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Managing Hospitalized Patients with Ambulatory Pumps: Part 2- Guidelines for the Use of Insulin Pumps During Hospitalization

The availability of lightweight ambulatory infusion pumps in the early 1980s has made infusion therapy possible in settings outside the hospital, including in the home. This mode of delivery may be used to administer medications, blood factors, nutrition, or hydrating solutions via the intravenous (IV), subcutaneous, epidural/intrathecal, percutaneous, intrawound, intrahepatic, or other parenteral routes. Their use is expected to grow at an annual rate of about 9% over the next few years.1 This means that, by now, many healthcare practitioners in hospitals have likely encountered patients presenting for treatment with an ambulatory pump. Thus, hospitals need to determine whether to allow patients to continue to use and self-manage their medications using the ambulatory pump, or to remove the pump upon admission and deliver the medications using an alternative method.

One year ago, we published the results of a survey we conducted to learn about practices and concerns associated with patients who arrive at the hospital with an external ambulatory pump.2 Overall, the results exposed a high degree of variability in assessing and managing these patients in the hospital, with many aspects of patient safety overlooked. We also found that a large number of respondents did not know whether certain policies, procedures, guidelines, or practices were in place in their hospitals to safeguard patients with an ambulatory pump.

If a therapeutically equivalent (alternative) medication pump is currently available in the organization (e.g., an IV infusion pump), the patient’s own ambulatory pump might be reasonably replaced with a hospital pump during hospitalization to continue the delivery of an important medication (e.g., epoprostenol). However, for some ambulatory infusion pumps, the hospital may have no compatible pump replacement. Furthermore, there may be a clinical benefit to allowing certain hospitalized patients to self-manage their medication via their ambulatory pump. One example is a subcutaneous insulin pump, which is used by more than a half million patients with type 1 or type 2 diabetes in the US.3-7

Insulin pumps

In a 2014 consensus statement, the American Association of Clinical Endocrinologists and the American College of Endocrinology encouraged hospitalized patients and their admitting physicians to not discontinue an insulin pump, but rather to consult the specialist responsible for the patient’s insulin pump management if the patient cannot manage his or her own pump.5 The American Diabetes Association7 and ECRI Institute8-10 make similar recommendations, both encouraging the continued use of an insulin pump during hospitalization after a screening process demonstrates the patient’s or family member’s physical and mental ability to use the pump. Furthermore, these patients or family members have often been extensively educated in diabetes self-management and have invested considerable time in mastering the insulin pump technology, and thus, are often eager to continue using the pump during hospitalization.11-14

Insulin is a high-alert medication and one of the leading drugs involved in harmful errors in hospitals. There are nearly a dozen different insulin pumps available in the US today, all featuring complex technology. The pumps rarely have standard components, making it difficult for hospital staff to gain familiarity with all the available pumps.6 Thus, the potential for errors is high, the most dangerous of which is an insulin overdose leading to clinically significant hypoglycemia. In fact, during our 2015 survey, 30% of the respondents reported such errors, some stating they were “too frequent” to list (previously unpublished data). Even allowing a very capable patient to manage his or her own insulin pump can be risky. For example, errors have been reported to ISMP in which a patient self-administered a bolus dose of insulin via an insulin pump without telling the nurse, and the nurse administered the same dose via an injection.

Insulin pump use during hospitalization

Safely managing hospitalized patients who present for treatment with an insulin pump requires extensive planning, widespread clinician education, clearly defined approaches to communication, and a commitment to attend to the myriad details associated with caring for these patients. Because insulin pumps are likely to be the most frequently encountered external ambulatory pump when patients present to hospitals, and have been recommended for continued use during hospitalization, the remainder of this article focuses on guidelines for establishing policies and procedures related to the use of external insulin pumps during hospitalization. The guidelines provide suggestions for developing policies, procedures, and associated documents that meet the dual goals of allowing patients the flexibility to continue using their insulin pump during hospitalization while ensuring their safety.6,12 If you have comments about the guidelines or would like to recommend any additions, we would love to hear from you!

The guidelines appear on pages 3-7 in the PDF version.

References

  1. Global home infusion therapy market will reach a valuation of US $27 billion by 2020: Persistence Market Research [news release]. New York, NY: Marketers Media; July 24, 2015. 
  2. ISMP. Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. ISMP Medication Safety Alert! 2015;20(23):1-3.
  3. Bruttomesso D, Costa S, Baritussio A. Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy. Diabetes Metab Res Rev. 2009;25(2):99-111.
  4. Chait J. Insulin pumps: not just for type 1. Diabetes Self-Management. Published August 31, 2006.
  5. Grunberger G, Abelseth JM, Bailey TS, et al. Consensus statement by the American Association of Clinical Endocrinologists/American College of Endocrinology insulin pump management task forceEndocr Pract. 2014;20(5):463-89.
  6. Bailon RM, Partlow BJ, Miller-Cage V, et al. Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract. 009;15(1):24-9.
  7. American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S112.
  8. Carson SL. Patient-supplied medication infusion devices in the emergency department: are you ready? J Emerg Nurs. 2012;38(3):267-9.
  9. ECRI Institute. Resources for managing the use of patient-supplied equipment. Health Devices. 2007;36(9):294-301.
  10. ECRI Institute. Patient-supplied equipment. Executive Summary. Medical Technology. May 2008;8(3):1.
  11. Leonhardi BJ, Boyle ME, Beer KA, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital: a review of one institution’s experience. J Diabetes Sci Technol. 2008;2(6):948-62.
  12. Cook CB, Boyle ME, Cisar NS, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting: proposed guidelines and outcome measures [erratum in Diabetes Educ. 2006;32(1):130]. Diabetes Educ. 2005;31(6):849-57.
  13. Healthcare Technology Foundation, ECRI Institute. Home infusion: a safety guide for patients and caregivers. 2013.
  14. Noschese ML, DiNardo MM, Donihi AC, et al. Patient outcomes after implementation of a protocol for inpatient insulin pump therapy. Endocr Pract. 2009;15(5):415-24.
  15. Lee SW, Im R, Magbual R. Current perspectives on the use of continuous subcutaneous insulin infusion in the acute care setting and overview of therapy. Crit Care Nurs Q. 2004;27(2):172-84.
  16. Nassar AA, Partlow BJ, Boyle ME, Castro JC, Bourgeois PB, Cook CB. Outpatient-to-inpatient transition of insulin pump therapy: successes and continuing challenges. J Diabetes Sci Technol. 2010;4(4):863-72.
  17. Lansang MC, Modic MB, Sauvey R, et al. Approach to the adult hospitalized patient on an insulin pump. J Hosp Med. 2013;8(12):721-7.

 

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