According to 2002–2003 data from the SEARCH for Diabetes in Youth Study, approximately 15,000 new cases of type 1 diabetes are diagnosed annually in the United States in youth under the age of 20.1 Those patients with type 1 diabetes have a lifelong need for exogenous insulin to survive. The landmark Diabetes Control and Complications Trial, conducted between 1983 and 1993, provided evidence that keeping blood glucose levels as close to a normal range as possible can greatly improve metabolic control and prevent or at least delay numerous diabetes-related complications.
To achieve this level of "tight" glucose control requires frequent testing of blood glucose and subcutaneous delivery of insulin by means of multiple daily insulin injections (using a syringe or insulin pen) or insulin pump therapy (sometimes called continuous subcutaneous insulin infusion). Although estimates vary, most sources confirm our experience that the use of insulin pumps by children in the United States continues to increase. Since children using pumps are being seen with more frequency in acute care settings, inpatient pediatric nurses need to know how they're used and how to support patients and their families in their diabetes self-care.
INSULIN PUMP THERAPY
Insulin pumps deliver rapid-acting insulin in small basal and bolus doses at short intervals throughout the day, a manner that isn't feasible using multiple insulin injections by syringe or insulin pen, both of which tend to be used to deliver somewhat larger doses of insulin less frequently. While good blood glucose control can be achieved using either method of insulin delivery and also depends on many other factors, such as diet, individual metabolism, exercise, and regular blood glucose testing, insulin pump therapy more closely resembles the insulin delivery patterns of the healthy pancreas than insulin injections do.
The pump itself is a small, beeper-sized device that's worn outside the body and connected to it by a soft tube through which the insulin flows to a thin plastic cannula inserted subcutaneously, usually in the abdomen, upper buttocks, or thigh. The pump uses only rapid-acting insulin, which has optimal absorption. Generally, patients that switch to insulin pump therapy from standard injection regimens tend to find that they require less insulin. The insulin pump can be adjusted to deliver basal doses to meet individual requirements such as metabolic patterns, exercise schedules, and fasting states. As with insulin doses delivered by syringe or insulin pen, insulin pump bolus doses are entered and delivered for meals and snacks or to correct for hyperglycemia. The insulin pump can improve glucose control in some patients; its other potential benefits include a reduced risk of hypoglycemia, as well as relatively easy adjustment of the basal dose before and during exercise. Its disadvantages include that it's attached to the body continuously; the effort and cost of maintenance; the possibility of diabetic ketoacidosis if insulin delivery is stopped because of malfunction, removal, or misuse; and a small risk of infusion site infection.
Insulin pump use in children. As insulin pump technology has improved, the safety and efficacy of its use with children and adolescents has also increased.2, 3 More families are now choosing insulin pump therapy because they feel that, despite the need for more frequent checking of blood glucose levels, this method provides greater flexibility than multiple daily injections in relation to sleeping and eating.4-6
The daily demands of managing type 1 diabetes can markedly alter the lives of individuals and their families, giving them the sense that most people don't understand the physical, psychological, and social burden of this disease.7 Having gained a hard-won awareness of the complexity of managing type 1 diabetes, many hospitalized patients and their families find it difficult to shift responsibility and control of insulin administration over to hospital staff.8 Parents of children who use insulin pumps may prefer not to change to an alternative insulin delivery system that has its own set of challenges.
Given the level of family involvement we've seen in patients' diabetes self-management, we've come to realize that it may not be enough to simply train pediatric inpatient nurses in the mechanics of using insulin pumps. Effective training works best when it includes an experiential component that better prepares nurses to support a collaborative diabetes care relationship and family-centered care model in the acute care setting.
What we're seeing at Children's Hospital Boston. The outpatient diabetes program at Children's Hospital Boston (CHB) estimates that approximately 35% of the pediatric diabetes population currently followed in clinic is on insulin pump therapy. This number is steadily increasing. As the safety of these devices has improved, more pediatric endocrinologists have supported transition to their use. Between October 2005 and September 2009, the inpatient volume of children at CHB on insulin pumps increased over 1000%, from nine unique patient admissions to 109 unique patient admissions. In addition, recovery room records from April 2008 through March 2009 show 73 patients with diabetes who required subcutaneous insulin; of these, 31 (42%) used insulin pumps as their home regimen—many of whom continued to wear their insulin pumps before, during, and immediately following surgery.
THE INSULIN PUMP PRACTICUM AT CHB
The inpatient diabetes program at CHB has developed from part-time coverage to a full-time, comprehensive, inpatient, interdisciplinary, consultative practice model. The program's development has included expanded inpatient diabetes nurse educator (DNE) coverage and the creation of innovative education and training for patients and staff, quality improvement and patient safety initiatives, and community education.
The inpatient diabetes program has adapted an experiential training program to meet the needs of inpatient nurses throughout the hospital. The experiential learning concept for insulin pump training is adapted from both saline pump start programs for patients new to pumps and classes provided for community clinicians and educators learning about pump therapy prescribed to their patients. The inpatient training program identified the following initial goals:
- to improve patient and family satisfaction using a collaborative family-centered care model to support continuity of home insulin pump therapy during hospitalization
- to meet the identified education needs of inpatient nursing staff while continuing to provide safe care for the hospitalized child on an insulin pump
To further promote patient safety, the inpatient diabetes program has developed a patient care policy on insulin pump therapy, a collaboration letter to inform patients and families of staff responsibilities related to management of insulin pumps during hospitalization, and electronic documentation and order sets for all insulin delivery.
Implementation. A pilot training program was initiated in September 2006, with a small group of nurses from three different inpatient units that typically have a higher volume of patients with diabetes. With the goal of maintaining all admitted patients on their home insulin pumps, we initially assigned patients who were admitted on insulin pumps to one of these three units. As the volume of patients using pumps increased, along with the complexity of these patients' medical and surgical needs, assigning patients to just these units was no longer feasible.
With the support of the staff development department, the inpatient diabetes program expanded the insulin pump training to make it accessible to all inpatient and specialty area nurses throughout the institution. The DNEs have developed the content and educational materials for the classes, which are offered quarterly with nursing contact hours. Since the training requires a considerable commitment, enrollment is encouraged but still voluntary. Nevertheless, since the program's expansion in 2007, the quarterly classes have been fully enrolled.
What participants learn. The didactic content of the practicum is provided in eight hours over two days and incorporates the following objectives:
- to provide the bedside nurse with the basic concepts behind insulin pump technology along with sufficient skills to safely manage insulin pumps in the inpatient setting
- to develop unit-specific nursing resources to provide continuity and support the care and management of patients with diabetes on insulin pumps throughout the hospital
- to enhance the nurse's knowledge and connection with the patient by simulating the patient experience
The training includes an overview of insulin therapy options, specifics of insulin pump therapy, nursing responsibilities for inpatient care, assessment and documentation, troubleshooting skills, hands-on demonstrations, pump self-insertion, and time for practicing other diabetes self-care skills. Insulin pumps filled with saline are inserted subcutaneously and participants wear the pumps, check their blood glucose levels, count carbohydrate intake, administer bolus doses of saline, and document their self-care on a daily log sheet.
Participants experience this approximation of "living with diabetes" for up to a week, incorporating diabetes management into both their work and home schedules. Often, as suggested by the three first-person accounts by training program participants that accompany this article (see Exemplars 1, 2, and 3; exemplars are written by every staff RN as part of their annual review process, and these accounts are used with the authors' permission), the experiential component of the training made the greatest impression on participants and provided them the deepest insight into what type 1 diabetes self-care really involves.
The insulin pump practicum has been offered hospital-wide since the fall of 2007; currently 97 participants, representing three disciplines across seven nursing programs, have completed the training. Ongoing program evaluation measures three key factors, including
- tracking insulin medication errors related to insulin pumps in order to evaluate whether the knowledge and skills provided are sufficient for safe management of these pumps in the inpatient setting. Although the number of patients using insulin pumps has steadily increased, the number of documented medication errors involving insulin pumps among inpatients at CHB has decreased: in 2008, there were nine; in 2009, six; and in 2010, only two.
- assessing patient and family satisfaction in the continuity and quality of care related to diabetes management in order to understand how patients and families feel about the improvement efforts. Although we'd planned to survey families, we have no formal data collection tool in place as yet, and have relied largely on verbal anecdotal results from patient and family feedback, most of which has been quite positive.
- assessing participating staff satisfaction and perception of enhanced knowledge and skills. Class evaluations have been consistent, with more than 90% of participants reporting an increased comfort level and ability to apply this experiential knowledge in the care and management of inpatients using insulin pump therapy.
Efforts to maintain staff knowledge about insulin pump use are ongoing and include
- an online NetLearning insulin pump module for quick and easy review.
- ongoing development of unit-specific resource staff to offer shift support. For example, the postanesthesia care unit limits the number of staff nurses trained in insulin pump management to less than 10. These nurses are scheduled to cover all shifts; because their numbers are limited, they see more volume and keep their skills current.
- sorting patients on insulin pumps to units on which more resources exist to support insulin pump management and more nurses have been trained in such management. For example, of the four general medicine units at CHB, only two will regularly admit patients on insulin pumps. The same is true of the general surgical units.
- expanded DNE coverage to provide daily consults for patients on insulin pumps and the staff responsible for their care.
Nurses often best acquire new skills and become comfortable with them through a variety of learning formats, including hands-on demonstration and direct experiential exercises. The training program we've described in this article gives nurses a deeper, more nuanced understanding of diabetes management and the role and use of technology such as the insulin pump. As evidenced by training program evaluations and by participant exemplars such as those accompanying this article, nurses have found that their increased knowledge and skills have helped them to better understand the challenges of families living with diabetes, more easily connect with families, and provide families with higher quality of care. Ultimately, such benefits make nurses themselves more satisfied with their work.