Standards of Diabetes Camp Dr Elaine Kwan QMH 16 September 2004

Mission of diabetes camps for children and adolescents To allow for a camping experience in a safe environment To enable children with diabetes to meet and share their experiences with one another To learn to be more personally responsible for their disease

Mission - for patients and families To be enjoyable To increase the confidence in both physical and social activities To promote diabetes education in a more relaxed and non-structural setting To review their management skill in daily life To impart a more positive attitude in coping with chronic illness

Mission - for patients and families To promote communication / understanding with staff and sharing of difficulties and feelings in coping with disease To allow parents a ‘vacation’ off diabetes care To allow campers to gain perspective on their own family dynamics To establish ongoing peer support networks

Mission - for medical staff To have better understanding of the struggles and difficulties that patients face in their daily living To build a good rapport and relationship with the patients and families To provide an opportunity to work as a team in running an educational camp To encourage sharing of responsibilities in diabetes care To gain practical experience in diabetes care

Diabetes camps for children and adolescents Should be an integral component of overall care and support Organised using an agreed set of standards and protocols specifying responsibilities, staff ratios etc Skilled medical and camping staff to ensure optimal safety and an integrated camping /educational experience A standardised medical information form should be completed for each campers

Diabetes camps for children and adolescents Often associated with increased physical activity Goals of glycaemic control more related to avoidance of hypoglycaemia than optimization of overall control Balance insulin dosage with activity level and food intake

Standardised Information before camp Past medical history Immunisation record Diabetes regimen including home insulin dosage Blood glucose record for the week before camp History of poor control and severe hypoglycaemia Previous HbA1c levels Other medications Psychological issues

Written camp management plan Include camp policies and medical management procedures General diabetes management Insulin injections/ pump therapy and BS monitoring Nutrition, timing, and content of meals & snacks Routine and special activities

Written camp management plan Hypoglycaemia and treatment Hyperglycaemia/ketosis and treatment Medical forms Assessment and treatment of intercurrent illness Psychological issues at camp

Written camp management plan When to notify parents and chief care physicians Risk management plan Universal precautions and policies for needle sticks Handling of infectious wastes Monitoring of medical equipment Incident/ accident reporting Policies for camp closure and returning home

Written camp management plan Emergency procedures (including natural disasters) Prevention of physical, sexual and psychological abuse Risk management plan

Standardised record during camp and feedback All blood glucose levels and insulin dosages Degree of activity Food intake Any major alterations during the camp Copy of camp record sent to health care team of patient To return to their pre-camp regiment

Camp Leader Led by someone with expertise in diabetes care, in paediatric care and in camping –Appropriateness in working with children Be responsible for daily reviewing of blood glucose results, insulin logs and other medications to make appropriate adjustments Overseeing all medical emergencies To ensure that the medical program is integrated into the overall camping experience

Camp Staff Composition Diabetes educators Dietitians Students Volunteers Camping experts

Training of staff All staff should undergo testing to ensure appropriateness of working with children All staff should receive training concerning routine diabetes management issues and the treatment of diabetes-related emergencies before camp (hypoglycaemia and DKA) Familiar with signs and symptoms of hypo/ hyperglycaemia, indications for blood glucose testing, and treatment of hypoglycaemia including administration of glucagon Camp policies and job descriptions available before camp

Facilities Routine first aid For treatment of intercurrent illnesses (allergies, asthma, sore throats, diarrhoea/ vomiting, minor trauma) Diabetes supplies (insulin, pen, pump, battery, catheters, glucose monitoring machine, stripes, lancets, syringes, alcohol swabs, gauze, glucagon, intravenous glucose solutions, simple sugar, urine ketone stripes, stethoscopes, thermometer)

Management protocol at camps - insulin To balance insulin dosage with activity level and food intake to ensure stable blood glucose 20% or more reduction of insulin dosage Extra reduction for extreme physical activity, prolonged hikes or water sports Pre- and post-camp insulin dose advice –Small reduction of 10% for immediate pre-camp dose

Management protocol at camps - monitoring Multiple BS determinations made throughout 24 hour period –Before meals, at bedtime, after or during prolonged and strenuous activity and in the middle of the night (for BS < 5.6 before bed), after extra doses of insulin or with symptoms of hypoglycaemia Daily record of camper’s progress –Insulin dosages, BS levels, degree of activity and food intake

Management protocol at camps - diet 3 meals and 3 snacks should be given at set times each day Meals balanced, with composition, carbohydrate component, exchange value, and/or calorie count taught to campers Enable campers to learn how to balance food and activity Supervision of food intake of younger children Give extra snacks for BS < 6.7 mmol/L Signs of eating disorders

Management protocol - others Universal precautions (appropriate containers for disposal of sharps) Formal relationship with a nearby medical facilities for emergencies

Hypoglycaemia No clear definition, usually defined as PG < 4 mmol/L Varies with metabolic control (threshold at higher BG level for poor control) Result of a mismatch between insulin, food and exercise Symptomatic/ asymptomatic Mild/ moderate/ severe –Moderate - requires help from someone else –Severe - semi-conscious/ unconscious/ coma/ convulsion

Hypoglycaemia related to exercise Hypo can occur –During exercise –Immediately after exercise or –6-8 hours after exercise The BS lowering effect is extremely variable and severity depends on many factors Recommendations for individuals can only be made on the basis of their age, size, individual experience and ‘trial and error’

Prevent exercise induced hypoglycaemia Extra snacks before and after exercise –Small rapidly absorbed carbohydrate for light exercise –Slowly absorbed carbohydrate for strenuous and prolonged exercise –Extra snack before bed for strenuous exercise in the afternoon or evening Reduce insulin dose Change injection site Monitor BG before exercise

High-risk sport when hypoglycaemia would be potentially dangerous Water sports, climbing, skiing, diving, riding bicycle etc Must do BS monitoring before, during and after exercise BS targets may be temporarily relaxed Extra rapidly absorbed carbohydrate must be available throughout the period Young people should perform strenuous exercise in the presence of a companion/ supervisor familiar with the recognition and treatment of hypo

Treatment of hypoglycaemia All measures to avert severe hypoglycaemia (give extra snacks for BS < 6.7 mmol/L) A set protocol for treatment of mild-to- moderate hypoglycaemia so that hypoglycaemia is consistently managed Repeat BS testing performed within 30 min to ensure resolution of hypoglycaemia

Guideline for management of hypoglycaemia in camp Check dextrostix if condition not critical Dextrostix 3-3.9: give 10 gm simple sugar, repeat after 3-5 min if necessary Dextrostix < 2.2: give 20 gm simple sugar, give another gm if still symptomatic after 3-5 mins Give extra 10 gm CHO if no meal within 1 hour Unconscious: give glucagon imi (0.5 mg for 6 years) Keep record of BS reading and inform i/c medical staff before next injections

Extra carbohydrate before and during exercise

Treatment of ketoacidosis Measure urine/serum ketone if BS persistently > 15 mmol/L (2 consecutive readings if asymptomatic) or if there is intercurrent illness Oral or intravenous hydration (oral: 2 L water/day) Extra insulin (10-20% of total daily dose as fast acting/ ultra-fast acting insulin bolus) if  BS and ketone +ve Avoid exercise Dextrostix and urine/serum ketone every 4 hours Flow sheet for documentation of progress To medical facilities if vomiting or if ketosis does not resolve within 8 hours

Diabetes Education and Psychological issues at camp Camp setting an ideal place for teaching diabetes self management skills Education programs should be developmentally appropriate Improve psychological well-being of campers

Diabetes Education - topics Insulin injection techniques/ insulin pumps Blood glucose monitoring Recognition and management of hypo/hyperglycaemia and ketosis Insulin dosage adjustment Carbohydrate counting Diabetes complications Importance of diabetes control Lifestyle issues (especially weight control and exercise) Sexual activity and preconception issues New therapies Problem solving skills

Research at camp Must not interfere with integrity of camping program Parents and campers should have a copy of the research protocol Informed consent

Thank you ! See you at the camp !