April 19, 2016

Best Practices for Inpatient Insulin Pump Use

Recognizing and supporting diabetic patients

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By Cecilia Lansang, MD, MPH

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Cecilia Lansang, MD, MPH

As endocrinologists, your patients with diabetes may be hospitalized for a variety of reasons, including cardiovascular, gastrointestinal or other disease. At Cleveland Clinic’s Endocrinology Consult Service, we help balance patients’ autonomy and safety as they navigate their hospital stay.

At Cleveland Clinic, at least 50 patients using an insulin pump were admitted last year, and more and more patients are choosing this option for managing their diabetes. This continuous subcutaneous insulin infusion (CSII) method of delivery allows patients to self-manage and affords them flexibility suited to their lifestyles.

When patients on insulin pumps are ill and hospitalized, however, they may need assistance with adjusting insulin doses, or may need to be switched to basal-bolus subcutaneous insulin injections if they are unable to continue to care for themselves. Therefore, physicians and other inpatient providers must be able to recognize these patients in the hospital, make the decision to continue the pump and guide patients regarding dose changes, or discontinue the pump with an appropriate change to basal-bolus insulin.

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Support for inpatient insulin pump use

The American Diabetes Association and American Association of Clinical Endocrinologists advocate for allowing patients who are physically and mentally able to continue CSII when hospitalized, and recommend that hospitals establish an appropriate policy and make available hospital personnel with expertise in pump management. Cleveland Clinic has such a policy, and strongly encourages an endocrinology referral for subspecialty partnership in taking care of these patients.

Here are highlights of the basics that we share with other providers:

  • Most insulin pump models require tubing, but some do not. They may be missed on physical exam as they can be inserted near the buttock, on the shoulders or on the thighs, and not just on the abdomen.
  • Insulin is delivered by a subcutaneous catheter continuously to provide the basal dose (called the “basal rate”). However, the patient must activate the pump for mealtime insulin or to correct for a high glucose, or both.
  • Pumps must be removed for certain procedures, such as CT scans, MRIs, fluoroscopy and electrocautery surgery. We recommend removing the insulin pump for surgery lasting more than one to three hours.

General contraindications to insulin pump use in the hospital:

  • Altered state of consciousness
  • Suicidal ideation
  • Prolonged instability of blood glucose levels
  • Diabetes ketoacidosis
  • Patient/family inability or refusal to participate in patient’s care
  • Insulin pump malfunction
  • Lack of appropriate supplies for the insulin pump
  • Other circumstances as identified by the physician, resident or licensed independent practitioner

Steps for guiding inpatient insulin pump therapy

Once patients requiring inpatient insulin pump therapy are identified, insulin pump orders must be issued to ensure that insulin is delivered to them from the pharmacy, to have their point-of-care glucose readings taken, and to receive assistance with dosing or carbohydrate counting.

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If the decision has been made to discontinue an insulin pump while in the hospital, patients are often best managed on a long-acting insulin for basal needs, mealtime insulin to cover the carbohydrates in the meals and supplemental insulin to correct for hyperglycemia.

Cecilia Lansang, MD, MPH, is Director of Inpatient Diabetes Services in the Department of Endocrinology, Diabetes and Metabolism at Cleveland Clinic and an Associate Professor of Medicine at Cleveland Clinic Lerner College of Medicine. She can be contacted at 216.445.5246 or lansanm@ccf.org.

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