1. Pumping at camp What do we need to know Summer 2008 Kris Tiernan RN, MSN, CPNP, ARNP, CDE

2. Many thanks to our friends at Camp Hertko Hollow for providing this presentation. Camp Hertko Hollow 101 Locust St. Des Moines, IA 50309 Ann Wolf, Executive Director 515-471-8523 a.wolf@camphertkohollow.com a.wolf@camphertkohollow.com Vivian Murray, Camp Director 352-750-6759 or 888-437-8652 (Toll free) v.murray@camphertkohollow.com v.murray@camphertkohollow.com

3. 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!

4. Pumps from 1978 - 1987

5. Insulin pumps of today

6. 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?

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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!

23. 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)

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. NEW CHALLENGES FOR CAMP NEW PUMPS CONTINUOUS GLUCOSE MONITORS FUTURE TECHNOLOGIES WE NEED TO CONTINUE TO MOVE FORWARD WITH THE CHANGES

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