Pumping at camp

What do we need to know

Summer 2008

Kris Tiernan RN, MSN, CPNP, ARNP, CDE

Many thanks to our friends at Camp Hertko Hollow for providing this presentation.

Camp Hertko Hollow101 Locust St.Des Moines, IA 50309 Ann Wolf, Executive Director515-471-8523a.wolf@camphertkohollow.com Vivian Murray, Camp Director352-750-6759 or 888-437-8652 (Toll free)v.murray@camphertkohollow.com

This presentation is intended to be a general guide that will help you create a thorough staff training tool for your camp. It is not intended to be a comprehensive resource or to fully cover the topic. We hope you will take this presentation and adapt it so that it fits your camp’s specific needs and meets the guidelines established for the safe and effective operation of your program.

Each diabetes camp operates under detailed policies and procedures that follow Board of Health and national accreditation standards that ensure the health and safety of children with diabetes. It is essential that camp staff be trained according to your camp’s policies and procedures. Staff should be encouraged to carefully review materials before arriving at camp, participate fully in pre-camp training, ask questions and use good judgment as they provide diabetes management supervision and educate youth with diabetes at camp.

While doing so, it is equally important that camp staff not lose focus – camp is a place for youth to have fun with peers – to feel supported and understood, and to feel part of a passionate community. Good luck!

Pumps from 1978 - 1987

Insulin pumps of today

Pumps simulate insulin delivery of the pancreas: 24/7 rapid – acting insulin

External glucose testing and response Basal rate

– Immediate manipulation vs. pooled insulin– Even absorption vs. interrupted absorption

Bolus– Easier to give– Easier to forget?

What is an Insulin Pump?

A pump is a delivery system for insulin A pump replaces insulin injections A pump delivers insulin through a small

catheter under the skin A pump can more closely mimic the

pancreas A pump uses only short acting insulin to

deliver both the bolus and basal insulin A pump is a computer that is programmed to

specific criteria individualized to the person

Blood Sugar Terms

Hypoglycemia: low blood sugar Nocturnal hypoglycemia: low blood sugar just

before awakening Dawn phenomenon: rise in blood sugar just

before awakening Hyperglycemia: high blood sugar Ketoacidosis: usually high blood sugar plus

ketones Ketones: fat breakdown when not enough

insulin is present

Pump terms

Basal insulin: insulin that is given continuously or the long term insulin given by injection

Meal bolus: insulin given to cover food intake determined by counting carbohydrates

Insulin sensitivity: indicates how much your blood glucose is reduced by 1 unit of insulin

Correction bolus: amount of insulin needed to return a high blood sugar back to a target range

Blood sugar target: predetermined blood sugar range Active insulin time: number of hours that the insulin

remains active in the body

Insulin Pump: Advantages

Increased precision in insulin dosing with rapid acting insulin

Increased flexibility in lifestyle by matching doses to eating, sleeping, and activity

No need for multiple injections Nighttime stability increased Math by computer decreases error in dosing Potential for decreased hypoglycemia Potential for improved blood sugar control

Insulin Pump: Advantages (cont.)

Easier to have frequent meals or snacks Can give insulin over a longer period of time

or split doses which comes closer to pancreas function

One type of insulin, no mix up Short acting insulin is more accurate than

long acting insulin, 3% error vs. 60% Can tailor the basal rate to meet individual

needs with up to 48 different rates

Does the pump have a brain? NO

Human needs to initiate doses and make the appropriate dose changes

Human still needs to carry the correct supplies

A person still needs to review the data and assess the quality of life

Even with a bolus calculator there is still the need for a human to determine whether the dose is correct or not

What a Pump is Not

It is not a cure to diabetes It does not have a brain It does not eliminate the need for blood sugar

monitoring It is not the perfect treatment for diabetes It does not require surgical placement

Insulin Pump: Disadvantages

Potential for inflammation and infection at infusion site

Susceptibility to ketoacidosis Potential for catheter occlusion Initial purchase expensive 24 hour attachment Potential to forget to bolus

Infusion Sets

Change site every 2-3 days Absorption via pump Check blood sugar 2-3 hours after set

change

inset

silhouette

Quick-set

Omnipod

Important to remember…

Pumps deliver a continuous SQ delivery of rapid acting insulin

What works quickly will also wear off quickly

Your pump will not necessarily tell you if the supply of insulin has been interrupted

Diabetes at Camp:Times are changing

A few years ago only a handful of kids at camp were on pumps

Today, many camps have 40-70% of their kids on pumps

Insulin pumps are changing camp

More technology More supplies and equipment Different terms (bolus, basal, Bolus Wizard, etc.) Different management Pump removal Pump malfunction Kids may or may not know how to use their pump

BIG DIFFERENCES BETWEEN PUMP AND INJECTIONS

PUMPS USE ONLY SHORT-ACTING INSULIN: NEED TO WATCH FOR HIGHS

SOME ARE WATERPROOF, SOME ARE NOT

SITE CHANGES EVERY 2-3 DAYS THERE ARE SEVERAL TYPES OF PUMPS ALWAYS USE CARB COUNTING WITH

PUMPS

INFORMATION PRIOR TO CAMP

1 WEEKS WORTH OF BLOOD SUGARS INCLUDING CARBS, INSULIN RATIO AND CORRECTIONS

ALL PUMP SETTINGS, INCLUDING TEMORARY SETTINGS AND WHEN USED

ACTIVITY LEVEL PRIOR TO CAMP LENGTH OF TIME ON PUMP CHILD’S LEVEL OF UNDERSTANDING AND

PARTICIPATION IN PUMP CARE

INFORMATION PRIOR TO CAMP

USUAL ROUTINE FOR SET CHANGES (HOW OFTEN, DOES CHILD SIT OR LIE DOWN, IV PREP, EMLA CREAM, INSERTER, ETC.)

HAS ANYONE BUT MOM OR DAD CHANGED THE SITE

PREVIOUS PROBLEMS WITH DIABETES CARES (FORGETTING BOLUSES, HIGH BLOOD SUGARS, ETC.)

WHAT DO YOU WANT YOUR CHILD TO LEARN AT CAMP

MOST IMPORTANT

WITH A PUMP HYPERGLYCEMIA IS INCREASED IF PUMP SITE IS BAD

CANNOT TELL BY LOOKING AT THE PUMP OR THE SITE IF IT IS BAD

PUMP DOES NOT ALARM IF INSULIN ISN’T GOING IN

MUST GO BY BLOOD SUGARS AND URINE KETONES TO KNOW IF PUMP IS WORKING

CAN GET SICK QUICK!

SITE CHANGES

MANY KIDS WITH MANY ROUTINES MANY PUMPS WITH MANY SETS IMPORTANT TO HAVE A CAMP ROUTINE SUGGESTION FROM CWD IS TO CHANGE SITES

EVERY OTHER DAY: GIRLS ONE DAY AND BOYS THE NEXT

SOME CHILDREN HAVE NEVER HAD ANYONE BUT THEIR PARENTS CHANGE THEIR SITES (WOULD BE NICE TO KNOW AHEAD OF TIME SO THAT PARENT CAN PREPARE THEM)

SITE CHANGES (CONT.)

LOOK AT CHILD’S OLD SITES SUGGEST NEW SITES IF OLD SITES ARE

PUFFY AND/OR RED BEST TO PLACE SITES IN ABDOMEN OR

HIPS/BUTTOCKS ARM AND LEG SITES CAN CAUSE LOWS PLACE SITES NEXT TO EACH OTHER,

NOT ALTERNATING SIDES

HOW DO WE HELP THEM AT CAMP?

IF BLOOD SUGARS ARE ALWAYS HIGH PRIOR TO CAMP MAY NOT NEED TO DECREASE BASALS

CHANGE ALL SITES EVERY 2 DAYS NO MATTER WHAT THEIR USUAL ROUTINE

DECREASE BASAL BY 20-50% IF THEY ARE LESS ACTIVE AT HOME

MAY NEED TO INCREASE BASAL IF MORE ACTIVE AT HOME

WHAT TO DO FOR HIGH BLOOD SUGARS

IF BLOOD SUGAR IS >250 GIVE CORRECTION BY PUMP AND CHECK IN 1 HOUR AND CHECK FOR KETONES

IF STILL >250 GIVE CORRECTION ACCORDING TO PUMP BUT BY SYRINGE AND CHANGE PUMP SITE

FOR KETONES, DO AS ABOVE AND ENCOURAGE FLUIDS

AVOID PUMP SITE CHANGES BEFORE BED WHENEVER POSSIBLE

SWIMMING AND PUMPING

CHECK BLOOD SUGAR BEFORE SWIMMING (MUST BE ABOVE 100 TO ENTER POOL AREA)

MAKE SURE ALL THE KIDS HAVE THEIR NAMES WRITTEN ON THEIR PUMPS

REMOVE PUMP FOR SWIMMING IF IT IS NOT WATERPROOF AND PLACE IN A SAFE, DRY PLACE AWAY FROM WATER

CHECK BLOOD SUGARS BEFORE SWIMMING AND EVERY 1 HOUR AND AS NEEDED WHILE SWIMMING

GIVE INSULIN AND/OR SNACK AS NEEDED FOR BLOOD SUGAR

KEEP HYDRATED WHILE SWIMMING

PHYSICAL ACTIVITY

MAY WANT TO DECREASE BASAL RATE FOR PHYSICAL ACTIVITY (TO 50% OR GREATER)

MAY WANT TO DECREASE BASAL AFTER ACTIVITY

MAY NEED TO TAKE PUMP OFF FOR CERTAIN ACTIVITIES (IE. CANOEING)

Staff training

Make sure to find out the type of pump campers are using at least a month before camp, longer if possible

Have all staff complete the online training for all pumps that will be used at camp (we plan to have a test with this online to be completed before camp)

Have at least 2 people at camp who are trained in each of the pumps and to help with site changes

Make sure that all staff are aware of the significance of high blood sugars with pumps

Staff training

Ideally a counselor in the cabin would have the same pump as the campers or know how to use it

At least one staff in cabin should have a basic understand of pump therapy

WHAT WE NEED TO DO

NEED TO STAY CURRENT ON THE LATEST TECHNOLOGY

KNOW WELL AHEAD OF TIME WHAT EQUIPMENT THE CAMPERS ARE USING SO THAT STAFF CAN BE TRAINED

HAVE COPIES OF ALL THE MANUALS AND EXTRA SETS FOR ALL EQUIPMENT BEING USED

Continuous Glucose Monitoring

Device that checks blood sugars on a continuous basis

Provides up to 288 glucose readings in 24 hours

Some have predictive arrows Potential for greatly improved blood

sugars (staying between the lines) Step closer to artificial pancreas SQ site like the insulin pump

NEW CHALLENGES FOR CAMP

NEW PUMPS CONTINUOUS GLUCOSE MONITORS FUTURE TECHNOLOGIES WE NEED TO CONTINUE TO MOVE

FORWARD WITH THE CHANGES

WE MUST CONTINUE TO MOVE FORWARD AND BE FLEXIBLE TO BE THE BEST WE CAN BE