Current Status: Retired PolicyStat ID: 3428552 Effective: 03/2017 Approved: 03/2017 Last Revised: 03/2017 Expiration: 03/2020 Owner: Department: References: Dustin Falk: Clinical Coordinator- Pharmacy Pharmacy CSM 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 outline 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. Page 1 of 9
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 Delivery 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 Page 2 of 9
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. 9. 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 selfmanagement 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. Page 3 of 9
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. E. 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. 4. The hospital assumes no responsibility in the safekeeping of patient's personal belongings. The patient is responsible for all maintenance and handling of the pump while in the hospital. The patient must provide the following: A. External insulin pump B. Syringes or reservoirs for the insulin C. Infusion sets D. Dressings (if needed) E. Extra batteries for the pump (CSM can provide some types of batteries.) Page 4 of 9
5. The pharmacist will assist the physician in entering insulin pump orders so that it is visible in the EHR. 6. Replacement insulin for the pump will be provided by the inpatient pharmacy using Columbia St. Mary's formulary equivalent. For example, insulin aspart (Novolog) is the formulary rapid-acting insulin. Patient's with either insulin glulisine (Apidra) or insulin lispro (Humalog) in their pumps prior to admission will be converted 1:1 to insulin aspart (Novolog) when a refill is required. 7. Nursing will be responsible for initial and ongoing assessment of the pump as outlined below. PROCEDURE/PROCESS: 1. On admission, nursing will: A. Identify the presence of the insulin pump. B. Check the patient's blood glucose to ensure it is within normal range. C. Notify the physician of the presence of the pump and if any contraindications for insulin pump therapy are present (listed under Key Points). D. If no contraindications exist, the RN will review and assess patient knowledge and skill level using Insulin Pump Patient Assessment Tool (Appendix A) in the EHR. E. The patient must be able to show the RN and identify the pump settings so that the RN can document the settings in the EHR in Documented Medications by Hx. If the patient is unable to do the following, they are not considered appropriate for inpatient use of their pump. 1. Confirm ability to safely manage his/her own device with the Insulin Pump Patient Assessment Tool (Appendix A). 2. Identify name, model, and serial number of the insulin pump. 3. Identify name and type of insulin used. F. Have the patient sign the Insulin Pump Patient Agreement Form (Appendix B). If patient refuses to sign, call physician and obtain orders for intravenous or subcutaneous insulin regimen. G. Have the patient sign the CSM Release of Responsibility For Administering Medication Not Dispensed by the Hosptial.(Appendix C). H. Immediately tag or secure to the pump, if being removed from the patient, identifying information: 1. Patient's name 2. Patient's phone number 3. Patient's home address I. Facilitate physician/endocrinologist in order process by ensuring the Insulin Pump Patient Owned PowerPlan has been ordered in the EHR. J. Instruct the patient to report all episodes of low blood glucose (<70 mg/dl) or high blood glucose (>300 mg/dl) throughout the hospital admission. K. If the insulin pump is discontinued permanently, obtain new orders for intravenous or subcutaneous therapy. Do not discontinue pump until alternative insulin regimen administered. 2. Ongoing nursing assessment will include the following: A. Documenting the following in the EHR: 1. Bolus doses delivered by the pump on MAR. Page 5 of 9
2. Blood glucose recorded by hospital glucometer at least four times a day. B. Observe patient whenever they deliver bolus doses of insulin or make changes in basal rates. Basal rates or any other pump settings should only be changed with an endocrinologist order or diabetes educator consult. RN should confirm rate changes with patient and document on MAR. C. If a patient is using a continuous glucose sensor, double check hypo- or hyperglycemic values using a hospital glucometer. D. Changes in pump settings: 1. Must be ordered by a physician in the Insulin Pump Patient - Owned PowerPlan. 2. Patient will be responsible for manually adjusting rates and/or settings. 3. RN will witness adjustments and document on MAR in a timely manner. E. Visually inspect the insertion site every shift to assess for leakage and/or infection. Observe and document infusion site change every 48-72 hours, assess as needed (see Documentation section). The infusion site should be changed if any of the following occur: 1. The infusion site is red, swollen, or warm to touch. 2. Bleeding is noted at the site. 3. If leakage of insulin is noted. 4. Discomfort is felt at the site. 5. A "no delivery alarm" where it is confirmed that the reservoir is not empty. 6. The patient has two consecutive blood glucose readings greater than 300 mg/dl (see step F). F. Hyperglycemia is defined as blood glucose >300 mg/dl. If the patient has a single blood glucose reading greater than 300 mg/dl perform the following: 1. Allow patient to correct with the insulin pump. RN should document correction bolus on the MAR. Recheck the blood glucose in 90 minutes. 2. If the repeat blood glucose is still >300 mg/dl, patient to administer correction bolus per the suggestion of the insulin pump by insulin syringe subcutaneously and RN to contact physician for further instruction. G. Hypoglycemia is defined as blood glucose <70 mg/dl. If the instance of hypoglycemia, follow the hospital hypoglycemia protocols. 1. Nurses should be aware that patients with a continuous glucose monitoring system who become hypoglycemic may have their pump turn off automatically and cycle back on. This is normal procedure for some pumps. Hypoglycemic policy should still be adhered to in conjunction with the patient's knowledge of their pump. H. Obtain physician order for Diabetes Education if more assessment and education are needed for patient. I. Reassess the patient frequently for any changes in mental or physical status (See Key Points). If an altered state of consciousness or inappropriateness is noted: 1. Check serum blood glucose immediately. a. If the patient is hypoglycemic (blood glucose < 70 mg/dl), initiate the Hypoglycemia Protocol and notify the physician. Page 6 of 9
b. If the patient is not hypoglycemic, notify the physician of the patient's change in condition. J. Disconnection Procedure ***Remember: Interruption in insulin delivery for more than 1 hour can lead to severe hyperglycemia and DKA which may be life-threatening*** 1. The insulin pump may be disconnected for a period of time 1 hour. Examples of when this may appropriate include: showering/bathing which may result in the insulin pump getting wet, a procedure which may result in damage to the pump or exposure to radiation. (See Appendix D - Disconnecting infusion sets) a. Temporary disconnection - the patient should follow manufacturer's guidelines for disconnection and/or temporary suspension of pump operation. b. Imaging radiation procedures must be performed promptly and without delay, to ensure the patient is not off the pump for more than 1 hour. i. For CT scan, X-Ray and other radiation exposure: Patient should remove the insulin pump, sensor, transmitter, meter, and remote control before entering the room. If the patient has a pump where the infusion set is integrated into the insulin pump (i.e. Omnipod ), the entire device needs to be removed. Patient or designated caregiver is responsible for security of the insulin pump while disconnected. It is imperative that the pump be resumed after the procedure is completed. ii. For MRI, PET scans due to presence of magnet: Metal infusion sets must be removed before an MRI or PET scan is performed (i.e. Sure-T infusion set). K. Discontinuation of the Insulin Pump for periods > 1 hour or indefinitely (i.e. going to surgery and anesthesiologist wants discontinued, altered level of consciousness) 1. Prior to discontinuation of the pump, call physician to obtain orders for a subcutaneous or intravenous insulin regimen. Do not disconnect the pump until able to deliver subcutaneous or intravenous insulin. 2. Document the reason for discontinuation of the insulin pump in a progress note. 3. Notify the patient and/or family/caregivers of the reason(s) for discontinuing the insulin pump. Send the insulin pump home with family or person designated by the patient. 4. Document whereabouts of pump in Valuables and Belongings form. 5. Have the patient disconnect the tubing from the infusion set. Have the patient remove the infusion set if disconnection is for more than 24 hours. a. If patient is unable to remove the infusion set or their status changes, the nurse should remove the infusion set and document that it was removed. L. Restarting Pump After Disconnection 1. When an insulin pump is restarted, the patient is at risk for hypoglycemia due to an overlap of NPH or Levemir insulin and the pump's basal insulin. In order to reduce the chances of hypoglycemia, it is our policy that a temporary basal rate is established during the restart of an insulin pump. 2. The temporary basal rate will be set to zero units/ml or a percentage determined by the provider for the remaining effective time from the last administration of NPH or Levemir. After this time passes, the temporary basal rate will expire and the patient's normal basal rate will resume. Page 7 of 9
a. NPH - a total of 12 hours will pass before the normal insulin resumes. b. Levemir - a total of 18 hours will pass before the normal insulin resumes. 3. Temporary basal rates can be set by the patient (if knowledgeable) and verified by the DTC or Endocrinologist; or can be set by the DTC staff or Endocrinologist. M. Pump Malfunction: 1. The most common malfunction is a no delivery alarm. In this instance the reservoir should be checked to see that it is not empty. If it is empty, replacement insulin should be obtained through the patient's own supply or by contacting pharmacy. 2. If the reservoir is not empty, the patient should change the infusion site. 3. If a malfunction occurs supervise the patient to contact the manufacturer using the toll-free number on the back of the insulin pump for troubleshooting. If the patient is unable to complete the manufacturer's recommended trouble-shooting or the pump continues to malfunction call the physician for further orders (see step K). DOCUMENTATION: 1. Form/Document title: A. Insulin Pump Patient Owned PowerPlan B. Appendix A: Insulin Pump History Power Form C. Appendix B: Insulin Pump Patient Agreement D. Appendix C: CSM Release of Responsibility For Administering Medication Not Dispensed by the Hospital. 2. Instructions: Each medical professional will document in the medical record where appropriate. Documentation of the following may be done by the physician, RN, diabetes educators, and CSM Diabetes Teaching Center. A. Physician B. Nurse 1. Presence of any contraindications for Insulin Pump Therapy (see key point #1) on the required insulin pump order form. 2. Name/model of insulin pump. 3. Type/name of insulin. 4. Actual pump settings: a. Basal rate(s) b. Insulin-to-carb ratio(s) c. Insulin sensitivity or correction factor/ratio(s) 1. Complete the Insulin Pump History Power Form in the EHR. 2. If patient is deemed competent to self-manage their insulin pump during the hospital stay: a. Complete and sign with patient the CSM Release of Responsibility Form for Administering Medication Not Dispensed by the Hospital. Page 8 of 9
b. Document that the patient has signed the Insulin Pump Patient Agreement Form (Appendix B). If patient declines to sign the agreement, document the notification of the physician, the alternate insulin regimen ordered, and discontinuation of the insulin pump in a progress note. 3. During the admission, if the insulin pump is discontinued, document the orders received for intravenous or subcutaneous insulin therapy and the date/time the insulin pump was discontinued in a progress note. Document the name of person who accepts responsibility for the discontinued pump (Patient Belongings Form). REFERENCES: 1. ADA Standards of Medical Care, Diabetes Care, Volume 39, Sup 1, January 2016 2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. 3. Institute for Safe Medication Practices. Managing Hospitalized Patients With Ambulatory Pumps: Findings from an ISMP-Survey Part 1. https://www.ismp.org/newsletters/acutecare/ showarticle.aspx?id=125 November 19, 2015 4. 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. Journal of diabetes science and technology (Online). 2008;2(6):948-962. Attachments: Approval Signatures Appendix A - Insulin Pump Patient Assessment Tool Appendix B - Insulin Pump Patient Agreement Appendix C - CSM Release of Responsibility Appendix D - Disconnecting infusion sets Step Description Approver Date Gloria Rawski: Policy/Clinical Database Coordinator 03/2017 Pharmacy & Therapeutics Committee Laura Alar: Dir. Pharmacy & Retail Med 03/2017 Laura Alar: Dir. Pharmacy & Retail Med 03/2017 Page 9 of 9
Insulin Infusion Pump Patient Owned: Provider Workflow Printable Job Aid Steps for managing patients admitted to the hospital who qualify for use of a home insulin pump. Step 1: Reconcile the insulin pump medications during Admission Medication Reconciliation. a) Click on Admission from the Reconciliation dropdown in the Orders module. The Medication Reconciliation Window will open. b) Click the circle under the green arrow to continue both Insulin Pump Basal AND Insulin Pump Bolus-Meals. The basal and bolus-meals settings as entered by the nurse in Document Medications by Hx will display under Order Comments c) For both the Basal and Bolus orders, click on the medication name on the right side to open the medication scratchpad and review order settings in the Order Comments tab. d) Also, in the Details tab, as a safety feature, select Yes to the required field *Insulin Pump Settings Entered in Comments? e) Reconcile other non-insulin medications as appropriate and sign. Step 2: Place Insulin Pump Patient Owned PowerPlan: a) Enter Insulin Pump in the Search box b) Select Insulin Pump Patient Owned c) Most orders within the plan are pre-selected based on Insulin Pump Policy. Customize these orders as needed for your patient. d) Initiate or Sign based on patient location. Columbia St. Mary s, Inc., Ascension Health. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express written consent of Columbia St. Mary s Inc. Updated: 4/20/17
Insulin Infusion Pump Patient Owned: Provider Workflow Printable Job Aid Step 3: Review MAR Summary as needed to monitor insulin administration. a) View the Basal settings check documented. b) View the number of units administered for the Bolus-Meals dose. Step 4: Prior to Discharge, reconcile the insulin pump medications with Discharge Medication Reconciliation. a) Click on Discharge from the Reconciliation dropdown in the Orders module. The Medication Reconciliation Window will open. Continue or discontinue the insulin pump orders as entered as Document Medications by Hx. Do not create a new prescription as order settings will not effectively convert. b) Reconcile other non-insulin medications as appropriate and sign. 2 Columbia St. Mary s, Inc., Ascension Health. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express written consent of Columbia St. Mary s Inc. Updated: 4/20/17