[Previous Months][Date Index][Thread Index][Join - Register][Login]
[Message Prev][Message Next][Thread Prev][Thread Next]

[IP] initiating outpatient pump therapy (Spain) - LONG

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 

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 
Few things are more important for a successful insulin pump experience 
than finding appropriate candidates. CSII is not for everyone. Some 
patients are not suitable because they exhibit some of the 
well-established contraindications to successful CSII. These include 
unwillingness to test their blood glucose four or more times each day 
and to adjust their insulin accordingly; lack of acceptance of their 
diabetes; unwillingness to call their health care provider when problems 
arise or inability to regularly attend scheduled medical visits; 
inability to handle an insulin pump technically due to severe physical 
disabilities; severe and unstable psychiatric conditions; intense fear 
of needles or pain; and lack of positive family and peer support. 

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 
Our program for initiation of CSII generally takes 3 weeks, but it is 
flexible and adaptable to each patient's learning capacity. 

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 

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 
We believe that a 3-week outpatient program has advantages over 
intensive inpatient programs. Outpatient programs allow patients to: 
•Complete a step-by-step educational process •Start CSII in real-life 
situations while continuing their normal lives with minimum interruption
 •Make more exact adjustments in their basal and bolus insulin 
requirements •Have an easier psychological adjustment to pump therapy •
Reduce the cost of CSII initiation 

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 
Hopefully in the next decade, implantable glucose sensors will be a 
reality and will provide basic information directly to the pump. The 
pump will provide insulin automatically, and insulin pump therapy will 
be common for people with type 1 diabetes. 

F. Menendez Alvarez and 
R.M. Antuña de Alaiz 

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
for HELP or to subscribe/unsubscribe, contact: HELP@insulin-pumpers.org
send a DONATION http://www.Insulin-Pumpers.org/donate.shtml