Tuesday, 28 April 2015

Pump clinic

Snowy mountains, blue sky and white clouds
Courmayeur, February 2015
I am lucky enough to have a pleasantly varied job which includes so many different aspects of diabetes. I work with Doctors, Nurses and other Dietitians, we see people with Type 1 and Type 2 Diabetes who are on medications alone, medications and insulin and insulin alone, using fixed doses, varying their dosage by carb counting using multiple daily injections or insulin pumps. We see them for individual consultations, in my very low carb group and in group education sessions, sometimes in the hospital as outpatients, in a community clinic and at a GP surgery. And that doesn't include the courses, conferences, study days and meetings with colleagues. Not forgetting that I don't have to do things that I find less congenial, like ante-natal clinics or paediatrics.

One recent meeting was all about updating our service to increase our capacity to see patients who are using insulin pumps, all of whom have Type 1 diabetes (because you don't qualify for NHS funding for a pump if you don't have Type 1). Very few people stop using a pump after they have started, so obviously numbers are increasing, and more children are being started on pumps who then transition to the adult service.

In our service, adults have to attend our structured education before they can have a pump, because it's an expensive and sophisticated bit of kit and we want people to get the best out of it. There's no point having a pump if all you do is give fixed amounts of insulin three times a day with meals; you might as well use a straightforward insulin pen. The pump can give fractions of a unit of insulin; you can extend a bolus over a period of time; you can set up different rates of background insulin over the course of 24 hours; you can adjust the background insulin up or down by a percentage for a period to allow for exercise or illness and much more. So we want people to be able to count their carbs and make informed decisions about adjustments in order to get the most out of the equipment.

This means that our pump clinics contain patients who are generally the most knowledgeable and skilled in carb counting and insulin adjustment. Their level of knowledge and skill does vary, because for example the young people moving from paediatric to adult clinics may have been given pumps without the specialist education if they were too young at the time. But some may have had diabetes for upwards of 50 years; I have been a diabetes dietitian for less than two and a half years. This fact has made me wary of intervening with most patients in the pump clinic.

My colleagues tell me that there is more I could be doing in terms of helping people to use their pumps to manage their diabetes, but before I feel confident to do more I have asked for two things. The first is to attend some sort of insulin pump training for healthcare professionals, and the second is to visit a Diabetes department in a different Trust where they manage pumps, so I can learn from the Dietitian there.

My colleagues are more experienced than I am, but they still feel they could do with knowing a bit more about the range of pumps on the market. Our service tends to favour one particular pump brand, although there are a few others that we support because patients using those brands have moved into our area. So we are setting up an afternoon when the five or six main manufacturers will be asked to demonstrate their products one after another, and we will compare features and costs.

Then there is the way that our pump clinics are organised. With three different overlapping roles - Nurse, Dietitian, Doctor - there can be some duplication. For instance, in order to analyse whether any changes are needed, the data about blood glucose levels, carbs and insulin delivery stored by the insulin pump can be downloaded and manipulated on a computer, which is much easier to do than using the handset. It is also easier to spot trends using graphs, and rates of insulin delivery can be adjusted by drag and drop. But it makes little sense for the Nurse and the Doctor to download and view the same data each in their separate rooms, so they are thinking working together. With two Doctors and two Nurses per clinic it is clear how things might be organised for them, but there is only one Dietitian. I'm not yet sure what I will be doing, but maybe when I've seen what other services do I will come up with some ideas.

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