2. Putting Pump Policies Into Practice- Case Study Conference Call Elizabeth Blair, ANP-BC,CDE Joyce Lekarcyk, RN, CDE

3. Objectives: Able to assess probable causes of hypoglycemia and hyperglycemia Able to interpret data to make changes in pump settings Able to identify other technologies available to determine insulin adjustment

4. Assessment Tools Assessment should include evaluating the following: Total daily dose- % of basal vs. bolus Evaluating I:C ratio and sensitivity factor Evaluating basals rates Trouble shooting, insertion sites, insulin usage, technique Glucose records can be used to determine whether the cause of hyperglycemia or hypoglycemia is related to basal vs. bolus

5. Basal vs. Bolus- Tips to decide Probable causes of hypoglycemia: Bolus Timing of bolus Stacking Carb counting vs. estimating Food choices Alcohol Activity New sites Basal rate Probable causes of hyperglycemia: Bolus Timing of bolus Grazing Carb counting vs. estimating Food choices Alcohol Activity Set change Basal rate Technique vs. compliance When and why does it happen ?

6. Case Study John O John has had Type 1 diabetes for 30 years The last 5 years he has been using a Medtronic insulin Pump 522 Three vessel CABG 9 years ago Hypoglycemic unawareness TDD: Basal: 14.6 Bolus: 27 to 36 units A1c 7.3%

7. Initial record review

11. Pump Settings Pump settings: 1:5 ratio SF: 30 Target glucose: 95 Basal 12a - 0.1 3a - 0.6 5a – 1.0 6a - 0.8 12p - 0.45 8p - 1.0 10p - 0.4

12. Your answers Why?

13. Your answers Which pump settings should you question? a) IC ratio and SF b) Target glucose c) Basal rates d) all of the above

14. Your answers What pump setting would you change first? a) Recalculate basal rate based on TDD b) Recalculate IC ratio and SF c) Wait for more trends d) Change glucose target e) All except for c

15. Tools to use Recalculating IC ratios and SF IC ratio- TDD divided by 450 Sensitivity factor: TDD divided by 1500 Any other way to change ratios?

16. Adjusting Bolus Rates per Policy PC-142 If BG is > than target for 2 days at the same time: increase the IC ratio:  Example: Change 1:15 to 1:12 If BS is < than for les than target for 2 days at the same time: decrease the IC ratio:  Example: Change 1:15 to 1:18

17. Recalculate basal based on TDD Possible basal: Average TDD=49 X.50 = 24.5 divided by 24=1.0 per hour 1500 divided by 49 =SF of 30 450 divided by 49 =IC ratio of 9 Compared to current basal: 14.7 units per day IC ratio of 1:5 Sensitivity factor of 30

18. First priority - Prevent the low’s Initial changes: I:C Ratio 10-10-9 SF: 40 Target:120 Basal: 12- 0.4 3- 0.6 5- 1.0 6- 0.75 11-0.8 6p-1.0 10p-0.4 Current rates: 1:5 ratio SF: 30 Target glucose: 95 Basal 12a - 0.1 3a - 0.6 5a – 1.0 6a - 0.8 12p - 0.45 8p - 1.0 10p - 0.4

19. BG records can only tell you so much! Is there a better way?

20. First Change: Overnight Basal Evaluation

21. Basal rate change After reviewing overnight Basal results would you: a) Increase the basal rate by 0.1 at 5am b) Make no change c) Consider changing supper IC ratio d) Increase basal from 10 to 2 by 0.1

22. Morning Fast

23. Morning basal evaluation What changes would you make after reviewing the morning basal evaluations results? a) Make no changes and repeat the fast b) Increase the basal by 0.1 at 8am c) Ask about activity d) A and C

24. Lunch Fast

25. Lunch basal evaluation What changes would you make after reviewing the lunch basal evaluation results? a) Make no changes b) Increase the basal rate by 0.1 at noon c) Increase the basal rate by 0.1 at 2pm d) Increase the basal rate by 0.2 at 2pm

26. Evaluating Morning Bolus

27. “My latest sugars still need a little work”

28. Your intervention In order to prevent the glucose spike after lunch what would you do first? a) Ask if his meals have change b) Nothing-wait for more trends c) Suggest doing a lunch bolus evaluation d) a and c

29. “I had a cortisone shot and my sugars are high” John gave his glucose by phone  24 hours glucose readings ranged from 200 to 350 mg/dl  Infusion set and insulin were changed  Ketones-small

30.  What Sick Day Management Guidelines would you give? a) 50% increase in basal rate for 4 hours b) 10% of total daily dose via pump c) 20% of total daily dose via syringe d) Either a or b Your intervention

31. Lunch bolus evaluation John ate 30 gms of carbohydrates: Glucose before lunch was 100 Glucose 3 hours later was 200

32. Your intervention What pump setting change would you make? a) Change I:C to 9 from 10 b) Inquire about activity and what he ate c) a and b d) Increase basal 0.1 at 1 pm

33. Pumping is less challenging to patients when there is a team approach and plenty of follow-up! Stay tuned to submit a final evaluation of this presentation !