A patient with type 1 diabetes admitted for lidocaine infusion to treat severe headaches initially seems competent to manage his own insulin pump. But physicians worry when he develops confusion. How do they convince him to have the pump removed during his stay?
Potentially difficult negotiations are just one of the issues that can arise when patients on continuous subcutaneous insulin infusion, or insulin pumps, are admitted to the hospital. With an estimated 400,000 type 1 patients with diabetes now using pumps, chances are that hospitalists will begin to encounter pumps more often.
“You won't always have a [pump] patient on your service, but almost all hospitalists will be exposed to these patients over the course of a few months,” said Gregory Maynard, MD, ACP Member, hospitalist and director of the Center for Innovation and Improvement Science at the University of California, San Diego. “There need to be some set criteria around who can and can't be on pumps and what to do if you stop a patient's pump.”
It may be unrealistic to train every hospitalist in the full complexities of pump management, but every hospital should have a protocol for dealing with pumps, he said. Hospitalists also should have access to an endocrinologist or, alternatively, an inpatient diabetes team or pharmacist with pump expertise.
“You need an infrastructure in place,” said Robert J. Rushakoff, MD, FACP, professor of medicine at the University of California, San Francisco (UCSF). “Appropriate nurse and physician training, order sets, policies and procedures should be there as a base, because just doing ad hoc management will lead to disaster.”
Heading off problems
Both the American Diabetes Association and the American Association of Clinical Endocrinologists recommend allowing patients to continue using their pumps while hospitalized if they are physically and mentally able. They also recommend having a policy on pump use and specialists in pump management on hand.
“In general, you're trying to keep the patient on their pump if you can,” said Dr. Maynard. “But you need a few knowledgeable people who know what to do if something goes wrong.”
In the absence of an endocrinologist, clinicians need to have at least a basic understanding of how pumps work to avoid potential problems, said Dr. Maynard.
If a hospital doesn't have an endocrinologist or other expert in pump management on site, it may in some cases be safer to remove the pump and switch the patient to subcutaneous insulin with pre-meal bolus injections, said Dr. Rushakoff. “If a physician [at a small hospital] takes care of one patient [with a pump] every 8 to 12 months, and it's a different pump every time, how can they be expected to help manage that patient?”
Certain other situations necessitate removing the pump, said Irl B. Hirsch, MD, FACP, professor of medicine and chair of diabetes treatment and teaching at the University of Washington in Seattle. For example, patients being treated with steroids for kidney transplant rejection should be placed on intravenous insulin, along with subcutaneous bolus injections for meals, for the first few days of their stay, to counter the glycemic effect of steroids. Patients who are receiving high-dose steroids are extremely difficult to manage with subcutaneous insulin alone, he said.
And any patient who is cognitively impaired or too sick to self-manage should be taken off the pump and placed on background insulin, pre-meal bolus insulin and correction doses, said Dr. Hirsch. However, clinicians should be aware that a patient's insulin needs could change significantly depending on their condition.
“If you don't know what their requirements are, you can go into the pump and scroll through to get an idea of how much insulin they would need,” he said. “But the person's basal insulin may be extremely different at home versus being sick in the hospital. We would put them on IV insulin drip so we can see exactly what their insulin requirements are.”
Whenever possible, involve an endocrinologist in care for patients with pumps. “There's not a lot of training around the device itself and how to correctly order the insulin around different clinical scenarios that arise, so it helps to rely on an expert to guide you,” said Doron Schneider, MD, FACP, chief safety and quality officer at Abington Memorial Hospital in Abington, Pa.
A specialist can also help deal with issues such as pump malfunction or dislodgement, which can ultimately lead to diabetic ketoacidosis, he said. Other potential problems include cessation of insulin flow while patients are being transferred to another bed or washed, for example.
“Co-managing with an endocrinologist is very helpful because these patients go through transitions during their stay—they have tests where pumps might have to be turned off or they change status from eating to not eating,” said Dr. Schneider. “There are so many transitions in the hospital environment that even with the patient who can self-manage, questions arise and having access to a specialist is really helpful.”
Patients with pumps at UCSF are seen by endocrinologists, according to Dr. Rushakoff. “Our standard policy is that if a patient comes in with a pump, there is mandatory consultation with endocrinology so the patient gets assessed and has appropriate follow-up,” he said.
In general, pump patients are usually very sophisticated about self-management, said Dr. Maynard. However, problems can arise in the hospital due to poor communication between patients and clinicians about each side's responsibilities during the hospital stay.
A good protocol for pump management begins with an assessment of patients' mental status to ensure they are awake, alert and ready to participate, said Dr. Maynard. However, physicians should remember that it is not always easy to ascertain whether or not patients are cognitively capable of managing their diabetes, said Dr. Hirsch. A patient could be alert, physically able and cognitively unimpaired but unused to managing the pump in a hospital setting.
Hospitalists should make sure patients are very familiar with how to make adjustments in their pumps, Dr. Rushakoff said. Some patients will appear competent to self-manage but actually know only enough to get by under normal circumstances at home.
Even competent patients might assume that they can continue to make adjustments to their doses on their own at any time, as they are used to doing at home, said Dr. Rushakoff. Meanwhile, without sufficient communication, hospital clinicians could be writing additional orders or administering insulin.
“Now, in the hospital, [the patient] is doing the same thing as at home, often with their own glucose meter that they didn't tell anyone they were using,” he said. “They're taking extra insulin and not telling anyone, and then they become hypoglycemic and no one knows why.”
If a patient is going to stay on a pump during hospitalization, he or she should agree to certain conditions, such as:
- Notifying hospital staff of all self-administered insulin doses;
- Understanding that the pump may have to be removed for certain tests, such as MRI scans; and
- Signing an agreement approved by the hospital pharmacist that the patient will be administering insulin stored in the pump (i.e., not prescribed by the hospital pharmacy).
“All those pieces have to be in place to make use of the pump safe and consistent,” said Dr. Maynard.
To ensure that patients are using their pumps appropriately, the University of Washington Medical Center requires that nurses record all glucose measurements and document every change in insulin so physicians can see the patients' progress and pre-meal bolus doses, said Dr. Hirsch.
The hospital's food menu also shows the amount of carbohydrates in every meal, so patients know how much insulin they will need to maintain the correct carbohydrate-to-insulin ratio.
With these precautions and a very close eye, patients with insulin pumps can be safely cared for in the hospital. “They need daily reassessment,” said Dr. Schneider. “It's really about having a negotiation and shared understanding between the patient and the hospitalist with the guidance of an endocrinologist.”