Ensuring safe insulin pump therapy during hospitalization

BY MARY MOYER JANCI, ARNP, BC-FNP, BC-ADM, CDE

Being in the hospital can be frightening for patients with diabetes and can lead to anxiety and frustration. This is understandable. Many healthcare teams are not as experienced in caring for patients’ blood sugars as well as their physicians. Many don’t even know what an insulin pump looks like. And people who use insulin pumps often want to use pumps during their hospital stay because their blood sugars at home are in good control.

Here’s an example: “Kathy” is 35 years old with type 1 diabetes. She wears an insulin pump. When she was hospitalized for planned surgery, she wore her pump during surgery with her surgeon’s approval. After surgery, her blood sugars went high so she increased her basal rate to cover the high sugars. She changed the infusion set one day before surgery thinking it would last through the hospital stay. But after increasing her basal rate and using more correction, she ran out of insulin early. She forgot extra pump supplies so her husband brought them in. She changed her infusion set and site, and continued to run her pump on the higher basal rates.

Two days after surgery she started having low blood sugars. She couldn’t figure out why, so she just kept treating the low blood sugar level without telling her health care team. Now her blood sugars were swinging too high and too low. Her decision not to talk to her healthcare team increased her chances of severe low blood sugars. And with all the high blood sugars, her danger of getting an infection in her surgical incision was stronger.

What are the reasons for her problems? She did not get the help she needed by telling her medical team about uncontrolled blood sugars. Then she increased regular basal rates instead of using temporary basal rates. She also should have changed her infusion set the day of surgery to make sure the insulin and site lasted longer. And she should have packed extra pump supplies in her suitcase. The bottom line… she put herself in danger by not communicating with her healthcare team.

So what can you do to help your healthcare team take better care of you during your hospital stay? Keep in mind you are often the person educating your care team on insulin pumps. These medical professionals want to help you, but can’t if they don’t know you are having problems. It is very important to keep blood sugar in good control while in the hospital because it will help with faster wound healing, a reduced chance of infection and shorter hospital stays. So speak up for yourself and educate those caring for you about how a pump works. You are the expert pump user!

Below is a list of 10 things to do when wearing your pump in the hospital.

  1. Talk to your surgeon about wearing your pump When you have a planned surgery, it’s important to ask your surgeon if you can wear your pump during surgery. And ask what part of the body will be the site for the incision. For surgery lasting less than two hours, you can safely use the pump. Ask your surgeon where you should insert your pump on the day of surgery so it is not in the way of the incision. Also, it is recommended not to place the pump in your buttocks or loin because it can be pulled out when the team moves you on and off the operating table. AND make sure you change the infusion set and site and use fresh insulin in the reservoir on the day of surgery. Then the pump can run for two to three days without needing to be changed.
  2. Tell your care team you are wearing a pump When you are admitted to the hospital, be sure to tell the care team (anyone who is touching your body) you wear a pump. Show them what a pump looks like. If the care team does not know you are wearing a pump, this can cause big problems and be unsafe. For example, you should take your pump off when sent to x-ray, CT scans, and MRIs, otherwise you can be injured and your pump broken. Call the 1-800 number on the back of the pump if you are unsure if it can be worn during an imaging study. Staying on your pump is a decision made by BOTH you and your healthcare team to ensure your safety.
  3. Tell your care team what type of insulin you use Most care teams expect all patients with diabetes to use insulin U100 in pumps (REGULAR, HUMALOG, and NOVOLOG). But this is not the case. Some people use insulin U500 REGULAR which is five times stronger than U100 insulin. If the care team doesn’t know this, you could end up using U100 when you need U500, and your blood sugars will go through the roof. It’s also important to tell one of your family members or friends in case you are unable to answer this question yourself.
  4. Allow your care team to remove your pump when it’s not safe to use You must be able to make decisions to operate your own pump when in the hospital. Sometimes situations occur or medications are needed that cause people to remain very sleepy and confused after surgery. When you can’t make safe decisions to run your pump, it must be stopped. Remember, your safety is now paramount. Your care team will choose another way to give you insulin, such as intravenously (IV) or subcutaneously (SQ) because you will get better control of high blood sugars and have less of a risk for low blood sugars. Having to stop your pump may be upsetting, but keep in mind your care team is on your side. This decision is in your best interest, and once your blood sugars are closer to normal, your pump can safely be restarted.
  5. Tell your care team the details when you eat meals This includes what time you eat, how much insulin you bolus and the amount of carbohydrates you eat. It is important your care team knows this information to better understand how well your diabetes is being treated. Your health care team will check your blood sugars before you eat and at bedtime. If you check your own blood sugars, tell your care team the test result.
  6. Bring extra pump supplies and change your set and site every 2-3 days Bring extra infusion sets and reservoirs because the hospital does not have these supplies. If you don’t have extra supplies, tell your care team so another way of delivering insulin (IV or SQ) is ordered and you can stop using your pump. If you decide to let your pump run longer than two to three days, your blood sugars will peak high. This can lead to infection, slow wound healing and lengthen your hospital stay.
  7. Report any low blood sugars to your care team Low blood sugars can be dangerous. It is not uncommon to experience lows after surgery because you are not eating for a while. When you are admitted, talk to your health care team about your diabetes regimen. Ask them to have juice ready at your bedside after surgery. Also tell your team if you are having low blood sugars because they can help you figure out what is causing these lows.
  8. Use your pump insulin-to-carbohydrate ratio to decide how much insulin to give at your meals. Don’t blindly guess! Guessing your insulin doses can cause very high and low blood sugars, which can lead to problems. Aiming for good blood sugar control is very important for proper healing and a shortened hospital stay.
  9. Take off your pump if it is not working properly Using a pump with error messages can be dangerous. You could get too much insulin and dangerous lows, or not enough insulin and end up in diabetic ketoacidosis. If this happens, make sure you share with your care team the 1-800 number found on the back of your pump and get your pump replaced.
  10. Tell your care team if you change your pump settings It is important for your care team to know exactly what is going on with your blood sugars and insulin doses. One example is changing your temporary basal rate to 110-120 percent after surgery to cover high blood sugars. It is your responsibility to tell your care team you are making these changes. And pump settings in the hospital often need to be reset to your home settings when you get discharged. Otherwise you will have problems. So tell your care team about any changes you make.

The healing process and recovery from surgery puts your body through a lot of stress. Before you go into the hospital, consider setting your next appointment with your diabetes care team one to two weeks after your surgery to make certain your blood sugars stay well controlled.

By following the above 10 steps, you can have a “sure and secure” hospital stay. These tips will keep you safe, keep your blood sugars in better control, lower your chance of infection and get you out of the hospital sooner.

AN INSULIN PUMP PRIMER

For those unfamiliar with insulin pumps, how they operate and the many advantages they offer as a treatment for diabetes, here are the basics.

An insulin pump is a small, computerized device about the size of a cell phone, worn externally and discreetly in a pocket, on a waistband or hidden under clothes, that some people with diabetes use to help manage their blood sugar. It works non-stop based on a programmed plan that is unique to each pump user. The pump releases insulin into the body slowly (much like how a healthy pancreas works) through a small flexible tube connected to the pump and placed under the skin in the belly. While people of all ages with type 1 diabetes — previously known as juvenile diabetes — use insulin pumps, people with type 2 diabetes have started to use them as well.

The pump cont inually delivers a precise amount of rapid-act ing insulin to the body between meals and overnight to keep the user’s blood sugar in the target range. This is known as the “basal rate.” When the pump user eats, he/she can program the pump to deliver extra insulin — known as a “bolus dose.” The bolus dose is determined by the pump user based on the grams of carbohydrates ingested and is based on settings that are determined by the user’s healthcare professional.

Pump users must st ill check their blood sugar at least four times a day. However, the device allows people with diabetes more freedom, allowing them to better match their insulin to their daily activities rather than matching their lifestyle to individual insulin injections.

Mary Moyer Janci is a clinician, educator and researcher at the University of Washington Medical Center in Seattle serving on both its inpatient Hyperglycemia Team and at its outpatient Diabetes Care Center. She is also a Teaching Associate in the School of Medicine, Division of Endocrinology. She has been published in journals Diabetes Care, The Diabetes Educator, CIN: Computers Informatics Nursing, Diabetes Spectrum, and AADE In Practice. She enjoys biking, traveling, gardening and time with her family.

One Person’s Perspective on Insulin Pump Use In A Hospital

By Vanessa Casillas, Psy.D

As a person with type 1 diabetes, the preceding article raises some important points.

If you’re like me, you may not have even realized that it’s an option to continue to wear your pump when admitted to the hospital. T he last time I was hospitalized I was told that I needed to take my insulin pump off immediately. Looking back, I realize that this request may have been because it was easier (or more familiar) for the hospital healthcare team and not necessarily because I could maintain better control of my blood sugar. I know now that another likely reason is because they didn’t have any supplies. Who knew? I will be bringing my own next time.

Additionally, leading up to and during a hospitalization, a person with type 1 diabetes is often in a position of particular reliance on their healthcare team. Part of me wants to believe that all medical personnel who work in a hospital know about every medical condition. While it’s somewhat hard to accept that this isn’t true, it’s important to acknowledge that not everyone on a healthcare team knows as much about diabetes and insulin pumps as you and your doctor do. During one hospitalization, I even had a person on my healthcare team admit to me directly that she had never seen an insulin pump before. I was caught off guard at the time, but appreciated her honesty. Unfortunately, this probably isn’t all that uncommon.

As persons with type 1 diabetes, we have the opportunity to continue to advocate for ourselves and insist on the best care and control over our diabetes as possible. T his may mean we may need to educate our hospital healthcare team about our conditions, our treatment regimens, and so forth. Every hospitalization is an opportunity for a person with type 1 diabetes to educate the healthcare team that they come in contact with. Taking this opportunity helps not only ourselves but also the patients that will come after us.

As suggested in the accompanying article, we can make hospitalizations a better and safer experience for persons with type 1 diabetes.

Vanessa Casillas has her Doctorate degree n Clinical Psychology and is the Clinical Director of Behavioral Health Integration for Providence Health and Services in Portland, Oregon. She was diagnosed with type 1 diabetes at the age of five and has worn an insulin pump for more than 10 years. She fondly refers to her insulin pump as “Jim.”