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[IP] initiating outpatient pump therapy (Spain) - LONG
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
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
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
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
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.
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
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.
MS, RN, CDE,
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