Personal Reflections on Journal Article- Optimizing Insulin Pump Therapy: A Quality Improvement Project

I spent part of my lunch break reading an article from the November/December issue of the Diabetes Educator. The title is  Optimizing Insulin Pump Therapy: A Quality Improvement Project.

From the abstract:



Purpose The purpose of the study was to assess insulin pump use and provide ongoing education.


Methods A quality improvement project using a pump assessment questionnaire was implemented at an endocrinology office in the southeastern United States. The questionnaire was designed to evaluate all aspects of insulin pump therapy, including pump operations, infusion set failure, management of acute complications, and usage of advanced device features. Eighty-nine patients (80% with type 1 diabetes and 20% with type 2 diabetes) completed the questionnaire at the endocrinology practice. A certified diabetes educator reviewed the questions with each patient, identifying deficiencies and training opportunities.


Results The most common areas of deficiency identified after implementation of the assessment form included the following: expired or no basal insulin prescription in the event of pump failure or removal, no mupirocin (Bactroban®, GlaxoSmithKline, Research Triangle Park, North Carolina) prescription for suspected site infections, lack of insulin syringe if pump stopped working, failure to check urine ketones, no antiemetic prescription for sick day intervention, using manual bolus instead of bolus calculator, and lack of in-date glucagon kit.


Conclusions Use of a pump assessment questionnaire allows for focused discussion concerning patient behaviors related to pump operations, troubleshooting, and self-management. Incorporating use of a pump assessment questionnaire into routine practice may result in improved patient education and avoidance of adverse events specific to insulin pump therapy.

Essentially, the authors of this paper gave questionnaires to patients in an endocrinology office who used insulin pumps.  Those who were included in this study were exclusively Medtronic users with a minimum of one year of experience using their pump. The survey used closed-ended questions to facilitate conversations between the PWD and their health care team. The office has 2 endocrinologists, and an FNP who deals with most of their pumpers. It's unclear from the paper as to whether or not annual visits to assess pump use were a given for this practice or not, but it seems the office will start using these questionnaires annually.

The authors achieved their goal of identifying weaknesses within their practice. Through use of their surveys, they were able to determine which topics each patient needed to cover in order to increase the effectiveness of pump therapy. I'd be interested in a follow-up paper to determine if spot retraining helped with overall control.

My personal reflection on this post is that I can identify with many of the shortcomings elucidated in this paper. The one that worries me the most, but I continually forget to mention with my doctor is a lack of a backup plan if something were to go wrong with my pump. I have not had a prescription for a basal insulin in over 10 years. Only once has anything gone wrong, but when it did I was testing and injecting Humalog like nobody's business. For a day and a half. It was pretty crappy. I should really do something about that.

Along the lines of preparedness, I haven't owned Glucagon probably since diagnosis. Thankfully, I've never needed it. But I suppose the point of emergency preparedness is to, you know, be prepared for emergencies that hopefully never happen. The article also stresses that we pumpers should have a prescription for mupirocin in our bag of tricks in the event of a site infection. It's not a bad idea, but the few infected sites I've ever gotten were easily worked out with Neosporin.

Other than those things, I feel pretty good.. Of the identified shortcomings, most of them deal with being prepared and not having prescriptions for glucagon, mupirocin, and antiemetic drugs. With the exception of basal insulin, I am decently prepared.

The key to using an insulin pump is using it effectively. Perhaps more endocrinology practices should use similar questionnaires to identify weaknesses in pump use. Personally, I haven't had pump training in... well... pretty much since Medtronic introduced the Paradigm with the Bolus Wizard. I think I got mine in 2007 or so. I'm sure there are some gaps in my pump education.

D-goals for 2014.

Inspired by the DSMA chat last night (1/8), I set out to make a list of diabetes goals that I have this year. It's not a long list.

• Bring A1C down below 8. How?
• Get better at carb counting. After 16 years, I've got the basics. What I need to get better at is determining the "weird" factor. For example, my body is weird with peanut butter sandwiches. Even when I measure the peanut butter, my blood sugar goes higher than it should, and I have to give an extra unit of insulin when I eat a PB sandwich. I need to identify more food patterns like this so I can bolus more effectively.
• Choose the lower carb option. This is self-explanatory
• Change my sets more regularly. I need to start putting my set changes on a calendar so I can keep better track.
• Figure out how to exercise without dropping 50+ points. It's annoying. Even when I disconnect my pump, my blood sugar drops at least 50 points when I exercise. It's not a big deal if I start out around 160, but anything below that usually ends with a snack. Which doesn't help me lose any weight, which I would like to do.
• Make this the year of the CGM. I've wanted one for a long time. Really. I've done my research on them, but I haven't brought it up with my endo in over a year. This falls under my non-D goal of being more assertive. 

That's it. That's my goal list. I don't normally set goals. Usually I give myself challenges like seeing how many days I can go without breaking 200. It's not a "go X days" goal, because diabetes is NOT as formulaic as we would like it to be. I only let myself get upset about breaking the streak if it's something I could have prevented, like forgetting to bolus, not changing my set in time to prevent bad absorption, etc. 

Someone remind me of this post in June. I'd like to see how I'm doing, and kick my own ass for not having had the CGM talk by then.

Change of (educational) Plans!

Depending on how well you know me, you might know that I'm quite passionate about anthropology. I have a Bachelor's in anthropology. I completed one semester of grad school for anthropology. I've been to Greece to study bones. My bookshelf is overflowing with anthropology texts. But... I quit. Anthropology no more, well, not as a career goal. What am I doing with myself now? I'm going back to school. For nursing. With any luck, I can eventually become a CDE. Even if  I don't make it that far, I think I will be happy in nursing. 

Don't get me wrong. I still love anthropology. I do. I doubt I'll ever be able to shake it. Why do I want to leave it? It's complicated. I am actually good at writing papers and giving presentations. I love reading. Unfortunately, I don't think I can spend the rest of my life doing it. Papers, teaching college, conferences. Even if I found a job as a career academic, I don't think it would make me as happy as it used to. 

I was hanging out in the grad lounge, waiting for my advising session when all of this hit me like a ton of bricks. I went into my advising session anyway, discussed research and classes to take, and walked out of there feeling numb. Suddenly I didn't care about any of it anymore. 

I don't cry. When I get upset, I get physical. I get deadly quiet and unleash it when I'm alone. I cried the entire walk back to my car. Anthropology was all I wanted to do since I was a junior in high school. I had a degree in the subject, and suddenly I didn't care at all. What was I going to do? As suddenly as it had hit me I didn't care about anthropology, another idea hit me: nursing. Before I wanted to be an anthropologist, I wanted to be a doctor. I don't want to be a doctor anymore, but nursing is something I think I can do. 

For people who know me casually, it seems like something I could do, caring for others. For people who know me pretty well, caring for others doesn't seem like something I'd do. I'm that misanthropic, caustically sarcastic bitch. For people who know me incredibly well, they know that caring for others is something that would fit me perfectly. 

My realizations hit me really fast, but it's taken a LOT of thought to actually go through with this. Dropping out of grad school and re-enrolling in my alma mater as an undergraduate again... it's hard. I'm on waiting lists for the important pre-requisite classes (chemistry and anatomy/physiology). I can (hopefully) apply for nursing school in the fall, to begin nursing school in fall 2015. I'm not sure how in hell I can pay for any of this. I don't have a job. It's going to be a long road ahead, but I think I can do this. Wish me luck. 

If diabetes were a person...

I think I'm going to make this a continual game on my blog. If diabetes were a person, what would I say to it on any given day? Today diabetes is being that friend that everyone has that they tolerate. Today diabetes is being that clingy friend that you feel irrationally bad about hating sometimes.

It started out simple enough. Like most of my Tweets, I just spat it out.

Why did I choose to express my hate at that moment? My BG was fine, my pump was perfect: set, reservoir, battery... all good. Diabetes wasn't even being challenging at the time. Why the rage?

I've been... otherwise occupied. Not busy, exactly, just occupied. My mother had back surgery on Friday. Since then I've been hanging out at my parents' house helping out. Cooking, cleaning, laundry. I'm trying to register for classes I need that are all full. I miss my boyfriend. It's really cold outside (seriously, 17 degrees in Atlanta. Yuck). Like it normally does, diabetes has been that "friend" following me around screaming "BUT WHAT ABOUT ME?!?" I just have to deal with it. Take a few minutes to assure it that I haven't forgotten about it, and manage things. All things considered, I suppose diabetes hasn't been so demanding recently; my numbers have been okay and my pump hasn't done anything stupid for a few days. 

I'm just tired of dealing with it. I have better things to be doing with my time. Here it is:

Diabetes,

I know I haven't been giving you the attention you're used to. I haven't synced my pump in a while. I know. But we did those blood tests together today. I changed my reservoir. I corrected for that high. Thank you for being understanding right now. I am helping my family right now and trying to get things together for the semester. So, thanks for not throwing a temper tantrum. I am fully aware you could be making things so much worse right now. Just know that while I do still hate you, I don't hate you any less just because I haven't been giving you the attention you're used to. I promise you at least 4 blood tests per day. 

Regards,

Courtney

Traveling With Diabetes

It’s holiday time, folks. That means travel. Most of my holiday travel involves driving, but for Thanksgiving I’m going to visit my boyfriend’s family in Dallas, so we are flying. It’s around this time of year that travel questions start popping up in the D community. I’m not a frequent flier by any means, but I have been through quite a few airports in my day, and I’d like to share my average experience.

I live in Atlanta, so that is the airport I see the most. It’s supposed to be the busiest in the world, or at least close to it. There’s just something about the hustle and bustle of Atlanta’s Hartsfield-Jackson that gets my blood pumping. With so many people coming through every day, they have their act together for the most part. If you’re going through the Atlanta airport, feel free to use the Special Assistance line at the security check. This line is for people with wheelchairs, strollers, and medical devices, and you get to the pat-down a little faster..

Yes, I opt for the pat-down. Every time. Why? Because Medtronic can’t be sure the body scanners are harmless, and the last thing I need is to be a thousand miles from home with a malfunctioning pump. Also, since Medtronic’s official stance on the body scanners is “don’t,” I don’t know how that would affect my warranty, if at all. At any rate, I feel better playing it safe.

Back to the security line: take off your shoes, your belt, your jewelry. Pull your laptop and electronic gadgets out of your bag. The bag for your liquids? This is not where I put my insulin. Nope. I leave it in its carton, marked with the prescription information, in my bag of medical things. All my meds stay together: insulin, strips, pills, sets, reservoirs, needles, etc. They stay together.

As I already said, I opt for the pat-down. I just tell the nice person working at the machine I’d prefer a pat-down. Then I get to stand around while they shout “female assist!” and my boyfriend (or other travel mate) collects my things for me. The pat-down is fairly standard. Spread your legs and hold your arms out, palms up. Someone of the same sex will be rubbing their hands along your body. Then they will test their gloves for explosive residue and tell you to touch your pump before they swab your hands, too. Most of the time, it’s fine and I get to go. Sometimes, though… sometimes I set off the explosive detector. The first time it happened it scared the crap out of me, but now I just take it in stride.

What happens if they think you’re explosive? They will take you to a “private screening room” to give you a more thorough pat-down. Someone else will go collect your bag, and they will pull everything out and test it for explosive residue. They really wipe down everything. The first time I was deemed explosive, it was 5:30 AM in a tiny airport in State College, Pennsylvania. I was so not in the mood to have my dirty laundry aired (literally). But they do what they have to do, and thankfully they’ve never determined me to be a threat.

My top advice for dealing with the TSA: be friendly. Have a sense of humor. They see thousands of jerks every day. Don’t be another jerk. Smile. Thank them when they’re done. Maybe even throw in a “Have a Happy Thanksgiving” for good measure.

I’ve been through LAX a few times, and they’re usually not very amused, so my goal is to get them to lighten up while they’re feeling me up and testing my laptop for bomb stuff. Last time I went through security at LAX the lady at the scanning machine didn’t want to let me have a pat down, but she called over the female assist agent, rolling her eyes. “This lady says she needs a pat-down for some insulin pump thing,” to which the assist agent replied, “well, she does. Even if she didn’t, it’s her right to opt out of the body scan.” Then they glared at each other. It was a tense thirty seconds.

Most TSA agents are friendly if you’re friendly to them, though. Don’t let anyone try to talk you out of getting a pat-down, if that’s the route you go.

My only overseas experience is in Greece. I used to know how to say “for diabetes” in Greek, but I can’t remember it anymore. I flew from Atlanta to Athens, then Athens to Heraklion (Crete), and then back. I had one slight incident in Heraklion where they wanted to find an English-speaking agent to clarify the diabetes thing, but it was no big deal. The bigger deal was finding someone to speak French with a lady who didn’t understand she needed her ticket, but that’s a different story. 

Thanksgiving...and thanksforgetting

Turkey Day. National Overeating Day. Thanksgiving. Call it whatever you want, but it usually involves copious amounts of food, and copious amounts of insulin. Couple that with the stress of being away from my family for the first time ever during a holiday. And the stress of meeting various members of my boyfriend's family. This should equate to a lot of insulin. So, I squeezed myself into a nice dress and clipped my pump to the inside of my thigh high pantyhose. It worked very well in terms of keeping my pump secure in a dress. It's the first time I've kept it there. On the way to Thanksgiving lunch (my boyfriend's family is dealing with kitchen renovations, so we ate out), I discreetly did my blood test. I rang in at 200, but stress and croissants will do that. Then I ate a huge meal including potatoes, green bean casserole, and pumpkin pie. And cookies. It was tasty. I was working on a way to discreetly get away from the table to go bolus (for both the 200 and the food), but I kept getting distracted. Can you guess where this is going? I never bolused. It took me about 7 hours to realize this. When I checked... 205. I ate a zillion carbs without insulin and I didn't die. It's a Thanksgiving miracle!

For those wondering, this is what it looks like when you keep your pump in thigh highs:

Surprisingly, keeping my pump in my stockings was not uncomfortable, even though I ended up with a large indention that looks eerily like my pump. It worked well, and would have been great if I had managed to get to the restroom to bolus. On the other hand, how low would I have gone?! 

"Alternate" Pump Sites

I have to start out by saying this: I am not an adventurous person. At all. It takes me forever to try something new. I don't jump into swimming pools; I wade in. It's the same with my diabetes care. I started thinking about pumping in 2000, but I didn't get one until 2002. For the first three years of pumping, I only put my pump sites on my belly. Then I expanded to my butt in 2005. Intellectually, I knew there were other places on my body, more real estate. I knew it would be better for me if I rotated my sites into new areas. Anything other than my belly and butt, everything else was uncharted, alternate locations.

Here's another thing about me: I have the most disproportionate body you'll ever see. I have scrawny little arms and scrawny little legs, no butt, a big belly, and huge boobs. Really. Here's a picture of me being grumpy on the 4th of July:

Anyway... I was afraid to put my sites anywhere except my huge belly or tiny butt. Most of the sites on my butt hurt, and it had more flab than my arms and legs. In an effort to expand my real estate, I ordered a sample of Silhouettes from Medtronic (these are the angled sets). The spring-loaded inserter always made me anxious, so I was also looking forward to manual insertion (I could never get it right with the QuickSets). This year, in 2013, I did my first ever thigh site:

This week, I tried my first ever ARM site:

Neither one of them hurt like I expected it to. Now I love having my site on my thigh. It's especially great if I'm wearing a shirt that either is tight or leaves lint all over my site. The only downside to the thigh site is forgetting it's there and snagging it on my underwear. Also, my thigh sites tend to come out really kinked. It usually doesn't affect the absorption much or at all; in fact, I get good absorption from my thighs. I don't know if it's the proximity to muscle or what, but my blood sugar drops a lot more when I exercise with a thigh site.

My new arm site... I'm not sold yet. Again, the absorption is great. I think part of my problem with my arm site is exactly where I put it. I keep catching it on my sleeve when I wear a T shirt. It was my first time putting it on my arm, and I didn't get the adhesive part down all the way. It's fluttering away, so I had to put some tape on it. If I want to do anything that involves a lot of stretching, I either have to take it off or clip it to my shirt/bra. For normal, everyday life it doesn't pull when I walk or anything (I'm 5'7", for reference). My biggest hurdle has been using the bathroom. The tubing doesn't stretch that much. I've also had some trouble changing my clothes because I'm not quite sure how to juggle everything yet. I might give the arm site another try because I haven't decided how much I like it yet.

The point I'm trying to get at here is that if you're thinking about new geography, try it. The worst that can happen is you'll need to take it out and put it back in your comfort zone. Take it from someone who is very resistant to change: you can do it. You can try something new, and you might even end up liking it!