Current Status: Retired PolicyStat ID: 3428552 Effective: 03/2017 Approved: 03/2017 Last Revised: 03/2017 Expiration: 03/2020 Owner: Dustin Falk: Clinical Coordinator- Pharmacy Department: Pharmacy CSM References: Applicability: Columbia St. Mary's Hospital Milwaukee Columbia St. Mary's Hospital Ozaukee Sacred Heart Rehabilitation Institute Subcutaneous Insulin Pump Management: Inpatient POLICY STATEMENT: Inpatient insulin pump management requires careful coordination between the patient and medical staff. To provide safe and optimal care, a set of criteria must be met on admission and throughout the inpatient stay if the insulin pump is to be continued. All ADULT patients admitted with an insulin pump will be assessed using criteria outlined below. PURPOSE: To outlineRETIRED the roles and responsibilities related to caring for inpatients on an insulin pump. This policy refers to any ADULT patient admitted to the hospital who is using an external pump to manage his/her diabetes. Pediatric patients do not fall under the purview of this policy. SCOPE: This policy applies to all staff involved in the care of diabetic patients within the Columbia St. Mary's organization. DEFINITIONS: EHR: Electronic Health Record Insulin Pump: Battery operated device the size of a pager, which provides continuous 24 hour insulin delivery utilizing rapid acting insulin. Insulin is delivered through a needle or soft cannula that is inserted into the patient's subcutaneous tissue and connected to thin plastic tubing attached to the pump or has no tubing in the case of Omnipod™ pump. The pump mimics normal pancreatic function and is programmed by the patient to deliver insulin via basal rates and at each meal as a bolus dose. Basal rate(s): The amount of insulin the patient requires to maintain a normal metabolic state when not eating. The basal dose is delivered continuously. Multiple basal rates are pre-programmed by the patient to automatically deliver insulin during a 24 hour period. Subcutaneous Insulin Pump Management: Inpatient. Retrieved 04/17/2017. Official copy at http://columbia-stmarys.policystat.com/ Page 1 of 9 policy/3428552/. Copyright © 2017 Columbia St. Mary's Hospital Milwaukee Prandial dose: The amount of insulin delivered rapidly by the insulin pump for each meal or significant carbohydrate intake. The bolus dose must be entered and delivered by the patient. The dose is calculated by using the pre-programmed insulin to carbohydrate ratio and having the patient enter the amount of carbohydrates within a given meal or snack. A correction bolus is sometimes given in addition to the prandial dose. Correction bolus: This refers to a dose of insulin which is used to correct hyperglycemia. This dose is calculated by the patient or through the use of an automatic feature integrated into the pump. The patient calculates the correction bolus by using their insulin sensitivity or correction factor (see below). This is most often given with the prandial dose. Insulin Sensitivity or Correction Factor: This indicates how many (mg/dL) the blood glucose is expected to drop from each unit of insulin administered. (I.e. a correction factor = 50 indicates that 1 unit of insulin will cause a 50 mg/dL drop in blood glucose.) This value is pre-programmed in the insulin pump. Insulin-to Carbohydrate Ratio: This ratio is used to express how many grams of carbohydrate are covered by 1 unit of insulin. (I.e. a ratio of 1:15 means 1 unit of insulin covers 15 grams of carbohydrate (1 carbohydrate exchange). The patient counts the grams of carbohydrate they intend to eat and then the pump calculates the amount of insulin needed to cover the carbohydrates in the meal. This value is pre-programmed into the insulin pump. Self test: A diagnostic test that checks that the insulin pump is operating properly. The insulin pump automatically runs internal diagnostics and checks for proper operations of the beep and vibrates modes during testing. Diabetic ketoacidosis (DKA): A life-threatening metabolic emergency condition where extremely high blood glucose levels occur due to insufficient insulin. Any interruption in therapy for more than 2 hours requires an alternate insulin delivery system to prevent DKA. Any interruption for more than 1 hour requires the alternative insulin delivery system to prevent DKA. No DeliveryRETIRED Alarm: An alarm signal (either audible beeps or vibration) that alerts the insulin pump wearer that insulin delivery through the pump has stopped (i.e. the pump detects a blockage or occlusion, or that the reservoir has run dry). The patient must change the entire infusion set. Total Daily Insulin Dose (TDD): The total amount of insulin received via the insulin pump in the previous 24 hours beginning at midnight (2400). TDD is equal to the sum of the basal rate(s) plus bolus doses. The information is located in the utility or review screen of the patient's insulin pump. Diabetes Treatment Center (DTC): Patients on insulin pumps can be co-managed by the diabetes educator and may be referred to the service by physician order in the chart. Nursing should contact the diabetes educator when they receive an order for diabetes consultation. This service is available at the Milwaukee and Ozaukee campuses. Continuous Glucose Sensor: A sensor that monitors real-time blood glucose fluctuations. Not to be relied upon exclusively - always confirm with hospital glucometer. See number 6 under Key Points. Temporary Basal Rate: A temporary basal rate allows an immediate short-term change to your basal insulin for a specified period of time. (30 minutes to 24 hours). EQUIPMENT 1. Patient's insulin pump Subcutaneous Insulin Pump Management: Inpatient. Retrieved 04/17/2017. Official copy at http://columbia-stmarys.policystat.com/ Page 2 of 9 policy/3428552/. Copyright © 2017 Columbia St. Mary's Hospital Milwaukee 2. Associated equipment KEY POINTS: 1. Patients may request the ability to use his/her own insulin pump and may benefit from continuing use of their pump during the hospital stay under specific circumstances. A. Inclusion criteria for use: 1. At least 18 years of age. 2. Alert; oriented to person, place and time. 3. Knowledgeable and competent to manage the insulin pump (see Appendix A - Insulin Pump Patient Assessment Tool) 4. Have adequate insulin pump supplies, including inserter for the cannula, infusion sets, reservoirs and batteries. B. Contraindications for continued inpatient insulin pump therapy: 1. An altered state of consciousness 2. The patient is currently in DKA 3. The patient is NPO in preparation for going to the operating room 4. The patient is unable to answer all assessment questions in Appendix A. 5. The patient is unable to demonstrate safe decision-making. 6. The patient is unable to demonstrate safe pump operation. 7. The patient is receiving medications which in the judgment of the physician may significantly impair state of consciousness. 8. The insulin pump is malfunctioning. RETIRED9. The patient does not have adequate supplies. 10. The patient is critically ill (e.g. sepsis, trauma) and needs intensive care. 11. Refusal or unwillingness to participate in self-care. 12. Caregiver support/assistance required to manage insulin pump. 13. Other circumstances as identified by the patient, nurse, physician or pharmacist. 2. Staff is unable to be fluent in ALL manufactured insulin pump devices and associated equipment available for purchase by patients and may not have had any previous insulin pump training. 3. Patients knowledgeable and managing their pump well prior to admission can be considered for self- management as long as there are no contraindications or nursing concerns. 4. A standard PowerPlan must be used for writing insulin pump orders. 5. Interruption in insulin delivery for more than one hour can lead to severe hyperglycemia and DKA. 6. A patient on insulin pump therapy must have their blood glucose monitored at least 4 times a day via a hospital glucometer. A patient may test their blood glucose with their own monitor, but any result prompting a change in pump settings must be confirmed by a hospital glucometer PRIOR to any modifications to pump settings. Subcutaneous Insulin Pump Management: Inpatient. Retrieved 04/17/2017. Official copy at http://columbia-stmarys.policystat.com/ Page 3 of 9 policy/3428552/. Copyright © 2017 Columbia St. Mary's Hospital Milwaukee POLICY/GUIDELINES: 1. Physicians will be required to assess for the following on admission: A. Contraindications for continued insulin pump therapy. B. Use the Insulin Pump - Patient Owned PowerPlan in the EHR or write orders for an alternative subcutaneous/intravenous insulin regimen if the pump is discontinued. C. Write orders for diabetes education and nutrition services consults if any of the following apply: 1. The patient's ability to self-manage the pump is unclear. 2. The patient is admitted for problems related to the pump, DKA, or severe hypoglycemia. D. If a patient on a pump is admitted with DKA the pump must be discontinued and the patient must be placed on an intravenous or subcutaneous insulin regimen. 2. Consider Diabetes Educators/CSM Diabetes Treatment Center consult to evaluate appropriateness of insulin pumps for ongoing management of diabetes. A. Verify current pump settings for insulin delivery: 1. Basal rates 2. Insulin-to-carbohydrate ratio 3. Insulin sensitivity factor 4. Correction bolus B. Recommend endocrinologist consult if needed. C. Assess need to initiate/reinforce carbohydrate counting skills/education. D. Document assessment and recommendations in EHR progress note. Inform physician of any pump discrepancies or problems that may affect treatment or patient safety. RETIREDE. If deemed inappropriate, physician to write orders for intravenous or subcutaneous insulin regimen. F. Assist nursing staff with documentation, evaluation, and care of the patient with an insulin pump. G. Provide staff education as needed. H. Participate in discharge planning. 3. The patient must sign the Insulin Pump Therapy Patient Agreement Form (Appendix B) and adhere to the Insulin Pump Therapy Patient Agreement in order to use his/her own insulin pump during the hospitalization.