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AACE Patient Safety - Ask the Experts - Discussion Forum

Inpatient insulin infusion pumps

Question from Siobhain McHale:
There is a need for policy and procedure to be written if one is to allow an inpatient to keep their insulin infusion pump while in the hospital.

Are there any hospitals that have policies and procedures in place that would allow inpatient's to keep their insulin infusion pumps and use them during their hospital stay? Is there any precedent or research that either supports this practice or is there literature that this would be too risky?

Answer from Irl B. Hirsch, MD:
As insulin pump use continues to grow, not only in the US but around the world, this topic is receiving much more attention. Currently, there is no standard on how to best deal with CSII in the hospital setting. Importantly, there are no randomized trials (to my knowledge anyway) using CSII in patients receiving outpatient pump therapy and assessing subsequent outcomes when continued on their pump.

The situation is complicated by the degree of illness (and cognition) by the patient and therefore level of potential for self-care and the level of comfort of insulin therapy in general and CSII in particular by the treating physician. Often the treating physician in the hospital has little to no experience with CSII further complicating what the best practice may be. On top of the typical patient on a medical floor, there are futher issues to consider for the patient in surgery if the anesthesiologist is not familiar with CSII.

With this background, each hospital needs to have a written policy on how to best handle patients using CSII. There are many potential options. In my hospital for example if the patient is able to self-mange his or her diabetes we simply allow the patient to handle the insulin with the nurse recording all insulin bolus insulin for the medical record. Other hospitals require automatic referral to an endocrinologist or endocrine team (which often includes a nurse or nurse practitioner with expertise in CSII). I have also seen hospital policy demand the patient remove the pump and instead move to multiple injections (often a "sliding scale" mentality with no scheduled insulin). Obviously, this is doomed to failure. If a decision is made to stop the pump and instead use multiple injections, at the very least basal insulin (glargine or detemir) and prandial insulin (rapid acting analogue) should be the approximate doses used with the pump.

This deserves more study but due to such variability in the understanding of insulin and CSII, any study may be difficult to interpret in the "real world".

Leave a Comment

There are 3 comments

Arvind Cavale – Feasterville, PA

July 31, 2008 - 23:35

Subject: CSII in Hospital

Unfortunately, based on my experience, community hospitals (even those with Endocrinologist on board) will almost always have this problem. The issue is not just hospital-based physicians (IMs, FPs, Cardiologists, Pulm/CC) but also nursing staff, that have no clue as to how to manage an insulin pump patient. Best practical option would be to have an RN/CDE or RD/CDE that is also a certified pump trainer on staff. This individual can be called in to advise the nurses and help admitting physicians on how to manage the pump. Another option would be for the hospital to contract with each pump manufacturer to have their certified trainer available for hospital visits to guide admitting physicians. In my experience, national policies very rarely help, especially community hospitals. Unlike University hospitals, most physicians in community hospitals simply don't have time to learn new protocols, etc. There has to be real-time professional help available to help the docs manage CSII patients. First, we must work to rid the hospitals of the "sliding scale virus".

Irl B. Hirsch, MD – Seattle, WA

July 25, 2008 - 22:14

Subject: Re CSII in Hospital

Great points! And my guess is you do very well with this issue in your hospital. But what about hospitals that don't have an endocrine team, or a clinical endocrinologist on the staff to help manage these patients? This is why your last point is the most important: we need national policies which both endocrinologists and non-endocrinologists can turn to which will help us better manage these patients.

Harmeet Singh Narula, MD – Stony Brook, NY

July 24, 2008 - 19:47

Subject: Re CSII in Hospital

Excellent question! I agree with Irl that all hospitals MUST develop their policy regarding CSII use in the hospitalized patients.
Our policy is to continue insulin pump use UNLESS the patient is unable to fully participate in their care (due to acute neuro-psychiatric illness, or acute medical illness or critical illness), and to have the Endocrine service follow each insulin pump patient, and IF the primary team wishes to discontinue the pump for any reason (surgery, etc), to discuss it with Endocrine first, and transition the patient to an appropriate basal-bolus insulin regimen FIRST before discontinuing the pump.
Would be nice for national societies (like AACE) to issue a statement calling on all hospitals to draft such policies, for patient safety, and prevent iatrogenic insulin mishaps (aka DKAs!).