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INDCSII-HCP-0313-005EN @2013 Medtronic, MiniMed Inc. All rights reserved.

Paradigm, Bolus Wizard, iPro and CareLink are registered trademarks of Medtronic MiniMed, Inc.

India Medtronic Pvt. Ltd. 1241 Solitaire Corporate Park, Bldg. 12, 4th Floor, Andheri-Ghatkopar Link Road, Andheri (E), Mumbai 400 093 Tel: +91 22 3307 4700/01/02/03 Fax: +91 22 3307 4704 e-mail: [email protected]

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Pumping Protocol A Simplified Guide to Insulin Pump Therapy Initiation and Medical Management

Medical Education Academia

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Table of Contents Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Overview and Fundamentals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Indications and Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Calculate Starting Doses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Simple Dosing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Carbohydrate Counting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Adjusting Pump Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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Purpose The Pumping protocol is for clinicians beginning to prescribe pump therapy and clinicians current prescribing, but would benefit from a systemic, streamlined methodology for initiating and managing patients with pump therapy. Fundamental concepts, candidate selection, and protocols for initiating and managing pump therapy are included.

Overview and Fundamentals Insulin Pump Therapy is the most physiological method of insulin delivery currently available1 and closely mimics a healthy functioning pancreas: 1. Administers only rapid-acting insulin for both basal and bolus insulin requirements.

Eliminating longer acting insulin helps improve glycemic control during fasting states because:



• T he action/peak time of rapid-acting insulin is more predictable and reproducible than longacting insulin2.



• T he tiny basal doses that are continuously delivered over each hour are more consistently absorbed by the body.

2. Pumps deliver insulin in two ways, basal and bolus.

• Basal Insulin is a continuous infusion of insulin that is delivered automatically 24 hours a day. The purpose of basal insulin is to cover hepatic glucose production and to maintain glucose stability during fasting states (between meals and during sleep). Basal rates are programmed to deliver a customized rate per hour, throughout the hour.



• Bolus Insulin is delivered “on-demand,” by the patient, for food intake and/or to correct glucose levels that are above the patient’s target range.

Components of Insulin Pump Therapy

Insulin Pump Time Reservoir status

Consumables

Up, Easy Bolus

Bolus Wizard

Back, Pump status Screen

Reservoir

Battery Status

Cannula Housing

Cannula

Down, Backlight

Serter Device

Adhesive Enter, Main Menu

Tubing

Insulin Pump: Small, computerized, battery operated device that contains the insulin delivery settings and controls insulin delivery. Physicians or patients can make changes to pump settings. Patients push buttons to deliver boluses. Cannula: Small tube that enters the individuals’ body where insulin is administered. Tubing: Attaches the pump to the infusion set. Insulin travels through to the cannula. Infusion set: Tubing, Cannula housing, cannula, and adhesive. Reservoir: Stores rapid acting insulin for 2-3 days. Reservoir holds 300 units of insulin. Serter Device: Facilitates the infusion set insertion.

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Purpose, Overview & Fundamentals

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Infusion Set Fundamentals • T he cannula is placed in the subcutaneous tissue.

• Infusion sets are changed every 2-3 days.

• Infusion sets are inserted with a needle, facilitated by the serter device. The needle is removed and the cannula remains under the skin, where insulin is delivered.

• T hey can be place on the arms, abdomen, buttocks, and thighs. • Patients no longer take injections. • Medtronic offers different infusion sets depending on clinical indication, body type, and activity.

Skin

Subcutaneous Tissue Cannula Insulin

Bolus Delivery Options No Carbohydrate Counting Deliver the Bolus using: 1. Manual Bolus: Enter bolus amount 2. Easy Bolus: Based on programmed bolus increments, press UP arrow required times Boluses can be calculated: 1. Set dose 2. Based on size of meal

Carbohydrate Counting Using the Bolus Wizard 1. Enter blood glucose value 2. Enter carbohydrate amount Pump will calculate accurate bolus based on settings: • Insulin to Carbohydrate Ratio • Sensitivity Factor (Correction Factor) • Target Glucose • Active Insulin (insulin on board from last bolus)

Easy Bolus

Bolus Wizard

Normal bolus through main menu

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Indications and Benefits Indications3-5 Type 1 and insulin-requiring type 2 patients who are unable to achieve acceptable glycemic control, including those with:

• Elevated A1C



• Glycemic variability



• Insulin resistance/glucose toxicity



• Post prandial hyperglycemic



• Large total daily dose



• Recurrent hypoglycemia, nocturnal hypoglycemia, activity-induced hypoglycemia and hypoglycemia unawareness



• Pregnancy/Pre-pregnancy



• Recurrent diabetic ketoacidosis (DKA)/recurrent hospitalizations



• Dawn phenomenon



• Gastroparesis



• Patient preference, meal-timing flexibility and normalization of lifestyle



• Low insulin requirements (not easily measured via syringe)



• Inability to self-administer insulin (pre-school/grade school)



• Inability to predict food or meal intake (infant/toddler)

Benefits3,4,6,7

• Improved glycemic control and decreased glycemic variability



• Improved control of dawn phenomenon



• Decreased severity and frequency of hypoglycemia



• Increased flexibility, normalization of lifestyle and sense of well-being

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Indications and Benefits

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Calculate Starting Doses Overview Pump Total Daily Dose (Pump TDD) Total Daily Dose The total amount of insulin (basal and bolus) delivered by the pump each day.

Reduce the current total daily injection dose by 25 percent, calculate the weight dose and then average the two together. R ed u ced D os e

Basal Insulin A continuous infusion of insulin given to cover hepatic glucose production. • Intended to mimic pancreatic basal secretion and maintain glucose stability in fasting states (between meals and during sleep). • R eplaces longacting insulin. • Programmed to match patient’s individual diurnal variation.

Based on daily injection dose

W ei g h t D os e Based on weight

Injection Dose x 0.75 = Reduced Dose

kg x 0.5 u = Weight Dose

I n it ial Pu mp T D D Take average of Reduced and Weight Dose (Reduced Dose + Weight Dose) ÷ 2 = Pump TDD E x a mple Pat ie n t

Type 1 Male Weight: 70 kg Current Daily Insulin Regimen

Rapid-acting: 11 units pre-meal x 3 33 u/day Long-acting: 20 units (Bedtime) + 20 u/day



Total Daily Injection Dose

Reduced Dose

Weight Dose

53 u/day x 0.75 = 40 u/day

70 kg x 0.5 u = 35 u/day

Bolus Insulin Given on demand by patient, as needed, for carbohydrate intake and correcting abnormal glucose levels.

Total Daily Basal Total amount of basal insulin delivered over 24 hours.

= 53 u/day

Initial Pump TDD (40 u/day + 35 u/day) ÷ 2 = 37.5 u/day

(Reduced Dose) (Weight Dose)

(Pump TDD)

Clinical Considerations Clinical Considerations for Pump TDD • Use less than a 25% reduction if daily injection dose is more than 70% rapid-acting insulin. • Pediatric patients who have good control on injections may require as little as a 5% reduction.

Total Daily Bolus: Total amount of bolus insulin (food and correction) delivered over 24 hours.

• For children & teens, TDD is variable. May require as much as 1.0 u/kg to calculate weight dose. •H  ypoglycemia or hypoglycemia unawareness, instead of calculating the average, use the lower of

the two values. •P  ersistent hyperglycemia, elevated A1C or pregnancy, instead of calculating the average, use the

lower of the two values. • Erratic glucose control, starting therapy at diagnosis or from oral medications, use weight method.

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Total Daily Basal and Total Daily Bolus First, determine the percent of TDD to be delivered as basal insulin and then multiply TDD by that percent. This will give you the Total Daily Basal amount. To calculate Total Daily Bolus subtract the Total Daily Basal amount from the TDD. BASAL

BO LUS

Pump TDD x % Basal = Total Daily Basal

Pump TDD - Total Daily Basal = Total Daily Bolus

E x a mple Pat ie n t

50% of TDD as Total Daily Basal Total Daily Basal

Total Daily Bolus

37.5 u/day x 0.5 = 18.75 u/day

     (Pump TDD)      (Total Daily Basal)

 

37.5 u/day – 18.75 u/day = 18.75 u/day

(Pump TDD)   (Daily Basal Amount)   (Total Daily Bolus)

Clinical Guidelines for Total Daily Basal and Bolus Percentages Total Daily Basal

Total Daily Bolus

Adults:

40% to 50%

50% to 60%

Puberty to Adult:

30% to 40%

60% to 70%

Pre-Puberty to Puberty:

20% to 40%

60% to 80%

Basal Rate Pump therapy is typically initiated with a single basal rate that is delivered evenly over each hour, 24 hours a day. To calculate the initial basal rate, divide 24 hours into the Total Daily Basal amount. I N IT IAL BASAL R AT E Total Daily Basal ÷ 24 hours = Hourly Basal Rate E x a mple Pat ie n t

Total Daily Basal: 18.75 u/day Initial Basal Rate     

18.75 u/day ÷ 24 hours = 0.78 u/hour (Total Daily Basal)        

(Hourly Basal Rate)

Start initial basal rate at 0.775 or 0.800 units per hour

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Basal Rate The amount of basal insulin programmed to deliver evenly over each hour.

Basal Rates 1 unit/hour Program in 0.050 unit increments.

Calculate Starting Doses

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Simple Dosing Patients that do not carbohydrate count

REDUCED Dose Method

Weight Method OR

Sum up ALL current daily insulin injection doses

Take current weight in kg

Multiply by 0.75

Multiply by 0.5 units/kg/day

Pump Total Daily Dose (TDD)

50%

50%

Total Daily Basal Dose

Total Daily Bolus Dose

Divide by 24

Divide by 3

Hourly Basal Rate (units/hr)

Bolus/Meal (units/meal)

Meal Bolus may be adjusted for portion size (Large, Medium, Small).

NOTE Consider using the weight method if bolus to basal ratio of the patient’s pre-pump total daily injection dose is significantly different from 50:50 (e.g., bolus/total dose = 60%)

E XA M P L E Type 2 Patient:

85 kg

A1C = 9.0%

Takes all insulin shots.

Eats similar-sized meals.

REDUCED Dose Method (units/day) 20 units x 3 (rapid acting) + 52 units (glargine) at bedtime = 112 units/day Multiply by 0.75

Pump Total Daily Dose (TDD) = 84 units/day

50%

50%

Total Daily Basal = 84 units/day x 0.5 = 42 units/day

Total Daily Bolus = 84 units/day x 0.5 = 42 units/day

Hourly Basal Rate =  42 units/day ÷ 24 hrs = 1.75 units/hr

Bolus per Meal = 42 units/day ÷ 3 = 14 units/meal

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Carbohydrate Counting Patients that carbohydrate count. Reduced Dose

Weight Dose

Based on Daily Injection Dose

Based on Weight

Injection Dose x 0.75 = Reduced Dose

kg x 0.50 = Wt. Dose

Pump Total Daily Dose (TDD) Average of Reduced Dose and Weight Dose* (Reduced Dose + Weight Dose) ÷ 2 = Pump TDD

Insulin Sensitivity Factor Insulin sensitivity factor, also known as correction factor, which means how much 1 unit of insulin will lower BG during the DIA (duration of insulin action) Insulin Carbohydrate Ratio Insulin to carb ratio (I:C is the same thing), which means how many grams of carbs are treated by 1 unit of insulin.

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Total Daily Basal Dose †

Total Daily Bolus Dose

Pump TDD x 40% to 50% = Daily Basal Dose

Pump TDD - Daily Basal Dose = Daily Bolus Dose

Basal Rate (BR)

Insulin Sensitivity Factor (ISF)

Insulin-to-Carb Ratio (ICR)

Daily Basal Dose ÷ 24 = Hourly BR

1700 ÷ Pump TDD = ISF

Daily Carbs ÷ Daily Bolus Dose = ICR OR

Insulin-to-Carb Ratio (ICR) 450 ÷ Pump TDD = ICR * Hypoglycemic unawareness or other concerns, use the lower dose. † The percentage split for total daily basal and total daily bolus varies, especially in pediatric populations.

Guidelines for Transitioning to Pump Therapy Goal: Eliminate as much intermediate/long-acting insulin as possible before starting pump. • Stop intermediate-acting insulin 12 hours before and long-acting insulin 24 hours before initiating pump therapy. •H  ave patient give injections using small amounts of rapid-acting insulin as needed (every 3 to 4 hours) to keep BGs acceptable until pump therapy is initiated. • In situations where intermediate or long-acting insulin is not discontinued, program a temporary basal rate to deliver a reduced basal amount (50% to 90% less than calculated starting rate) for the first 12 to 24 hours of therapy.

Calculate Starting Doses

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Adjusting Pump Settings General Adjustment Rules: • Fix lows first, then highs • Make only 1-2 adjustments per visit with a patient • Hyperglycemia Adjustments: Make adjustments after observing pattern for 3 to 7 days. • Hypoglycemia Adjustments: Consider adjusting if any lows occur. Avoiding lows during adjustment phases is key, because lows and the treatment of lows disrupts BG patterns. 1. Overnight Basal 2. Daytime Basal 3. Bolus Dose 1. If pre-meal fasting BG < 70, decrease overnight basal 10-20% (12am-8am). If fasting BG >130, increase overnight basal 10-20% (12am-8am). 2. If all pre-meal BG < 70, decrease basal 10-20% (8am-12am). If all pre-meal BG > 130, increase Basal 10-20% (8am-12am). 3. If next period pre-meal BG < 70, decrease prior meal bonus 10-20%. If next period pre-meal BG >130, increase prior meal bonus 10-20%. If post-meal BG < 70, decrease bolus 10-20% . If post-meal (1.5 hr - 2 hr) BG ≥ 180, increase bolus 10-20%.

Basal Adjustment Rules: Key Concept Basal insulin delivers in tiny amounts each hour and its affect on glucose takes place over a period of time. Therefore, changes made to basal rates should be programmed to begin 2 to 3 hours prior to the observed BG rise or fall. Goal: Prevent the glycemic excursion from occurring.

Overnight Basal Adjustment Guidelines Goal: BG remains in target (does not rise or fall >30 mg/dL) through the night. Evaluation Guidelines Assess overnight control by observing rise/fall patterns across time segments (bedtime to midsleep; mid-sleep to wakeup). Adjust basal insulin to match diurnal variations.

Daytime Basal Adjustment Guidelines Goal: BG remains within target (does not rise or fall >30 mg/dL) through the day. Adjustment Guidelines • If BG rises or falls >30 mg/dL: Adjust rate by 10–20%, 2 to 3 hours before observed rise or fall. • If BG drops below 70 mg/dL: Instruct patient to treat the low and decrease rate 10–20%.

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Bolus Adjustment Rules: Meal Bolus Adjustment Guidelines Goal: Two-hour post-meal BG is between 30 mg/dL to 60 mg/dL higher than pre-meal BG. • If 2-hour post-meal BG has increased less than 30 mg/dL from the pre-meal BG: Increase ICR or total bolus 10–20%. • If 2-hour post-meal BG has increased more than 60 mg/dL from the pre-meal BG: Decrease ICR or total bolus 10–20%. Correction Bolus Adjustment Guidelines Goal: Post-correction, 2-hour BG is about halfway to target and at target by 4 hours. • If 2-hour post-correction BG is not halfway to target and 4-hour post-correction is not at target: Adjust ISF or correction bolus 10–20%. Adjusting ICR and ISF Ratios When working with ICR and ISF ratios: • To decrease bolus amounts, increase the ratio. • To increase bolus amounts, decrease the ratio. Example: For 60 grams of carbohydrate if ICR is : 1:15 = 4 units; 1:12 = 5 units; 1:10 = 6 units.

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Adjusting Pump Settings

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Calculate starting doses: simple dosing A1C: Patient Name:

DOB/Age:

Current Insulin Regimen Premix (2 or 3/day)

Basal: Lantus / Levemir / NPH /Humulin N

_________ units

_________ units am _________ units HS

Total

Morning

Bolus: Humalog / Novorapid (Novolog) / Apidra

Bedtime

Pre-Pump Total Daily Dose (TDD)

Breakfast:

Lunch:

Dinner:

______ units

______ units

______ units Basal + Bolus = ______ units/day

Pump TDD (select ONE of the following) Weight Method

Reduced Dose Method 0.75 x Pre-pump injection dose

0.5 x Weight (in kg)

OR Pump TDD = _________ units/day x _____ = _________ units/day Prepump TDD

Basal Rate (hourly)

Pump TDD = _______ kg x _____ units/kg/day = ________ units/day Patient weight

Bolus Dose (per meal)

Total Daily Basal = _________ x 50% = _________ units/day

Total Daily Bolus = _________ x 50% = _________ units/day

Hourly Basal Rate = _________ units ÷ 24 hrs = _________ units/hour

Bolus Dose/Meal = _________ units ÷ 3 = _________ units/meal

Pump TDD

% Basal

Total Daily Basal

Pump TDD

% Bolus

Total Daily Bolus

If portion size varies, modify doses to fit patient’s diets and habits Breakfast: Lunch: Dinner: Snack: ______ units

______ units

______ units

______ units

Comments:

Instructions for Adjustments • If nocturnal, fasting/pre-meal or bedtime BG > target, increase basal 10–20% • If nocturnal, fasting/pre-meal or bedtime BG < target, decrease basal 10–20% • If post-meal BG > 60 mg/dL above pre-meal BG, decrease carb ratio by 10–20% • If post-meal BG < 30 mg/dL above pre-meal BG, increase carb ratio by 10–20% Elevated BG: Verify trends 2–3 days before adjusting Low BG: Consider immediate adjustment

Adjustments should be made when BGs are outside of these ranges Fasting/pre-meal: __________ to __________ mg/dL Post-meal:

__________ to __________ mg/dL

Bedtime:

__________ to __________ mg/dL

Nocturnal:

__________ to __________ mg/dL

These instructions shall be valid for 6 months unless otherwise specified here: ______________months. Prescriber Name:

Signature:

Date:

Call Doctor for severe low BG or ketones. Call Medtronic for technical issues at +91 22 3307 4700/01/02/03.

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Calculate starting doses: carbohydrate counting A1C: Patient Name:

DOB/Age:

Current Insulin Regimen Premix (2 or 3/day)

Basal: Lantus / Levemir / NPH /Humulin N

_________ units

_________ units am _________ units HS

Total

Morning

Bedtime

Bolus: Humalog / Novorapid (Novolog) / Apidra

Pre-Pump Total Daily Dose (TDD)

Breakfast:

Lunch:

Dinner:

______ units

______ units

______ units Basal + Bolus = ______ units/day

Calculations for Insulin Pump Initiation Settings Formula Pre-pump Injection Dose x 0.75 = Reduced Dose

__________ units/day x 0.75 = __________ units/day

Weight Dose

Weight (in kg) x 0.5 = Weight Dose

__________ x 0.5 units = __________ units/day

Pump TDD

(Reduced Dose + Weight Dose) ÷ 2 = Pump TDD

( ______ units/day + _______ units/day) ÷ 2 = ______ units/day

Basal Rate

Total Daily Basal Units

Pump TDD x % Basal (40–50%) = Total Daily Basal

__________ units/day x _________ = __________ units/day

Initial Basal Rate

Total Daily Basal ÷ 24 hours = Hourly Basal Rate

__________ units ÷ 24 hours = __________ units/hour

Bolus

Total Daily Bolus Units

Pump TDD - Total Daily Basal = Total Daily Bolus

________ units/day - ________ units/day = ________ units/day

Insulin-to-Carb Ratio

Daily Carb Grams ÷ Total Daily Bolus = Carb Ratio

________ grams ÷ _______ units/day = _________ grams/unit

ISF

Pump TDD

Reduced Dose

ICR

Calculation

Insulin Sensitivity Factor

Reduced Dose

Injection Dose

Weight Dose

Weight (in kg)

Reduced Dose

Pump TDD

Weight Dose

Pump TDD

% Basal

Initial Basal Rate

Total Daily Basal

Total Daily Basal

Pump TDD

OR

Daily Carbs

Total Daily Basal

Total Daily Bolus

Total Daily Bolus

Insulin-to-Carb Ratio

450 ÷ Pump TDD = Carb Ratio

OR 450 ÷ _______ units/day = _________ grams/unit

1700 ÷ Pump TDD = Insulin Sensitivity Factor

1700 ÷ __________ units = __________ mg/dL/1 unit

Pump TDD

Pump TDD

Insulin-to-Carb Ratio

Insulin Sensitivity Factor

Pump Settings Carb Ratio

Basal Rates 1) 2) 3) 4) 5)

Time 12 a.m. _______ _______ _______ _______ _______

@ @ @ @ @

Rate _______ _______ _______ _______ _______

(B)

Sensitivity Factor ISF = _________ mg/dL/1 unit

(L)

Pump Settings Active Insulin Time

(D)

___________ hours

Max Basal Rate: ______ units Max Bolus: ______ units

Adults: Children: Pregnancy:

4-5 hours 3-4 hours 3-4 hours

Bolus Wizard® Calculator Target Ranges Day

Night

_______—_______

_______—_______

Day Night Adults and Adolescents (13+ yrs): 90–100 mg/dL 100–110 mg/dL School Age (6–12 yrs): 90–110 mg/dL 100–120 mg/dL Toddler to Pre-school (0–6 yrs): 100–120 mg/dL 110–130 mg/dL Hypoglycemia Unawareness: 100–120 mg/dL 110–130 mg/dL Pregnancy: 80–90 mg/dL 90–90 mg/dL

Comments:

Instructions for Adjustments • If nocturnal, fasting/pre-meal or bedtime BG > target, increase basal 10–20% • If nocturnal, fasting/pre-meal or bedtime BG < target, decrease basal 10–20% • If post-meal BG > 60 mg/dL above pre-meal BG, decrease carb ratio by 10–20% • If post-meal BG < 30 mg/dL above pre-meal BG, increase carb ratio by 10–20% Elevated BG: Verify trends 2–3 days before adjusting Low BG: Consider immediate adjustment

Adjustments should be made when BGs are outside of these ranges Fasting/pre-meal: __________ to __________ mg/dL Post-meal: __________ to __________ mg/dL Bedtime: __________ to __________ mg/dL Nocturnal: __________ to __________ mg/dL

These instructions shall be valid for 6 months unless otherwise specified here: ______________months. Prescriber Name: Signature:

Date:

Call Doctor for severe low BG or ketones. Call Medtronic for technical issues at +91 22 3307 4700/01/02/03.

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Forms

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Type 2 Insulin Pump Training Checklist Training Checklist: Simple Dosing Pump __________________________Pump Pump Serial Number: ___________________Date: Date:________________ ________________ Pump Model: Model: __________________________ Serial Number: _____________________ Patient Name: ___________________________ __________________________ Trainer Trainer Name: Name:_________________________ _________________________Phone: Phone: _______________ _______________ Note to trainer: On training day, program patient’s basal rate ________units/hour, change Max Basal and Max Bolus limits in pump. If RF linked meter is used, link the meter and the pump by changing meter option to ON and put in meter ID. Introduction to Insulin Pump Therapy

Reservoir and Infusion Sets

 Overview (basal, bolus)  Pump supplies and how to reorder

Infusion Set Type _______________________________

Self Management Skills

     

Hypoglycemia and hyperglycemia: How to manage How to troubleshoot unexpected hyperglycemia Back-up MDI plan BG test frequency and targets ranges Removal for CT scan, MRI Sick day guidelines

Overview

    

Battery type and insertion Button Functions

Infusion set change frequency Filling a reservoir/purge air bubbles Attach reservoir to infusion set Rewind/reservoir setup Insert reservoir into pump Insert an infusion set Disconnect the infusion set Tape options and site prep

Alarms and alerts

Main Menu Patient has selected Alert Type

Basic Features and Programming

 Date and time  Suspend /Resume delivery  Easy Bolus. Increments (Change to 1 unit increment) ____ times. Press

Site selection and rotation

Note: DO NOT Prime while being attached

Home Screen icons

Press

          

ACT

 Bolus amount/meal.

 Open and closed circles  No Delivery  Low reservoir  Troubleshooting

 When to call healthcare provider  When to call Medtronic

Breakfast:_____, Lunch:_____, Dinner_____, Snack_____

 How to change basal (if needed) Comments/Notes:

Patient Signature: _______________________________________________________ Date: ______________________ Trainer Signature: ______________________________________________________ Date: ______________________ Forms Simplified Pumping Protocol CC_Final_Print.indd 9

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Insulin Pump Follow Up Checklist (Routine Visit) Patient Name:___________________________ Phone:_______________________Date of Pump Start:_ ______________ At each routine visit

 Evaluate progress. Determine whether goals have been reached.  Perform A1C test. New A1C target ______________  Address any major BG issues (hyperglycemia, hypoglycemia) and alarms.  Assess BGs. Review BG log and CareLink reports for basal/bolus adjustment (below).  Consider iPro evaluation at 3 months if not at goal. Date scheduled: ____________________________________  Assess patient’s comfort and confidence with pump therapy.  Assess skin/infusion set site. Address any site issues.  Assess whether adjustment to medications is needed (especially if side effects are present): ________________

____________________________________________________________________________________________  Reinforce lifestyle habits (e.g., diet, exercise, weight management) and dietary principles (carb counting):_______________________________________________________________________________  Remind patients to monitor 2–3 BGs/day; if low BG, correct with fast-acting carbohydrate; if low or high BG trend is persistent, call healthcare provider.  Assess readiness or need to use other features: Bolus Wizard and temporary basal ____________________________________________________________________________________________  Refer to trainer/educator/MDT for additional education_ _____________________________________________  ____________________________________________________________________________________________ Progress Notes

Current A1C: ________________

 BG Targets: ADA (70–130 mg/dL)