Insulin pump pathway and criteria for adults (Guidelines)

Referrals to the pump service should be made by healthcare professionals with diabetes specialist skills, after the patient has completed appropriate structured education and is using an intensive multi-dose insulin regimen therapy, to the best of the their ability.  Individuals may also refer themselves if they feel they meet criteria or would like clarification on requirements to obtain an insulin pump.  Please see appendix 1

Indications for CSII in adults with Type 1 Diabetes Mellitus (over 16 years)

1. Individuals experiencing recurrent unpredictable hypoglycaemia
2. Individuals pre-pregnancy who despite completing structured education do not achieve pre-pregnancy targets, 3 months post structured education
3. Individuals with unstable diabetes control impacting negatively with significant measurable  consequence on quality of life despite having completed structured education (e.g. HEIDI)
   1. recurrent hospital admissions
   2. ongoing fear of hypoglycaemia or frequent mild episodes (especially if nocturnal or if impaired hypo awareness) being a barrier to tightening glycaemic control to HbA1c < 69mmol/mol
   3. ability to manage current employment
4. Individuals engaging in physical activity on a regular basis which interferes significantly with blood glucose control despite structured education.

Considerations

Individuals must have stable mental health that does not impact on their ability to self manage or engage with the specialist team.

Potential candidates will be seen in a consultant led clinic first, and then referred to the MDT members. The following will be assessed by and documented by the MDT :

• relevant past diabetes history, including acute and long term complications
• current insulin regimen and usage
• current knowledge and understanding of optimal diabetes management
• evidence of level 3 structured education eg HEIDI
• patient’s health beliefs regarding barriers to optimal management eg fear of hypos
• commitment to self care as evidenced by blood glucose monitoring, insulin dose adjustment, insulin injection technique, dietary habits, carbohydrate counting and lifestyle
• willingness to alter current diabetes management
• willingness to engage with pump service i.e. attend regular appointments, and keep in touch with DSN / dietitian between appointments as required
• any expectations of pump therapy
• medical, drug and social history that might impact on ability to self manage an insulin pump

At this stage a brief over view of what insulin pump therapy involves, followed by supporting literature will be given out. Following this individuals return for separate appointments to see pump DSN and / or pump dietitian as part of the initial assessment, depending on the needs identified.

Pre-Pump Visits & Preparation

Once funding for pump therapy is secured for an individual, a date and week to initiate pump therapy will be arranged. Prior to this 2 pre-pump start education sessions are provided on Friday afternoons with the pump DSN and dietitian for basic pump technology education. An opportunity to wear the pump with saline in the reservoir for a few days to further familiarise themselves with the device is provided in the second session. Pumps from various manufacturers will be used, the specific device offered to an individual will depend on preference, clinical issues, NHS procurement and device costs.

Pump Initiation Week

Individuals will usually attend the Diabetes Centre within the Centre for Health Science at Raigmore Hospital on a Monday morning and will then be in regular contact with pump DSN until Friday where a face to face appointment is required the week insulin pump therapy is commenced. Groups of 2 - 4 patients will start pump therapy together, this reduces the pump educator’s time spent per patient initiating pump therapy, and provides peer support. If anyone has a specific need that requires initiation as a one to one this will be considered on a case by case basis. Individuals are advised that they are required to have 1 week without work or activity when commencing insulin pump therapy.
The starting regimen for pump therapy will be individually calculated according to current practice.
Education sessions during pump initiation week will follow the NHS Highland pump curriculum and will be delivered by either the pump DSN or dietitian.

Followed up is provided in a group setting 6 - 8 weeks post pump initiation to further provide peer support and education.

• Pump education refresher annually
• Consultant led pump clinics yearly
• The offer of DSN & or dietitian individual appointments for specific problem resolution on an as needed basis. If such appointments occur more than every 3 months the DSN & or dietitian may refer patient back to consultant led clinic to reconsider pump therapy benefits depending the on specific issues raised.

All individuals established on insulin pump therapy will have the benefits or adverse effects of therapy documented on an annual basis as part of the insulin pump service audit. The following circumstances which may lead to discontinuation of funding for insulin pump therapy are:

1. Individual no longer wishes to continue pump therapy
2. Failure to demonstrate adequate clinical benefit of pump treatment, for example but not exclusively:
   • HbA1c level remaining above 69mmol/mol without extenuating reasons
   • Ongoing unstable control due to incorrect use of pump
   • Pump treatment has not resolved the clinical issue for which the therapy was initiated e.g. hypoglycaemia, recurrent admissions, achieving pre-pregnancy targets
   • Self care commitment is insufficient to make insulin pump safe i.e. failure to monitor blood glucose 6 to 8 times per day
   • Failure to attend pump clinic appointments without appropriate agreed alternative diabetes care in place e.g. attendance at another hospital diabetes service which may be appropriate after the initial assessment and insulin pump initiation
   • Failure to keep in touch with the pump multi-disciplinary team and attend agreed education appointments
   • Individual no longer lives within NHS Highland catchment area. If a patient moves to live in a new health board area their diabetes care should transfer to the new health board and also the responsibility of insulin pump funding.

Process for Discontinuation of Insulin Pump Therapy

1. As part of the annual assessment of pump therapy, the pump MDT will assess whether individuals are receiving benefit from therapy and use the pump device safely
2. If any issues are raised, the pump MDT will arrange to meet the individual and discuss the issues with them and the possible recommendation to discontinue pump therapy. This discussion in clinic will be followed by written confirmation to person concerned.
3. Individuals thereafter will have a 3 month period for reflection, during which time they can take measures to address the issues raised and hopefully resolve them.

Referral to insulin pump MDT

Please complete the above form and email it to nhsh.csii-raigmore@nhs.scot