Noticeboard: Vol 13 No 10

Insulin pumps on holiday
Q One of the people attending our diabetes centre is 28 years old and has had type 1 diabetes for 14 years. She commenced insulin pump therapy 6 months ago and feels that she is managing well with only the occasional mild episode of hypoglycaemia, which she easily manages herself. Her most recent HbA_1c level was 7.2% (55 mmol/mol).

The lady in question is getting married soon, and is planning to spend her 2-week honeymoon in Mexico. She is planning on going to the beach, and anticipates spending up to 6 hours there each day. She has been thinking about what to do with her insulin pump, and is uncertain whether she actually wants to wear on these days. She has asked what she should do with it. Any advice would be greatly appreciated.

Jacky Ryder, DSN, Bournemouth

A Your patient is clearly doing well on her insulin pump and planning ahead is to be commended. You state she is not sure if she wants to wear her insulin pump on her beach days.

Coming off insulin pump therapy and returning to a basal–bolus regimen is unsettling for blood glucose levels, as it takes three injections of basal analogue insulin to reach the “steady state”. It is possible that a human intermediate insulin taken twice-daily as part of a basal–bolus regimen could be more helpful. To keep blood glucose levels under control, an increase in testing and corrective injections of rapid-acting insulin is usually required. This can increase anxiety and bring the unpredictable nature of diabetes to the centre of attention, which may be unwelcome.

If she decides to continue with insulin pump therapy, disconnecting and re-connecting the device every 1–2 hours will be a new experience, and will require careful decision-making.

There is also the consideration of keeping the insulin cool. A pump Frio bag is useful (but bulky). I would recommend changing the insulin in the pump more frequently than usual (perhaps every 2 days) before it deteriorates in the hot weather and becomes less effective. When not in use on the beach I would suggest a plastic container or cool bag to put the pump in (cover any ice packs to prevent the unit freezing) or put the Frio bag and pump in the container to protect from sand.

This question raises an important issue that I do not believe has been addressed by research or consensus. Perhaps a user consensus on managing insulin pump therapy on holiday would be most useful. There does not appear to be an easy answer, and there remains, even with insulin pump therapy, no holiday from type 1 diabetes.

Mary Hayes, DSN, Tower Hamlets

Ability to administer insulin
Q As a DSN working within an acute Trust, insulin administration when individuals with type 1 diabetes or with other types of diabetes requiring insulin treatment lack the cognitive or physical ability to self-administer their insulin, and who do not have a relative to administer the insulin for them, is an issue which we are coming up against frequently. Community nurses are reluctant to take on this role other than in the short-term. We are currently in discussions with district nursing leads to develop a training package for carers to give them the skills to administer insulin. We are also developing training for residential care home staff on diabetes, but this does not currently cover insulin administration.

Do any DSNs have a policy that allows carers to administer insulin, and what training was developed to enable the relevant skills to be taught and assessed? The issue of ongoing support for these staff and delivering training to district nurses on diabetes is also an area we are interested in. It would be helpful for us to know how other regions manage this.

Maggie McDonald, Diabetes Clinical Nurse Specialist

Injecting glucagon
Q We are currently looking into a training programme for teaching staff in schools regarding glucagon injections. This is in light of recent International Society for Pediatric and Adolescent Diabetes guidelines and increasing requests from parents. Does anyone have experience of introducing this training into schools and have any information that they are willing to share?

Helen Edwards, Paediatric DSN, Wiltshire

A As a rule, in my practice I do not teach school staff how to administer glucagon, as our policy is for staff to call 999. However, I have recently trained staff in one school for a teenager with specific issues around severe hypoglycaemia. We use a competency document that outlines the basic understanding the carer or support worker must have, and a record must be kept of these basic skills. The person must then renew their competency annually.

If you would like a copy of the competency document that we use, Competency: Administering Glucagen Hypokit Injection to Children and Young People, then please contact the journal at the usual address.

Jackie Angelo-Gizzi, Paediatric DSN, Welwyn Garden City