| Diabetes Spectrum Volume 12 Number 3, 1999, Page 185 Initiating Outpatient Insulin Pump Therapy: Highlights of an Outpatient Education Program Developed in Spain Our diabetes clinic, Clínica Diabetológica, is a private outpatient diabetes care and education center in Gijón, in northern Spain. It was founded in 1985. The clinic's full-time staff consists of a physician, a nurse, and a dietitian. Of the 622 active diabetes patients, most are self-referred due to poor diabetes control or complications. Twenty-six percent of our patients have type 1 diabetes, and the remaining 74% have type 2 diabetes. Of those with type 2 diabetes, 36% use insulin and 64% control their diabetes with diet and oral agents. In 1996, our clinical team decided to start an insulin pump program, having found that some of our patients could not achieve good glycemic control with conventional multiple daily injections (MDI) of insulin. Knowing that continuous subcutaneous insulin infusion (CSII) had been available in the United States for years, we contacted Ruth Farkas-Hirsch, MS, RN, CDE, of the University of Washington in Seattle, an educator and insulin pump therapy expert, for assistance. A visit to Seattle was arranged for one of the authors (FMA) to actively learn and participate in pump therapy education under Ms. Farkas-Hirsch's guidance. During the visit, FMA was able to learn first-hand how to properly initiate and manage pump therapy and to see the potential benefits of greater freedom, fewer hypoglycemic episodes, and lower HbA1c levels for our patients interested in pump therapy. Upon returning home, after discussing the ease of use and benefits, our clinical team agreed to initiate a program of its own. Normally in Spain, administration of insulin pumps is handled on an inpatient basis. Inpatient care can disrupt a patient's life. With a flexible outpatient care program and 24-hour health provider availability for assistance, the patient's life can more quickly approach normal after initiation of pump therapy. Our patients are able to work normally, go to school, and remain in their familiar surroundings with regular office visits. We are now the only diabetes education and training center with an insulin pump program in northern central Spain, an area with a population of 1 million. Sixteen percent (26) of our type 1 diabetes patients now use insulin pumps. Now that our program is 2 years old, we feel great satisfaction in seeing the positive impact pump therapy has had on our patients' quality of life. For our health care team, few things are so rewarding. The Spain Outpatient Program Choosing candidates CSII is especially helpful for highly motivated individuals who are unable to achieve acceptable control with MDI or simply choose or need to have more freedom in their lives. In our own practice, the first reason for initiating CSII was recurrent hypoglycemia and hypoglycemic unawareness. Some pregnant women also choose CSII, and they generally do well because pregnancy is an extremely motivating event. We believe that, in order to avoid frustration and discontinuation of therapy, it is mandatory to be honest and to explain clearly to patients what to expect from CSII. Obviously, CSII is not a cure or a magic solution, but it may be extremely helpful in some patients' efforts to live a good life and to get the most out of all their efforts to control their diabetes. Implementation of the program Week 1. The first week includes three 1-hour sessions on separate days, which allows patients to learn at a reasonable pace and to discuss questions with the diabetes health care team. From the start of our program, we emphasize the patient's role as the real decision-maker. We provide diabetes expertise, education, and psychological support, but they must see us as partners in the care process. Thus, from the first encounter with the patient, we try to avoid formal lectures about the facts and try to build the confidence that will allow us to talk frankly to the patient to promote a problem-solving approach. We start week 1 by reviewing and updating basic diabetes knowledge. Most of our CSII candidates already use MDI and already have a good level of basic diabetes education. We also assess their attitudes towards a new therapeutic method. We ask patients to bring along a support person, who will hopefully be present during the entire educational process. When the first training week is completed, we put the patient in contact with a pump user of similar age because, undoubtedly, the advice of a peer who has experienced the challenges of going on an insulin pump can best help an insulin pump "rookie." Week 2. During the second week, we explain the technical aspects of the pump during two 1-hour sessions. We allow patients to take a pump home to practice pump programming. Week 3. During the third week, we see patients twice and then closely monitor by phone. Patients arrive at the clinic early before breakfast following the educational session. They start to wear the pump during the morning, performing a midmorning blood glucose test and returning to the clinic to discuss their experiences. Then the pump is disconnected. The next day, after the last educational session, the procedure is the same. During these two consecutive days, patients must make early-morning phone calls to the clinic to discuss their boluses and basal rates, depending on their blood glucose level. During the first days of pump therapy, we ask patients to try to keep the carbohydrate contents of their meals as constant as possible in order to better calculate the correct insulin dosage. Patients will wear the pump until bedtime, disconnecting it before going to sleep. Finally, on the fifth day of wearing the pump, the patient is allowed to sleep with the pump and is required to check a 3:00 a.m. blood glucose level every night for the first week and weekly thereafter. At the end of the program, patients receive a personalized certificate for the completed course signed by all the team members who participate in the course. For any CSII outpatient initiation program, a 24-hour "diabetes hotline" attended by an expert staff member is essential. The educational process is ongoing, and a pump review course is a must, at least bi-annually, for all insulin pump users. If possible, the health care provider should schedule it upon completion of the course. All the additional communications channels, such as fax and e-mail, should be kept open in order to keep patients updated and motivated. We also offer updated information about pump therapy and general diabetes education on our clinic website. We encourage our pump patients to attend CSII support group sessions because it is normal to sometimes feel overwhelmed and to experience some degree of frustration. At such times, a support group can be extremely helpful. Advantages of the Program
At our clinic, the first 10 patients to complete the program lowered their HbA1c levels during the first 3 months from a mean of 8% to 6.7%, and this reduction was maintained for 6 months. There was also a significant decrease in the number and severity of hypoglycemic episodes, although we have not yet completed our statistical analysis of that data. To date, there have been no episodes of hypoglycemic coma and only one episode of ketoacidosis. We hope to present final data on the program outcomes at the Spanish Diabetes Association meeting to be held in Bilbao, Spain, in spring 2000. The Future F. Menendez Alvarez and Gijón, Spain Editor's note. This was a wonderful example of how we educators can work together to promote international ties and networking. Ms. Alvarez was able to develop and promote a new program based on what she had learned during her clinical preceptorship at our clinic, the University of Washington Diabetes Care Center. This clearly illustrates the value of mentorship arrangements. I would encourage other educators to seek funds to allow for these types of relationships, and I would encourage potential sponsors to assist these educators, as well. —Ruth Farkas-Hirsch, Diabetes Spectrum Copyright © 1999 American Diabetes Association Last updated: 9/99 |