Insulin infusion pump managementInpatient guidelinesStatewide Diabetes - PDF document

Insulin infusion pump managementInpatient guidelinesStatewide Diabetes Clinical NetworkJuly 2016 Page 2 Insulin infusion pump management: Inpatient guidelines Published by the State of Queensland (Queensland Health), July 2016 This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au © State of Queensland (Queensland Health) 2016 You are free to copy, communicate and adapt the work, as lon g as you attribute the State of Queensland (Queensland Health). For more information contact: Healthcare Improvement Unit , Department of Health, GPO Box 48, Brisbane QLD 4001, email Statewi de_Diabetes_Network@health.qld.gov.au , phone 3328 9302 . An electronic version of this document is available at http://qheps.health.qld.gov.au/caru/networks/diabetes/default.htm Disclaimer: The content presented in this publication is distributed by the Queensland Government as a n information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such i nformation. Page 3 Contents Purpose ................................ ................................ ................................ ............... 4 Background ................................ ................................ ................................ ......... 4 Gu i d eli n es ................................ ................................ ................................ ....

....... 5 Comp e t e n c y ................................ ................................ ................................ ......... 5 Con t r ai nd ica t i ons ................................ ................................ ................................ . 6 Do c um e n t a t i on ................................ ................................ ................................ ..... 7 Con s u l t a t i ons ................................ ................................ ................................ ....... 7 I n s u li n a d j u s t m e nt ................................ ................................ ................................ 7 B l ood gl u c o s e m on i t or i ng ................................ ................................ ..................... 8 Continuous glucose monitoring systems ................................ .............................. 8 D e v ic e m a n a g e m e nt ................................ ................................ ............................ 9 O p e r a t i ons a nd p ro c e dur es ................................ ................................ .................. 9 O t her ci r cums t an c es ................................ ................................ ........................... 11 Paed i a t rics ................................ ................................ ................................ ......... 11 Appendices ................................ ................................ ................................ ....... 12 References ................................ ................................ ................................ ........ 14 Page 4 Purpose T h e se g u i d e li ne s ha v e b ee n d e v e l ope d t o p r o v i d e ad v ice a n d g u i da n c e t o Q ue e n sl a n d H ea l t h s t a f f so t h a t i nd i v i dua ls w ho se d i a b ete s

is be i n g t r eate d in t h e ou t p a t i en t s ett i n g wi t h a c ont i nu o u s s ub c u t an e ou s i n s u lin i n f u si o n ( C SII ) de li v e r e d w i t h a n i n s u lin p u mp , c a n c o nt i n u e t o b e m ana g e d s a f e ly w i t h the ir i n s u lin p u m p du r i n g the ir ho s p i ta lis at i o n . Background A n i n s u lin p um p is a c o m p l e x e l e c t r on ic a lly - c ont r o ll e d d e v ice f o r th e c o n t i n u ou s s u b c u t an e ou s i nfu si o n o f i n s u lin t o pa t i ent s w i t h t y p e 1 d i a b e te s m e lli tu s. It s ad v an t a g e o v e r m u l t i p le d a ily i n s u lin i n j e c t i on s is tha t p at i e nt s c a n de li v e r m o r e p h y si o l o g ic a l a m ount s o f i n s u lin b et w ee n m ea l s an d a t m ea l t i m e s. T h e r e a r e m an y i n s u lin p u m p s no w a v a il ab le an d a ll i n s u lin p u mp s ha v e d i ffe r en t m a nag e m en t p r o gr a m s. I t is h i g h ly un lik e ly tha t n o n - s p e ci a lis e d m ed ic a l o r nur si n g s taf f w ill k no w t h e e x a ct deta ils o f h o w t o p rogr a m a n d o p e r a t e ea ch de v ice a n d e v e n h i g h ly s pe ci a lis e d s t a f f w i th in di abete s and e n do c r i n e u n i t s m a y no t ha v e th is k no w l ed g e un l e ss the y w o r k in cli n ics w he r e pat i e nt s u si n g the se de v ic e s ar e s ee n r e g u l a r l y . H o w e v e r , th e ba sic p r i n c i p l e s o f i n s u lin a d m i n i s t r at i o n u si n g C SI I w i t h a n i n s u lin p u m p is no t d issi m il a r t o th e p r i n ci p l e s i n v o l v e d in a ba s a l bo l u s m u l t i p le i n j

e c t i o n i n s u lin r e g i m en . T h is i n v o l v e s m a i nta i n i n g c on s t a n t b a c k gr oun d i n s u lin a d m i n is t r at i o n ( ba s a l i n s u lin the ra p y ) w i t h bo l u s e s o f i n s u lin ad m i n is te r e d w he n f o o d is c on s u m e d ( bo l u s t he r ap y ) an d c o rr e c t i o n s be i n g g i v e n w h e n b l o o d g l u c o se is ou t o f ta rg et . I t is r e c o m m en d e d t h a t i n s u lin p u m p s d e li v e r u l t r a - s ho r t a c t i n g ana l o g u e i n s u lin ( N o v o r ap i d , H u m a l o g) . T he r e is p r o s pe c t i v e d at a c o n f i r m i n g tha t a n a l o g u e t he r ap y a c h i e v e s b e tte r g l y c ae m ic c ont r o l. T he r e is n o l o n g a c t i n g i n s u lin ad m i n is te r ed . C e ss at i o n o f i n s u lin p u m p t h e r ap y will r e s u lt in th e p at i en t b e c o m i n g r e l at i v e l y i n s u lin d e f i ci en t w i th i n o n e hou r an d ab s o l ute ly i n s u lin d e f ici e n t w i th in f ou r h o u r s. T h e r e is a m a j o r r isk o f s e v e r e h y pe r g l y c ae m ia an d k e t oa ci d o sis o cc u rr i n g w i th in hou r s fo ll o w i n g d isc ont i n u at i o n o f the ra p y . I n s u lin r ep l a c e m e n t the ra p y m u st b e c o m m e n c e d i m m ed i a t e ly ( e g I V i n s u lin i n fu si o n o r i nte r m i tt e n t s ub c u t an e ou s i n j e c t i o n s) o n d isc ont i n uat i o n o f i n s u l in p u m p the ra p y . H o s p i ta l s t a f f s h o u ld a ss u m e , un l e ss ot h e r w i se ad v is ed , t h a t t h e o n ly pe r s o n w h o c a n ma na g e th e pu m p du r i n g the ir ho s p i ta lis at i o n is t h e pat i ent , o r in t h e

c a se o f c h il d r e n the ir pa r ent/ g ua r d i a n . An y c han g e s in i n s u lin ad m i n is t r at i o n w ill n ee d t o b e m a d e b y th e pat i e nt/ p a r en t / g ua r d i a n w h o m u st b e c o m pe t en t in m a n a g i n g th e pu m p a n d ph y sic a lly an d m e n t a lly ab le t o a cc ep t a n d i n s t i tut e the se r e c o m m en d at i o n s. T h e s e g u i de li ne s p r o v i d e a f ra m e w o r k fo r ho s p i ta l s t a f f t o a ss e ss c o m p et e n c y , do c u me n t a p a t i ent ’s s u i t a b ili t y t o c ont i n u e o n C SI I t h e r ap y a n d p r o v i d e r e c o m m e nd a t i on s w h e n p u m p t h e r ap y s hou l d b e d isc ont i n u e d . Page 5 Gu i d eli n es Comp e t e n c y An y pat i en t w h o is ad m i t t e d t o h o s p i ta l u si n g a n i n s u lin pu m p m u st b e a s s e ss e d fo r the ir c o m p et e n cy t o u se th e ir de v ic e . I f t h e y c a n d e m o n s t r a t e t he ir p h y sic a l a n d m e nta l c o m pe t en cy t o m a n a g e t h e d e v ic e , t h e p a t i en t s h o u ld b e a l l o w e d t o c o nt i n u e o n t h e ir i n s u lin p u m p . The Insulin pum p management checklist (Attachment 1) should be used as a tool to guide this assessment of the patient’s competency to manage the insulin pump during the admission. O n a d m issi o n t o ho s p i ta l, e i t h e r t o a w a r d o r e m e rg en cy d epa r t m e nt , t h e pat i e n t m u s t de m on s t r at e t o t h e s a t is fa c t i o n o f t h e a ss e s si n g hea l t h p ro f e ssi on a l tha t the y ha v e th e ab ili t y t o u se t h e m ana ge m e n t p r o gr a m o f t h e de v ice a n d u nde r s t a n d h o w t o m o d i f

y th e p r o gra m . I t is a ck no w l ed g e d t h a t t h e a ss e ssi n g h ea l t h p r o f e ssi o na l m a y ha v e n o c o m p et e n cy in th e p r a c t ic a l m a n a g e m en t o f th e i n s u lin p u m p . T h e r o le o f t h e h ea l t h p ro fe ssi o n a l is t o a ss e ss t h e c o m p e ten cy o f t h e p at i e n t t o u s e t h e i n s u lin i n fu si o n p u mp . T h is w ill i n v o l v e a ski n g th e pat i en t t o d e m on st r at e t h a t the y : 1. c a n o pe n t h e m a n a g e m e n t m e n u o f t h e d e v i c e 2. a r e a b le t o a d j u st t h e ba s a l r a t e 3. a r e a b le t o a d j u st t h e bo l u s do s e 4. c a n r e - si t e the ir p u m p c an n u l a . T h is c o u ld i n v o l v e d isc u ssi n g ho w it is do n e , r athe r t ha n a c t ua lly unde r ta ki n g t h e a c t i v i t y a t th is i n i t i a l a s s e s s m e n t 5. c a n d e m on s t ra t e t e c h n ic a l c o m p e ten cy r e g a r d i n g c annu l a si te s / h o w the y w ou ld m a n a g e i n f u s i o n li n e o b s t r u c t i o n s / si t e l ea ks 6. c a n u nde r t a ke a p p r o pr i at e p ro b l e m s o l v i n g a c t i on s i f B GL s a r e h i g h o r l o w 7. h a v e ade q ua t e s u pp l i e s o f i n f u si o n s e t s, s par e bat t e r i e s a n d th e i n s u lin u s e d in th e i n s u lin p u m p a v a il a b le f o r t h e ant ici p at e d du r at i o n o f t h e a d m iss i on 8. h a v e bee n pe r fo r m i n g r e g u l a r b l oo d g l u c o s e m on i t o r i n g te s t s ( fo r e x a m p l e , fou r te s t s p e r da y ) . T h e d i ab e te s e d u c a t o r o r d i abe

te s r e s ou r c e pe r s o n f o r th e h o s p i ta l s hou ld b e not i f i e d up o n ad m issi o n o f a p at i e n t w i t h a n i n s u lin p u m p ( S e c t i o n 4 ) . A n u rg en t c o n s u l t a t i o n s hou ld b e obta i ne d i f t he r e is a c on c e r n a b o u t c o m p e t e n cy o f t h e pat i en t t o c ont i n u e o n p u m p t he ra p y . T h e r e s ou r ce pe r s o n m a y b e ab le t o ad v ise o r r e c t i f y an y iss ue s o r c on c e r n s, a ll o w i n g th e pat i en t t o c ont i n u e o n t he ir i n s u l i n p u m p . I f t h e p at i e n t ( o r pa ren t/ g ua r d i an ) c an n o t c o m p e te n t ly de m on s t r a t e o r d e sc r i b e t h e a c t i on s abo v e , th e i n s u lin p um p s hou l d b e d isc o n t i nu e d . T h e pat i en t s h ou ld b e p l a c e d o n a n I V i n s u lin i n fu si o n o r s ub c u t an e ou s i n s u lin r e g i m e ( e g , ba s a l / b o l u s i n s u lin r e g i m e n in adu l t s) du r i n g the ir h o s p i t a lis at i on . Page 6 Con t r ai nd ica t i ons T h e u s e o f t h e C SI I is c ont r a i nd ic a te d in si t u at i on s w he r e t h e pat i e nt ’s s a fet y m a y b e c o m p r o m is e d b y t h e p h y sic a l ill ne ss o r m e n t a l s ta t e o f t h e p at i e n t . Ab s o l u t e c o nt r a i nd ic a t i on s f o r C S I I u s i n g a n i n s u lin p u m p a re : - 1. patients with an impaired level of consciousness Note: insulin pump therapy can be continued during anaesthesia (with decreased level of consciousness) as long as the an aesthetist is aware of and willing to manage the pump during anaesthesia. 2. patients with critical illness requiring intensive c

are 3. patients with major psychiatric disturbance 4. diabetic ketoacidosis 5. patients refusing or unwilling to participate in self - care 6. l ack of infusion sets, spare batteries and other equipment required to maintain patient on CSII therapy 7. any other medical circumstance deemed unsuitable by the supervising medical officer. I f t h e p at i e n t p r e s ent s w i t h an y o f above it e m s t h e i n s u lin p u m p m u s t b e d isc o n t i n u e d an d th e de v ice m ana ge d a cc o r d i n g t o th e ho s p i ta l’s p o licy f o r s to r a g e o f p a t i en t v a l uab l e s. W he n s to r i n g th e p u m p b e s u r e t o r e m o v e th e b at t e r y f r o m th e d e v ice t o p r e v e n t on g o i n g pu m p a l a r m s. T h e pat i e n t s h o u ld b e p l a c e d o n a n I V i n s u lin i n fu si o n o r s ub c ut a n e ou s i n s u lin r e g i m e ( e g b a s a l /bo l u s i n s u lin r e g i m e n in a du l t s) du r i n g the ir h o s p i ta l i s at i on . I n t h e c a s e o f It e m 7 , a n u rg en t d is c u ssi o n o f t h e pat i e nt ’s c o n d i t i o n a n d m a n a g e m en t w i t h th e d i ab e te s s pe ci a lis t , d i abe t e s edu c ato r o r d i abe t e s r e s ou r ce p e r s o n f o r tha t h o s p i t a l s hou ld b e c on si de re d . Page 7 Do c um e n t a t i on Before a patient continues on CSII as an inpatient, the following criteria must be documented. 1. It must be clearly written in the medical record and on the blood glucose monitoring f orm that the patient is on an insulin pump. 2. The brand name and model of the pump must be written in the medical record. 3. The type of insulin used in the insulin pump must be identified and recorded in the blood gluc

ose monitoring form. 4. The current basal and bolus insulin doses must be documented in the medical record. Ideally the pump data would be downloaded and the print out stored in the medical chart for reference. 5. That competency has been assessed and deemed satisfactory, as per Section 1. 6. The patient a grees to notify the medical staff of any changes they make to their insulin pump. Con s u l t a t i ons T h e f o ll o w i n g hea l t h p r o f e ssi o na ls s h ou ld b e c on s u l t ed :  endocrinologist or physician with interest in diabetes  diabetes educator or diabetes resource person tra ined in insulin pump management  dietitian. I n s u li n a d j u s t m e nt Changes to the patient’s insulin therapy may be made at any time by the patient provided the change is notified to the medical staff. Any change to the insulin regimen recommended by the medica l staff will be documented in the medical record and confirmed by the patient at the time of implementation. Page 8 B l ood gl u c o s e m on i t or i ng Patients on an insulin pump should perform a minimum of four blood glucose tests per day. These should be performed befo re each main meal and before going to sleep at night. In patients with less satisfactory control, six tests per day should be performed (one test before and two hours after each of the three main meals). An overnight test (eg 0200hrs) may be necessary. Add itional blood glucose levels may be undertaken at any time by the patient. Additional tests may also be performed at the request of the medical officer or nursing staff when clinically indicated. The number of tests performed each day can only be reduced o n the orders of the medical officer and can never be reduced to less than four tests per day. Continuous glucose monitoring systems Continuous glucose monitoring systems (CGMS) measure level of glucose in the inter

stitial fluid and gives a reading every 5 mins. The CGMS works through a sensor inserted under the skin, the glucose level is interpreted in a transmitter and then sent to a receiver. The receiver can either be a specific receiver, the insulin pump or a phone depending on the make / model of the transmitter. The CGMS sensor is disposable and changed according to manufacturer recommendations (generally every 6 to 7 days). The sensors require calibration minimum of 12 hourly to promote accuracy this is done using a capillary blood glucose check. CGM S sensor readings provide excellent information regarding glucose trends and patterns. At the time of writing only one sensor (Dexcom5) has approval with the Therapeutic Goods Administration (TGA) and is deemed accurate enough to be used for the calculatio n of insulin doses, all other CGMS have not received TGA approval to do so and capillary blood glucose level must still be done for this purpose. During a hospital admission, especially in times of rapidly changing conditions and in and episodes of diabe tic ketoacidosis, CGMS should not be used for diabetes management. Page 9 D e v ic e m a n a g e m e nt The patient or guardian:  is responsible for ensuring the correct operation of the insulin pump  will rotate the infusion set consistent with the recommendations for the device. This will be every three days, unless other documentation is provided  will make the adjustments to the insulin pump program  will be responsible for all bolus dose administration. I f t h e p at i e n t is n o t c ap ab le o f u nde r t a ki n g th e se a c t i o n s, t h e i n s u l in pu m p m u st b e d isc o n t i nu e d. O p e r a t i ons a nd p ro c e dur es T h e u s e o f t h e C S I I in ope ra t i n g th e at r e s and p r o c e d u r e r o o m s is no t c ont r a i nd ic a t ed . It

s u s e m u st b e c on s i de r e d c a re f u lly in c on s u l tat i o n b e t w ee n th e a n a e s th e t is t , s u rg eon , p h y sici an , d i ab e te s e du c a to r a n d pat i e nt . The outcomes of discussion about the use of insulin pumps during operations and procedures should be documented in the Insulin pump management checklist (Appendix 1) and in the patient’s chart. B y de li v e r i n g s tab le an d c on sis t e n t i n s u lin a d m i n is t ra t i o n o v e r hou r s t h e i n s u lin p u m p c a n p r o v i d e e x c e ll en t pe r i - o p e r at i v e b l o o d g l u c o se c ont ro l. I n t h e ba s a l i n fu si o n m od e o n l y , it c a n b e c o n si de re d e q u i v a l ent t o v e r y l on g a c t i n g i n s u li n . A s w i t h a ll pat i e nt s w i t h d i a bete s u n de rg o i n g s u rg e r y , pat i e nt s w h o a r e un c on sci o u s n ee d t o b e m on i t o r e d c a re fu lly du r i n g an d a fte r t he ir s u rg ic a l p r o c e du r e . T he ir b l oo d g l u c o s e s h ou ld b e m ea s u r e d f r e q ue n t ly w h ile t h e ir c on sci ou s s t a t e is i m pa i r ed . P ati e nts c o nti n uing on CS I I p e r i - ope r ati v ely  The patient (or parent /guardian) must consent to continuing on insulin pump therapy peri - operatively.  CSII and IV insulin therapy should not run at the same time.  The infusion site must be placed away from the operation site with consideration also given to where a diathermy pa d may be placed. Ensure the insertion cannula is plastic not metal. If the pump is to be used during surgery, the patient must replace metal cannulas with plastic insertion cannulas before any surgical procedures that may involve diathermy are performed.  A n identification tag must be attached to t

he patient that states that the patient is using an insulin pump. This should be sited in a readily visible position appropriate for the procedure to be undertaken.  The anaesthetist must have access to the insulin pump during surgery to enable it to be turned off or disconnected, if necessary. Page 10  The patient’s BGLs must be monitored every hour peri - operatively until they have satisfactorily regained consciousness and the patient (or parent/guardian) is capable of makin g decisions regarding managing their insulin pump.  In the event of the blood glucose levels increasing to an unsatisfactory level peri - operatively, an IV insulin infusion should be commenced and the insulin pump turned off, or disconnected.  In the event o f the BGL levels falling below 4mmol/l peri - operatively, the insulinpump must be turned off and/or disconnected. The hypoglycaemia should be treated with IV glucose. Once euglycaemia is restored, there are three choices regarding recommencement of the CSI I: 1. Recommence the pump at a lower insulin infusion rate (if the medical staff are able to program the device). Consideration should be given to using a temporary basal rate rather than adjusting the usual basal rate. This offers more flexibility and may av oid confusion if basal settings are not restored to usual when the patient has recovered. 2. Recommence the pump at the usual basal rate with a higher IV glucose infusion rate to prevent further episodes of hypoglycaemia. 3. Leave the pump off and commence an IV insulin infusion to control the patient’s BGLs. The use of CSII in major procedures should be only considered in rare circumstances due to the strong probability that an adjustment to the patient’s insulin therapy will be required during the prolonged pe ri - operative period. Discontinuation of the insulin pump and commencement of IV insulin therapy is recommended in this s

ituation. Patients not continuing on CSII peri - operatively Pat i e n t s w ho se i n s u lin pu m p is d is c ont i n ue d pr i o r t o s u rg e r y W I L L req u i r e e i t he r a n i nt r a v enou s i n s u lin i n f u si o n o r s u b c u t a n eou s t he r ap y a cc o r d i n g t o t h e ho s p i ta l’s p e r i - ope r at i v e t y p e 1 d i a be t e s m ana ge m e n t g u i de l i ne s. Disc o n t i n u at i o n o f t h e i n s u lin pu m p fo r e v e n s h o r t p e r i od s o f t i m e w i t h n o a l te r nat i v e s o u r ce o f i n s u lin w ill r e s u lt in th e ra p id d e v e l op m en t o f h y pe rg l y c ae m i a . T h e C SI I c a n b e r e - c o m m en c e d w he n: 1. t h e pat i e n t ha s r e g a i n e d fu ll c on sci ou s ne ss, an d 2. it is c on si d e r e d m e d i c a lly app r op r i ate . Page 11 O t her ci r cums t an c es The insulin pump may need to be discontinued temporarily duri ng a number of circumstances during hospitalisation. In this situation, discontinuation of the insulin pump for more than 30 minutes may result in significant hyperglycaemia. Such circumstances where the insulin pump needs to be temporarily disconnected in clude:  any radiological investigation (pump must be removed)  CT scan (pump must be removed)  MRI scan (pump must be removed, including metal cannula)  physiotherapy (depending on the therapy)  hydrotherapy (even if the pump is labelled as water - proof). Patien ts whose insulin pump needs to be discontinued for longer than one hour may need to be considered for an injection of subcutaneous insulin, eg subcutaneous soluble insulin (Actrapid, Humulin R, Humalog, Novorapid or Apidra) to cover their short term requir ements. Alternatively, the pump can be discontinued for up to

two hours at the discretion of the treating doctor if the patient is clinically stable and blood glucose levels are being monitored regularly. Upon recommencement of the pump, blood glucose shou ld be rechecked and if needed a correction bolus can be given. Patients needing to be regularly disconnected from their insulin pump should be considered for basal/bolus subcutaneous insulin injection therapy. Paed i a t rics The continuation of CSII in a chi ld in hospital needs to be considered carefully in consultation between the patient, their parent(s) or guardian and their medical team. In the circumstances that the guardian or parent is responsible for the management of the insulin pump, the medical off icer must be satisfied that the responsible person can satisfy all the criteria listed in this document. This decision may be made in consultation with a credentialed diabetes educator, when appropriate. Additionally, the parent or guardian must be able t o stay with the patient at all times during the admission so that adjustments to the insulin pump can be made at any time. If the above conditions cannot be met, the insulin pump should be discontinued and subcutaneous insulin injection should be commenced . Page 12 Appendices Page 13 Page 14 References Policy: Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital: Shore Health System, University of Maryland Medical System Dalton M, Klipfel L, Carmichael K. 2006, ‘Sa fety Issues: Use of Continuous Subcutaneous Insulin Infusion (CSII) Pumps in Hospitalised Patients’, Hospital Pharmacy, vol. 41, no.10, pp956 - 969. Cook C, Boyle M, Cisar N, Miller - Cage V, Bourgeois P, Roust L, Smith S, Zimmerman R. 2005 ‘Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital Setting: Proposed Guidelines and Outcome Measures’. The Diabetes Educator, vol 31, pp849 -