• Cross site guidance

• Improving glucose management, time in target range (TIR) whilst using a hybrid closed loop Insulin Pump (HCL)

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Abbreviations

Hybrid Closed Loop (HCL), Insulin pump therapy can be very effective when used correctly and safely. However, due to the lack of long-acting insulin cover, the risk of DKA is increased. This is why it is so important to use the pump with an appropriate continuous glucose monitoring system (CGMS), blood glucose testing and carbohydrate counting. This plan aims to identify areas that require attention to enable us to support the children and young people (CYP) within our care to continuously improve and optimise their overall blood glucose management and time in target range (TIR).

• How often are set/pod changes being carried out, how and when?

• Are insulin boluses being given before (preferably 15-20 minutes) every meal and snack alongside when glucose is elevated above 10mmol/L?

• Are glucose levels being checked before every meal, snack and bed?

• Are blood glucose levels being checked following a hypoglycaemia episode if glucose is still presenting as low (<4mmol/L) on the CGMS?

• Is activity mode being used for exercise (preferably started 60-90 minutes before the activity and for the duration of the activity)?

• Does the target glucose level, insulin to carbohydrate ratios (ICR) and/or Insulin Correction Factor (ICF) require any changes?

• If using a tandem insulin pump, do the basal rates require changes?

• Do we need to adjust their manual basal rates on the pump?

• What is their TIR?

• Are they always in automated mode?

• Is the CYP and/or parent overriding the pump?

• Do we need to adjust their weight on their pump?

• How is the CYPs Mental wellbeing?

• What support is in place at school?

• Does the CYP and/or parent have signs of lipohypertrophy?

• Is the CYP and/or parent managing Hypoglycaemia episodes correctly and effectively

• Does the CYP and/or parent require support around healthy eating, glycaemic index and/or administering insulin for complex meals?

• Is the CYP and/or the parent carbohydrate counting correctly?

• Is the CYP and/or parent administering insulin corrections when the glucose level is high? Is this continued 2 hourly until it falls within target range (4-7mmol/L)?

• Does the CYP and parent know how to manage a cannula and/or pump fail? Are they familiar with the ‘ABCC rule’?

• Does the CYP and parent know how to manage illness using the ‘sick day rules’?

• Does the CYP and parent know who to call if they are experiencing technical issues with either the CGMS or the HCL pump?

• Do they know how to review their data?

• Is their diabetes tech linked to our accounts?

• Has the CYP been admitted to the ward in DKA? Was a safety plan made? Have they followed this?

1. Download pump every week

2. Review data weekly before contacting the team to discuss changes

3. Follow diabetes safety plan

4. Complete a detailed diabetes diary and attend an appointment with the Dietitian

5. Attend appointments on PAU/clinic for reviews

6. Contact the team if any problems or require further support

7. Aim for TIR of 75%.

8. Attend an appointment with our Clinical Psychologist

9. Contact the diabetes team for advice if glucose level rise alongside ketones, to reduce the risk of diabetic ketoacidosis.

If the CYP experiences a Diabetic Ketoacidosis (DKA) admission whilst using an HCL insulin pump, we will re-educate the CYP and parents during the admission and create a robust safety plan for them to follow following discharge. If this is not adhered to and the CYP requires further admissions for DKA, we will consider removing the pump for the safety and wellbeing of the CYP. This would be discussed and agreed upon as a team. We would aim to change back to insulin pens and review in clinic after 1 month. If the CYP would like to return to insulin pump therapy, we would need to see an improvement in diabetes management for at least 2 months before this would be considered.

An admission for stabilisation will be considered if it has been 1 month since the pump was removed and diabetes management has not improved. This will be a planned admission for 3-5 weekdays and a parent/carer is expected to be available to stay with their CYP throughout the day. During the admission period, all diabetes management will be supervised by nursing staff alongside the completion of a food diary. The CYP will be encouraged to create SMART goals, which will be incorporated into their updated safety plan prior to discharge.