Quality Standards for Diabetes Care Toolkit

Implementation advice

Type 1 diabetes management and multidisciplinary team approaches

A NICE care pathway for people with type 1 diabetes can be found at: http://pathways.nice.org.uk/pathways/diabetes.

Insulin pumps and continuous glucose monitoring systems

According to the Ministry of Health Service Specification (2003):

‘The regional service must use a documented assessment process, and attempt first to maximise MDI. This may require continuous glucose monitoring (using interstitial glucose sensors). The regional service should support secondary hospital diabetes services where it is practicable to undertake this assessment remotely.

The service should include a detailed programme for pre-insulin pump assessment, implementation, support, and on-going review of patients on insulin pumps. The service should provide for a trial period of insulin pump therapy to suitable patients.

Personnel requirements include:

a specialist diabetes physician/paediatrician with experience in the selection and supervision of patients on insulin pumps

a diabetes nurse specialist trained in continuous glucose monitoring and insulin pump therapy

a specialist dietician with experience in providing appropriate dietary education for patients planning to use insulin pumps’ (p 2).
Reporting requires that for each referral the service must maintain a register that includes:

the NHI and patient demographics including ethnicity,

the indications for referral (using the referral criteria in this service specification),

the report and outcome from an assessment using continuous glucose monitoring (if applicable)

the final treatment (including optimised MDI, insulin pump, other specific treatment modalities, or assessment and treatment not completed) (p 3).
The Australian Clinical Guidelines for Management of Type 1 (2011) suggests that individuals who may be likely to benefit from CSII pump therapy, as part of intensive diabetes management, are:

some children and adolescents, including infants and young children, and pregnant women (ideally preconception)

individuals with microvascular complications of diabetes

individuals with reduced hypoglycaemia awareness

individuals (or their supervising adults) with desirable motivational factors; for example, those seeking to improve blood glucose control and having realistic expectations

individuals exhibiting desirable CSII treatment-related behavioural factors, including those who:

are able to perform carbohydrate counting

are currently undertaking four or more blood glucose tests per day

have reliable adult supervision (in paediatrics), and a history of good self-management skills (in adults)

are able to master the technical skills of CSII

are reliable in follow-up health care.
The UK’s NICE guidelines state that continuous subcutaneous insulin infusion or insulin pump therapy is recommended as a possible treatment for adults and children 12 years and over with type 1 diabetes mellitus if:

attempts to reach target HbA1c levels with multiple daily injections result in the person having ‘disabling hypoglycaemia’, or

HbA1c levels have remained high (69 mmol/mol or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes.
Insulin pump therapy is recommended as a possible treatment for children under 12 years with type 1 diabetes mellitus if treatment with multiple daily injections is not practical or is not considered appropriate. Children who use insulin pump therapy should have a trial of MDI when they are between the ages of 12 and 18 years.
Insulin pump therapy should only be started by a trained specialist team. This team should include a doctor who specialises in insulin pump therapy, a diabetes nurse and a dietitian (someone who can give specialist advice on diet). This team should provide structured education programmes and advice on diet, lifestyle and exercise that is suitable for people using insulin pumps.
Insulin pump therapy should only be continued in adults and children 12 years and over if there has been a sustained improvement in the control of their blood glucose levels. This should be shown by a decrease in the person’s HbA1c levels or by the person having fewer hypoglycaemic episodes. Such goals should be set by the doctor through discussion with the person or their carer.