@wadawabbit ,
Dorie the term alarm laddering is not new with me. I saw it a few years ago when Tandem’s CIQ first released. I watched and searched for articles about alarm laddering and there were none. I wrote this piece about the technique that enhances situational awareness. This piece also contains my two pieces TRUST and PATIENCE also,
Alarm laddering is using technology and understanding technology. Here is my collection of bits & pieces.
BLUF**: Learn as much as you can about any pump system & CGM so you can use the tool to the maximum. *** Learn the integrated display software for your pump system. There are various web based and phone based display options. Some are Glooko (formerly known as Diasend in some countries. Glooko & Diasend have merged) or Tandem’s tConnect.
There are two lessons with any pump system, they are TRUST and PATIENCE.
[1] Start with ‘patience’, knowing several pieces of information or facts.
[1a] insulin does not act instantly if given by pen or syringe. The same is true for a pump. Insulin takes time to work.
[1b] any pump system takes time to adjust insulin according to the ‘software’ in the pump. Pick a set of ‘Emergency Action Points’ or EAPs. These are points where safety intersects waiting. My points vary depending on my perception of near future events related to activity and range from 130 to 200mg/dL for HIGH and 59mg/dL LOW. For example, if you are going low, watch what your pump system and CGM are doing in the t:Connect app. You may not need to act as your pump system will throttle back basal insulin allowing the body to bring BG up on its own without intervention. Be careful. Because of the way your pump system cuts back basal, any carbs may cause BG reported by the CGM in the next hour to rocket upwards like a skyrocket.
[1c] work with your local Dexcom rep and pump team to learn the display and interpretation of CGM data. Case in point, what does a real COMPRESSION LOW look like? How will the CGM respond? What are the signs the CGM has recovered? What action do you need to take during the recovery? Patience is part of the ‘knowing what to do’ and sharpened with ‘knowing when you should act.’
[1d] master the differences between the various physiological parameters in the game.
What is the difference between a finger stick, medical lab glucose, and the CGM? What is the difference between the Dexcom GMI, a Sugarmate projection & a real lab A1C? What do you need to remember when juggling all of this information? Here patience is ‘knowing what the numbers mean’ and make the ‘best practices’ decision because you are ‘knowing how to use the numbers to your advantage.’
[2] The second lesson is TRUST. Just like all of the thoughts above. You will need to learn to trust your pump and your gut so everything works to keep you in a good position.
[2a] Because I had been taught by my pump team (endo, office nurse CDE pump trainer, Tandem nurse CDE pump trainer, and Dexcom nurse CDE) when a COMPRESSION LOW woke me up, I looked to t:Connect. I saw the red line and knew CIQ had turned off the basal insulin. I could go back to sleep.
[2b] Trust the pump programming is correct as reflected in the combined CGM & your pump system information. Software displays integrated data from both the insulin delivery system (the pump) and the CGM. The pump system software integrates the data and adjusts the insulin delivery. Observing this interaction and consistent interaction is a place of trust.
[2c] When the CGM dots disappear, the CGM is checking the sensor and interstitial fluid glucose and may not restart until it is sure of itself. It is wise to be patient with the system. Patience is derived from trust.
The term alarm is used throughout this article for notifications, alerts, and alarms. The concept of CGM (Continuous Glucose Monitor) alarm laddering can be used to keep the person with an insulin pump (PUMPER) informed of deviations or excursions from the desired range of interstitial glucose values measured by a CGM. Situational awareness of glucose levels and the ability to respond timely helps glucose management.
The origin of alarm laddering in the world of diabetes technology has no real origin. There are no articles present when literature (professional journals, etc.) reviews and searches are conducted. The closest similar use of a parallel concept is in the investment world with the laddering of bonds in an investment portfolio. In the investment world, the rungs of the ladder are tied to different bond maturation dates.
Laddering is done by using two or more pieces of software on a smartphone, in addition to and or including a software enabled pump’s own alarm structure. For example, the Tandem X2 with CIQ software alarms at LOW of 80 mg/dL and HIGH of 180 mg/dL. Many pumpers want tighter control.
Next, there are the alarms of the Dexcom G6 CGM which are set at 70 & 200mg/dL. You can change the alarm settings to values you have chosen to achieve you goal of glucose control or awareness.
Third, it is possible to add a third reporting app like SugarMate to the technology suite or software on your phone.
PUTTING IT ALL TOGETHER: Using the customizing features of the various apps, you can set the alarms and their tones to suit your glucose level management style. In countries where Tandem’s t:Connect software is available you can watch what is happening & how CIQ is helping by observing the t:Connect app. In countries where t:Connect is not available, consider the Glooko aka Diasend suite, a web-based platform. Regardless of the platform, the key point is to learn how the CIQ technology receives, calculates, and responds to deviations reported by the Dexcom CGM. Using the available software, it is possible to have a series of notifications tied to the pumper’s glucose level. The comparison to a ladder follows.
After observing the interaction between the CGM and CIQ software, the first lesson is “Don’t fight CIQ”. It is best to leave the CIQ alarms alone and note them in your ladder and consider these suggestions (these are only suggestions and should be individualized to suit you, your clinical picture, and the rules or laws in the jurisdiction where you live):
150mg/dL – 8.3mmol - CIQ High (determine action required)
135mg/dL – 7.45mmol - CGM High (rise confirmed)
120mg/dL – 6.7 mmol - SugarMate High (starting to rise)
80mg/dL – 4.4mmol - CGM Low (be aware of fall)
70mg/dL – 3.9mmol - CIQ Low (stop activity, prep to treat)
60mg/dL – 3.3mmol - SugarMate Low (treatment point watch action in t:Connect)
55mg/dL – 3.0mmol - FDA (USA) mandated PANIC Low
By having these settings, you can take appropriate action and be well informed of your CGM reporting so you can take action to fit your plan:
[1] let CIQ deal with the drift into undesired areas, or
[2] take carefully calculated and proportional action to supplement the CIQ’s own actions dependent on the specific pump settings.
[3] Pick a set of ‘Emergency Action Points’ or EAPs. These are points where safety intersects waiting. My points vary depending on my perception of near future events related to activity and range from 130 to 180mg/dL for HIGH and 59mg/dL LOW. For example, if you are going low, watch what CIQ and CGM are doing in the t:Connect app. You may not need to act as CIQ will throttle back basal insulin allowing the body to bring BG up on its own without intervention. Be careful. Because of the way CIQ cuts back basal, any carbs may cause BG reported by the CGM in the next hour to rocket upwards.
Hope this makes sense and supports your journey thru the battle with glucose.
References:
Bond Laddering Definition Bond Laddering Definition
Continuous Glucose Monitoring Continuous Glucose Monitoring - NIDDK
Thoughts?