapy involves and the willingness to spend the time needed working with the child and healthcare professionals.

• Demonstrates independent diabetes management. Ideally, MDI therapy precedes pump therapy. MDI as a “stepping stone” to pump therapy often reveals the patient’s suitability. At the very minimum, the prospective pump user should have knowledge of the basics of diabetes education. A thorough knowledge of diabetes and its management and the ability to demonstrate appropriate self-care behaviors (including trouble-shooting and problem-solving skills) provide the foundation for the advanced self-management skills required by pump users. This is one of the reasons pump therapy may not be recommended for newly diagnosed patients (Shalitin 2012).

• Is willing to learn. The person must be able and willing to learn, practice, and demonstrate an understanding of carbohydrate counting, insulin action, and premeal bolus dose calculations using their insulin-to-carbohydrate ratio(s) and correction factor(s), and be able to make insulin dose adjustments in response to hypoglycemia, hyperglycemia, exercise, stress, and illness.

• Has ability to problem-solve. i.e., can use newly acquired skills in managing diabetes.

• Welcomes challenges. The initial few weeks of pump therapy require detailed record keeping of SMBG results, dietary intake, insulin doses, and exercise, as well as frequent (minimum of four daily) blood glucose checks, including “middle of the night” checks (typically at 3:00 a.m.), and frequent (sometimes daily) telephone/email/fax communication with the healthcare professional(s). The pump user must also have patience during the pump initiation period, when appropriate basal rates and insulin-to-carbohydrate ratios are being determined.

• Has the support of family or significant other(s). The decision to initiate pump therapy is a lifestyle-changing decision. Emotional support is crucial to the success of pump therapy. Family members, friends, coworkers, teachers, and others can be of great assistance to the pump wearer. Education about diabetes in general, along with pump therapy education, can help ease the difficulties and challenges of pump therapy initiation.

• Can afford it. Pumps and pump supplies cost thousands of dollars, so verifying the patient’s ability to afford pump therapy is essential. The pump wearer must have either personal resources or adequate insurance benefits. Insurance coverage can range from 50 to 100% for the pump and/or pump supplies. Ask the potential pump wearer to verify their benefits with their health insurance carrier; some pump manufacturers will provide this service to patients. Some insurance companies require a letter of medical necessity from the healthcare prescriber. Additionally, an insurer may cover only a specific brand of pump but may provide benefits for a nonformulary brand with a letter of medical necessity outlining why a specific pump brand (i.e., the pump’s features) is most appropriate for the patient. Medicare covers a pump for a patient with type 1 or type 2 diabetes who (A) has completed a comprehensive diabetes education program, performs at least 4 daily SMBG checks, uses at least 3 injections per day, and meets one or more other glycemic control-related criteria; OR (B), if a patient has been on a pump prior to enrollment in Medicare and has documented frequent (minimum of 4 daily) SMBG checks during the month preceding enrollment and meets one or more other glycemic control-related criteria. Additionally, a prospective or current pump patient must have a documented fasting C-peptide level ≤110% of the lower limit of normal of a lab’s range (e.g., up to and including 0.99 ng/ml, if the low range is 0.9 ng/ml) or be beta-cell autoantibody positive for Medicare insulin pump coverage. The positive autoantibody test allows patients with latent autoimmune diabetes in adulthood (LADA), referred to as type 1.5 diabetes, to qualify for a pump. Always confirm current Medicare coverage. The pump must be ordered by and follow-up care must be managed by a physician who manages multiple pump patients and who works closely with a team, including CDEs, RDs, and nurses who are knowledgeable in use of pump therapy (DHHS 2013).

• Is capable intellectually, physically, and technically. A patient contemplating pump therapy must be able to demonstrate an understanding of the therapy. Intellectually, the patient must demonstrate understanding of insulin-to-carbohydrate ratios and correction (sensitivity) factors and the applications of these parameters to determine appropriate insulin bolus doses. The ability to insert the pump battery(ies), fill and/or place the insulin cartridge/reservoir into the pump, insert the infusion set, wear the pump, and perform the technical functions of the pump is essential.

« Patients with moderate to severe hand arthritis or neuropathy may not be able to press the pump’s buttons or remote device or handle the insulin cartridge/reservoir and infusion sets.

« Patients who are blind or visually impaired may be limited in their choice of pump because of a lack of audio functions or small screen displays.

« Patients who are deaf or hearing impaired may be at greater risk for interruptions in insulin delivery because they have difficulty hearing the pump’s alarm. Pumps with vibrating alarms may be essential.

• Demonstrates emotional stability. The pump patient must routinely attend education sessions and attend to tasks that require routine. A patient with untreated depression, eating disorders, manipulative behavior, or other psychoses is usually ill-suited for pump therapy. Carefully assess the pump candidate’s psychological status, or refer the patient to a mental health professional. Suggest treatment options for behaviors that may interfere with pump therapy.

Young or old, age in itself is not necessarily a contraindication to successful pump therapy. Children as young as newborns and people in their 70s have had success with pump therapy.

The patient’s education level is not a deciding factor in pump therapy. However, diabetes knowledge and an understanding of the relationship between insulin and food, stress, and exercise are key factors in assuring successful pump therapy.

Contraindications: Red Flags

Why the Patient Isn’t Ready for Pump Therapy

Although pump therapy does not increase the risk of mortality among its users, the frequency of adverse events increases with:

• Poor candidate selection

• Infrequent SMBG

• Insufficient or inadequate supervision and monitoring by the diabetes healthcare professional or team

• Inexperienced pump therapy practitioners

Indications that the Patient Is Not an Appropriate Candidate

There can be numerous reasons why a patient may not be an appropriate candidate for pump therapy. However, this doesn’t mean the patient may not ever be ready for an insulin pump. Behavioral changes, diabetes knowledge, and maturity in dealing with diabetes challenges come with time and education. Be aware that any of the concerns below can be corrected, thus improving the patient’s readiness to take on pump therapy:

• Complains of performing frequent blood glucose checks: thinks that pump therapy reduces or omits the need to perform SMBG

• Is “tired of meal planning,” counting carbohydrate, and calculating mealtime insulin doses: believes that the pump automatically calculates necessary bolus doses without any user input

• Does not want to carry any “diabetes supplies,” e.g., back-up injection device, insulin, hypoglycemia treatment (and when using pump therapy, spare infusion sets)

• Doesn’t understand the causes, prevention, and treatment of hypoglycemia

• Is not aware of glucagon and doesn’t have a plan for its use (i.e., a family member or significant other trained in the administration of glucagon)

• Doesn’t understand the causes, prevention, and treatment of hyperglycemia

• Is not aware of ketone strips, does not have ketone strips, or does not know when/how to check for ketones

• Lives alone and does not have a readily accessible support team (family, friends, coworkers, access to emergency services)

• Has evidence of a psychiatric disorder, including severe or recurrent depression, severe eating disorder, or a history of attempted suicide

• Lacks insurance or means to pay for an insulin pump and pump supplies

Steps for Helping the Patient Determine and Achieve Readiness

You may be able to identify good candidates for insulin pump therapy, but patients still need to decide whether pump therapy is for them. Here is an education plan for helping the patient make this decision.

1. Give the patient a general overview of what pump therapy entails. Discuss the advantages and challenges, as well as realistic goals and expectations for pump therapy.

2. Review the prospective pump user’s medical history and evaluate his or her diabetes knowledge. Consider using written pre- and post-tests.

3. Demonstrate how an insulin pump works (bolus delivery). Explain basic pump therapy terms, including basal rate, bolus dose, infusion set, infusion sites, dressing, and insulin cartridge/reservoir. Show available models, and encourage the patient to learn the features offered by each brand of pump. Explain that he or she can disconnect the pump for bathing, intimacy, and intensive sports.

4. Have the patient handle a pump. Some patients mistakenly believe the pump is worn only during the day and removed at bedtime. Others believe an insulin pump is surgically implanted or permanently attached. Most people are surprised to learn how small a pump is and how it is worn.

5. Show the differences between a pump that uses tubing that connects to an infusion site and a pump that is worn without tubing and is directly connected to the body.

6. Show the available infusion sets. Explain that tubing (if applicable) is available in various lengths to accommodate where the pump is worn. Explain how a pump with tubing can be worn in and under clothing, such as in a pocket, sock, or bra. Show pump accessories, such as clips, leather cases, fanny bag–type cases, clothing with built-in pump pouches or pockets, and Velcro-attached removable pockets or small (infant-sized) socks. Show appropriate sites for wearing a “patch” pump that does not require tubing.

7. Demonstrate the insertion and removal of an infusion set. Demonstrate an infusion set inserter device, if appropriate. Allow the patient to practice a self-insertion. There is a commercially available injection pad, or “rubber belly,” that attaches to the patient’s abdomen, thigh, or upper arm with an adjustable strap. Does the patient want to wear an infusion set for a few days to get accustomed to the feel of it? If possible, offer the option of wearing a demo pump with saline for a few days to determine how the patient likes that particular pump and pump therapy in general (see Optional Saline Trial). When parents are considering pump therapy for their child, this experience sometimes results in postponing pump therapy; the parents recognize the learning curve and time commitment a pump requires, or they discover that their child is not quite ready. Because saline is a prescription item, the prescribing physician will need to provide a “saline-start” order and a prescription for saline. Pump manufacturer personnel—either a Certified Pump Trainer or clinical staff—will provide brief training on the pump. Some patients wear two or three brands of pumps before making a final decision.

8. Provide a list of the various pump manufacturers with names and telephone numbers of the local sales representative, corporate office telephone numbers, and website information. Encourage the patient to access pump company websites (monitored by the pump company) and contact the manufacturers’ sales representatives, who will offer “sales calls” to patients and/or provide additional information, such as literature and a DVD. Pump company “online pump school” website instructions may also be available. Does your protocol place the responsibility of contacting pump manufacturer sales representatives on you? Is there a local pump support group meeting that the patient can attend to meet pump users and other potential pump patients? Encourage the patient to speak with other pump wearers and potential pumpers via face-to-face conversations or the use of social media.

Are YOU Ready?

Additionally, the HCP who initiates pump therapy should also consider his/her ability to effectively start and maintain a patient on an insulin pump. Although there are benefits to the patients for insulin pump therapy, there is also the potential for confusion and inadequate training (Skyler 2007), which can create additional work and anxiety for the HCP. An effective and efficient office practice infrastructure is essential. Do you have the time and/or staff to help prepare a potential pump patient and then follow/manage the new pump patient closely the first few weeks after pump initiation (Hirsch 2010)? Ineffective follow-up, likewise, can create problems for the HCP as well as for the new pump patient. Learn about the resources available to you—local Certified Diabetes Educators (CDEs), diabetes centers, and pump company clinical support staff (company-employed or per diem contracted CDEs) can be of great assistance.

References

Department of Health and Human Services (DHHS) Centers for Medicare & Medicaid Services: National Coverage Determination (NCD) for Infusion PUMPs (280.14) http://www.cms.gov/medicare-coverage-database/details/nca-details.aspx?NCAId=40&NcaName=Insulin+Infusion+Pump&CoverageSelection=National&KeyWord=insulin+pump&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA& Accessed 10 February 2013

Department of Health and Human Services (DHHS) Centers for Medicare & Medicaid Services: Decision Memo for INSULIN Infusion PUMP (CAG-00041N) http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=40&NcaName=Insulin+Infusion+Pump&CoverageSelection=National&KeyWord=insulin+pump&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAEAAA& Accessed 10 February 2013

Hirsch IB: Practical pearls in insulin pump therapy. Diabetes Technol Ther 12 (Suppl 1):S23–S27, 2010

Shalitin S, Lahav-Ritte T, Lebenthal Y, Devries L, Phillip M: Does the timing of insulin pump therapy initiation after type 1 diabetes onset have an impact on glycemic control? Diabetes Tech Ther 14:1–9, 2012

Skyler J, Ponder S, Kruger D, Matheson D, Parkin C: Is there a place for insulin pump therapy in your practice? Clin Diab 25:50–56, 2007