Managing Hospitalized Patients With Ambulatory Pumps: Part 1- Findings From An ISMP Survey
In our September 10, 2015 newsletter, we invited readers to complete a survey about current practices and concerns associated with patients who arrive at the hospital with an external ambulatory pump, including insulin pumps, elastomeric pumps, and IV pumps (non-elastomeric). Implanted pumps were excluded from the survey. We sincerely thank the 370 readers who participated in the survey—you have provided ISMP with valuable information on this topic along with details we believe cannot be found elsewhere.
Overall, the results exposed significant breaches in safe practices associated with managing patients with external ambulatory pumps. This is a serious risk given that the use of ambulatory pumps is no longer a rare occurrence—more than half a million people with diabetes are using ambulatory insulin pumps, alone. We also found that a large number of respondents did not even know whether certain policies, procedures, guidelines, or practices were in place in their hospitals to safeguard patients with an ambulatory pump. In Part 1 of our 2-part article, we highlight the key findings from the survey. Full results can be found in Table 1.
|Abbreviated Survey Question||
Insulin Pumps (%)
Elastomeric Pumps (%)
IV Pumps (%) (Non-elastomeric)
|a||Policy/procedure/guideline on ambulatory pump management?||21||3||75||1||22||6||46||26||25||15||40||20|
|b||Halt use of ambulatory pumps during hospitalization?||16||41||39||4||20||14||27||39||24||22||24||30|
|c||Process to determine if patient is an appropriate candidate to manage pump while hospitalized?||64||11||18||7||13||4||47||36||21||9||48||22|
|d||Would suicidal ideation exclude pump access?||65||9||5||21||35||6||10||49||42||8||10||40|
|e||If patient needs assistance, a knowledgeable person/staff remains in hospital at all times?||47||10||30||13||14||3||35||48||20||6||35||39|
|f||Before continued use, must the ambulatory pump be inspected to verify it is functioning properly?||6||2||82||10||6||0||63||31||8||0||63||29|
|g||Contact the outpatient provider responsible for the patient’s ambulatory pump infusion for input as needed?||26||10||57||7||10||3||56||31||12||10||54||24|
|h||Specify the content of complete orders (e.g., basal rate, bolus doses, infusion rate, related monitoring)?||71||6||17||6||39||4||24||33||44||8||24||24|
|i||Require prescriber with specialized knowledge to provide orders for pump’s continuation?||38||11||42||9||8||3||51||38||13||10||46||31|
|j||Require patient to sign an agreement/consent specifying the risks &responsibilities of self-management?||50||7||29||14||16||2||42||40||19||3||42||36|
|k||Provide patients with a flow sheet to document all doses, monitoring results, site changes, rate changes?||27||9||56||8||3||3||55||39||6||4||62||28|
|l||Device and medications or solutions infusing via the pump listed on the patient’s MAR?||68||13||11||8||37||15||13||35||42||17||15||25|
|m||Require nurse to document medication/product administration at least daily on the MAR/other record?||68||10||12||10||37||11||17||35||43||10||16||31|
|n||Is medication/ solution being administered via pump or used for refill dispensed/ verified by the pharmacy?||51||16||24||9||32||9||27||32||40||11||23||26|
|o||If pump requires refill, have guidelines regarding who can prepare the solution, fill the device, & program it?||54||8||28||10||19||8||37||36||22||11||35||32|
|p||Refills of pumps carried out by clinicians who have specific competencies?||17||10||57||16||12||7||32||49||9||9||42||40|
|q||Refills of medications or solutions require an independent double check before restarting pump?||25||6||48||21||10||0||41||49||15||3||41||41|
|r||If pump/ medication is investigational, specify from where the medication will come if a refill is necessary?||28||6||23||43||23||4||15||58||23||7||19||51|
|s||In-house expert knowledgeable about ambulatory pumps who can be consulted when necessary?||32||16||42||10||11||9||46||34||9||11||48||32|
|t||Clinicians who might encounter pumps educated about those seen most often in their care settings?||18||20||45||17||8||10||42||40||9||12||41||38|
|u||Organization maintains resources about pumps being used that clinicians can easily access?||11||7||64||18||3||4||62||31||5||5||60||30|
|v||Require anesthesia to evaluate patients prior to procedures requiring general anesthesia to determine appropriateness of continuation during procedure?||56||8||12||24||37||4||10||49||36||4||10||50|
|w||Specify how to communicate that patient is receiving medications/solutions via an ambulatory pump?||49||16||25||10||34||12||27||27||37||11||26||26|
|x||Specify how to manage pumps during a radiology procedure to avoid exposure to radiation/
|y||Process to ensure that clinical staff know how to turn the pump off in case of an emergency?||35||8||41||16||11||7||44||38||13||7||47||33|
|z||Ensure patients discharged with pumps understand how to use/ monitor the pump and medication/ solution?||53||11||20||16||41||6||13||40||44||9||13||34|
|aa||Provide patients with written information about how to stay safe at home with infusion via a pump?||39||11||23||27||31||0||27||42||32||3||26||39|
|bb||Specify how to disconnect a pump, where to store it, when to reconnect it if stopped during hospitalization?||40||10||34||16||15||6||38||41||17||7||41||35|
|cc||Specify how to manage patients whose pumps have been discontinued while hospitalized?||50||15||24||11||14||6||44||36||18||5||43||34|
|Key: Y = Yes S/P = Sometimes or Partly N = No DK = Don't Know|
Survey respondents were mostly pharmacists (55%), nurses (31%), and diabetes educators (6%). Forty-one percent of all respondents held staff-level positions and 31% held supervisory, managerial, or administrative positions. Respondents were from organizations of varying sizes, with 16% from hospitals with less than 100 beds, 37% from hospitals with more than 400 beds, and the remaining 47% from hospitals with 100 to 400 beds.
Policies, patient selection criteria, and pump removal. Three-quarters (75%) of survey respondents do not have a policy, procedure, or guideline in place regarding the management of patients who present for care with insulin being delivered via an external pump. Of those who have a policy, procedure, or guideline, almost 1 in 5 respondents do not have a process in place to determine if patients are appropriate candidates to manage their pumps while hospitalized.
It is the policy to halt use of the insulin pump during hospitalization in 16% of respondents’ hospitals, which may place patients at risk for ketoacidosis unless the hospital has a robust system for replacing the needed insulin (e.g., IV insulin infusion; not just sliding scale insulin). But only half of respondents’ hospitals provide guidance regarding how to manage the patient with subcutaneous or IV insulin if the pump must be halted. Also, if an insulin pump must be temporarily discontinued, just 40% of respondents specify how to do this, where to store the pump, and when to reconnect it.
Readiness for patient self-management. If the insulin pump will be used by a hospitalized patient, very few respondents reported that the pump must be inspected to verify functionality. While almost 3 in 4 hospitals specify the content of complete orders when an insulin pump will be used by the patient during hospitalization, just 38% require the inpatient prescriber to have specialized knowledge of insulin pumps, and even fewer expect the inpatient prescriber to contact the outpatient prescriber responsible for the patient’s insulin pump for input as needed. Only half of respondents require the patient to sign an agreement or consent form specifying the risks and delineating the responsibilities of self-management of their insulin pump.
Special conditions. Almost half of respondents with policies, procedures, or guidelines told us they specify how to communicate that the patient is receiving insulin via an ambulatory pump (pumps may be hidden under bedclothes), or how to avoid pump exposure to radiation or magnetic fields during radiology procedures. Prior to a surgical procedure that requires general anesthesia, 56% of respondents expect anesthesia to evaluate the patient to determine the appropriateness of continuation of the insulin pump during the procedure. One worrisome survey finding shows that only 35% of the respondents indicated that their hospital has a process to ensure that clinical staff know how to disconnect an insulin pump in case of an emergency.
Documenting administration. About two-thirds of respondents include the insulin pump on the patient’s medication administration record (MAR) and expect nurses to document insulin administration at least once daily. However, only 1 in 4 hospitals provide the patient with a flow sheet to document all self-initiated doses, glucose monitoring results, site changes, and rate changes.
Refills. Approximately half of respondents told us that any insulin used to refill the pump must be dispensed or verified by pharmacy, and that guidelines exist regarding who can prepare the insulin, fill the device, and program it. However, few respondents reported that refills are carried out by clinicians with demonstrated competencies (17%), or that an independent double check is required for refills before restarting the pump (25%).
Staff resources, competency, and patient education. Just 32% of respondents reported that their hospitals have an in-house expert knowledgeable about insulin pumps who can be consulted when necessary. Even fewer told us that their hospitals maintain resources about insulin pumps that can be easily accessed by clinicians, or that staff are educated about the insulin pumps seen most often in their care settings. Just half of the respondents ensure that patients discharged with insulin pumps understand how to use them, and even fewer provide the patient with written information about how to stay safe at home with an insulin pump.
Elastomeric and IV Ambulatory Pumps
Policies, patient selection criteria, and pump removal. Between 22% and 25% of respondents, respectively, have a policy, procedure, or guideline in place for managing patients who present for treatment in a hospital with an ambulatory elastomeric or IV pump. About 1 in 4 respondents reported that they halt the use of an ambulatory elastomeric or IV pump upon hospital admission, but of these, few specify how to disconnect the pump and store it, or how to manage patients whose pumps have been discontinued during hospitalization. Among respondents with a policy, procedure, or guideline for managing ambulatory elastomeric or IV pumps, a specific process to determine if the patient is a candidate to self-manage an elastomeric or IV pump while hospitalized is provided in only 13% (elastomeric) and 21% (IV) of respondents’ hospitals; of these, less than half believe patient access to pumps would not be permitted if the patient exhibited suicidal ideation.
Readiness for patient self-management. Less than 10% of respondents reported that an ambulatory elastomeric or IV pump must be inspected to verify appropriate function prior to use during hospitalization. Less than half of respondents specify the contents of a complete order associated with an elastomeric or IV ambulatory pump, and less than 15% contact the outpatient provider responsible for the patients’ ambulatory pump for assistance with the orders. Less than 15% require the prescriber to have specialized knowledge of the pump and medication, and fewer than 1 in 5 respondents require the patient self-managing an elastomeric or IV pump to sign an agreement or consent outlining the risks and responsibilities.
Special conditions. Just 1 in 3 respondents have established a process to communicate to clinicians who provide care to the patient that he or she is receiving medications/solutions via an ambulatory elastomeric or IV pump. Approximately one-third of respondents require anesthesia to assess the patient to determine if the ambulatory pump and the solution it delivers should be continued during a procedure requiring general anesthesia. Only about 1 in 10 respondents are confident that clinicians know how to disconnect an ambulatory elastomeric or IV pump in case of an emergency.
Documenting administration. Only 37% of respondents said that medications or solutions delivered via an ambulatory elastomeric pump are listed on the patients’ MARs or that nurses need to document administration at least once daily; 43% reported the same for ambulatory IV pumps (non-elastomeric). Less than 10% of respondents provide patients with a flow sheet to document all self-managed doses and rate changes.
Refills. One in five hospitals provide guidelines for preparing and refilling the ambulatory elastomeric or IV pumps; 1 in 3 hospitals require the pharmacy to dispense or verify the medication or solution used for refills. Very few require specific competencies for those who can refill the devices.
Staff resources, competency, and patient education. Eleven percent or fewer respondents report having an in-house expert on ambulatory elastomeric and IV pumps to consult when needed, and 5% or fewer report that the hospital maintains resources about these pumps that are easily accessible to staff. Less than 10% of respondents’ hospitals provide education to staff about ambulatory elastomeric or IV pumps. Yet, 2 in 5 hospitals reported they provide education to patients discharged using an ambulatory elastomeric or IV pump. Only 1 in 3 provides written information to patients utilizing an ambulatory pump.
Safely managing hospitalized patients who present for treatment with external ambulatory pumps requires extensive planning, widespread clinician education, clearly defined approaches to communication, and a commitment to attend to the myriad of details associated with caring for these patients and preparing them for self-management at home. Our survey showed a high degree of variability in assessing and managing these patients in the hospital, with many aspects of patient safety overlooked. Using this survey data and other resources, ISMP plans to develop guidelines to help hospitals establish a safe environment for patients with an ambulatory pump, and to advance the skills, knowledge, and abilities of staff who care for these patients. In Part 2 of the article, we will highlight strategies to accomplish these goals.