Neobook — clinical reference

Team Selection

The concept of specialised and designated facilities for CSII is becoming an international norm and helps to ensure the best possible outcomes for patients and funders. Insulin pump therapy requires an above average level of diabetes management, more intensive patient education and training, and close follow-up.

All of this needs to take place within a care framework that is suitably equipped to take the technological peculiarities of this form of treatment, its associated risks, the entailed change in lifestyle and its cost, into account. The establishment of a diabetes treatment facility conceived specifically to deal with patients who are treated by pumps is an ideal for which to strive.

This requires a full multidisciplinary team, that at the very least, must include:

A physician with a special interest in type 1 diabetes and insulin pump therapy
A diabetes nurse or educator with special training in CSII
A dietitian with special expertise in managing type 1 diabetes

TEAM SELECTION

Currently, there is no medical supervision or certifying process to regulate the use of this complex therapy. Any medical practitioner is free to prescribe CSII. The growth in the number of doctors wanting to prescribe CSII has been driven mainly by the manufacturers of CSII devices, and often patient support is provided only by employees of the manufacturer, a practice that should be discouraged. Both funders and patients receive no guidance with regard to provider expertise.

At present, ACE-SA is unable to issue a comprehensive guidance on the choice or accreditation of all medical practitioners who wish to provide CSII services. This stems from the fact that any practitioner may claim to have a special interest (without formal training) in type 1 diabetes and CSII, and it is not possible for ACE-SA to verify these individual claims.

However, endocrinologists (paediatric and non paediatric), by the very nature of their training, are deemed to have the requisite knowledge and experience to manage type 1 diabetes and MDI.

Therefore, ACE-SA recommends the following:

All registered endocrinologists who have completed an ACE-SA-approved training course in CSII, should be considered to be preferred providers for the initiation and maintenance of pump therapy
Training in the use of CSII should become available to endocrine registrars and fellows, either through access to a local CSII facility, or through the establishment of CSII facilities and expertise within training hospitals, so that graduating endocrinologists will automatically qualify to initiate pump therapy in the future
Practitioners who are considered to be diabetologists by their peers, and who are referred patients by their colleagues for CSII, should also be considered as preferred providers for CSII therapy, provided that they have completed an ACE-SA approved training course in CSII. For the purposes of this document, a diabetologist is defined as a medical practitioner whose workload involves managing diabetes mellitus > 80% of the time
ACE-SA recommends that for non-endocrinologists and non-diabetologists wishing to undertake CSII therapy, the funders of health care (public and private) will need to establish managed care programmes in conjunction with known experts in this field, in order to facilitate a wider preferred provider network for CSII, if this is deemed necessary
Educator and dietitian selection: Members of the Diabetes Education Society of South Africa (DESSA) and dietitians wanting to manage insulin pump therapy must first be experienced in managing type 1 diabetes. Then, they will also need to acquire the additional skills necessary for managing CSII patients. It is hoped that DESSA will establish a formal training course for this purpose. Dietitians must also possess additional expertise in educating patients on carbohydrate counting. Educators and dietitians are also required to attend at least one ACE-SA-approved CSII course
All members of the specialist team should engage in continuing medical education activity relating to CSII annually
The initiation and maintenance of insulin pump therapy by industry representatives is no longer an acceptable practice. However, industry representatives may only participate in device training and troubleshooting prior to, or during, the initiation process. They are not permitted to participate in insulin dose setting or adjusting

The responsibilities of the healthcare team will include:

The provision of an environment and facility that is fully capable of training and educating the patient (and family) in pump usage
The provision of a 24-hour emergency number or “hotline” staffed by someone who understands pump therapy, and who can provide medical and technical counselling 24 hours a day throughout the year
Having access to and knowledge of continuous glucose monitoring systems
Getting informed consent from patients to enter their demographic, clinical, laboratory and self-blood glucose monitoring data into a national CSII register