In the Journals

Consensus statement: More data needed on inpatient insulin pump therapy use

Bithika Thompson
Bithika Thompson

Hospital protocols are needed to outline the proper use of insulin pump therapy in the inpatient setting, but with careful management, many patients with diabetes can safely continue to use insulin pumps while hospitalized, according to a new consensus statement published in the Journal of Diabetes Science and Technology.

“Patients with insulin pumps are being seen with increasing frequency in the hospital setting,” Bithika Thompson, MD, assistant professor of medicine in the division of endocrinology at the Mayo Clinic in Scottsdale, Arizona, told Endocrine Today. “Although this patient population represents a small percentage of those hospitalized with diabetes, it is a high-visibility population. There is a large potential for error on the part of the health care team if they lack familiarity with these devices.”

In May 2017, the Diabetes Technology Society convened a panel of U.S. endocrinology experts in Atlanta to discuss current and future use of insulin pump therapy in the inpatient setting. Thompson, along with Curtiss B. Cook, MD, and Mary Korytkowski, MD, served as moderators for three topics: current evidence for inpatient use of insulin pump therapy, recommended contraindications for inpatient use of pump therapy, and best practices to ensure safe transitions of pump therapy during an inpatient stay. Panelists also assessed findings from six retrospective reviews and two case reports on pump therapy in the inpatient setting.

Evidence for hospital use

There is little data comparing the use of pump therapy with conventional basal-bolus therapy in hospitalized patients, the panelists wrote; however, the committee agreed that patients successfully using the technology in the outpatient setting should be allowed to continue the use of pump therapy as an inpatient, provided the patient is deemed competent to do so.

“There is evidence that patients who are allowed to continue [pump therapy] in the hospital setting feel more involved in their care, and as a result, report higher levels of satisfaction with their care,” the panel wrote. “Panelists also pointed out that evaluation of pump use in the inpatient setting is a unique opportunity for the physician to examine current settings for basal rates, insulin-to-carbohydrate ratios and correction factors on a day-to-day basis in a structured setting.”

The panelists recommended the development of institutional protocols for inpatient use of pump therapy to ensure compliance with desirable behaviors, such as obtaining an endocrinology consult, documenting patient agreement forms and entering necessary orders. The panel cautioned that insulin pump use in the hospital can cause confusion among hospital staff who may be unfamiliar with the technology, increasing the risk for medication errors and glycemic events.

“Insulin pumps can be used safely in the hospital provided there are protocols in place to ensure this safety,” Thompson said. “Clinicians should be able to assess a patient to determine ability to safely continue use of the pump in the hospital and recognize when transition to alternate treatment would be advisable.”

Contraindications for use

Not all patients utilizing insulin pump therapy are good candidates to continue pump use in the inpatient setting, the panelists noted. Upon admission, providers should assess patients for their ability to safely continue pump therapy.

“Special consideration should be given to the reason for hospitalization (eg, monitoring, surgery, treatment), the acuity of the condition for which the patient is hospitalized, as well as the willingness and ability of the patient to operate the pump during the hospitalization,” the panel wrote.

Pump therapy should be discontinued in patients hospitalized with a critical illness, including diabetic ketoacidosis or hyperglycemic hyperosmolar state. In specific cases, such as before upcoming major surgery, practitioners may proactively consider transitioning a patient to basal-bolus insulin therapy, the panel wrote. Insulin management can also become difficult when high doses of glucocorticoid therapy are initiated, which can cause elevations in blood glucose.

“In many cases, insulin pumps should be removed for patient safety,” the panel wrote. “As the clinical course changes, this decision should be constantly reassessed to determine the need to remove the pump or the ability to restart the pump. Providers must work closely with patients to decide on the best course of action.”

Thompson added that large, multicenter studies of insulin pump use demonstrating safety and efficacy of continued use in the hospital are lacking, and that institution-specific reports of insulin pump use would be useful to gain a better understanding of inpatient use of this technology.

The guideline pertains to adult inpatients only and does not apply to perioperative or labor and delivery settings. – by Regina Schaffer

For more information:

Bithika Thompson, MD, can be reached at the Mayo Clinic, Division of Endocrinology, 13400 E. Shea Blvd., Scottsdale, AZ 85259; email: thompson.bithika@mayo.edu.

Disclosures: One author reports she has served on an advisory board for Novo Nordisk; another reports he has served as a consultant for Ascensia, EOFlow, Intarcia, Lifecare, Novo Nordisk, Onduo and Voluntis.

 

 

Bithika Thompson
Bithika Thompson

Hospital protocols are needed to outline the proper use of insulin pump therapy in the inpatient setting, but with careful management, many patients with diabetes can safely continue to use insulin pumps while hospitalized, according to a new consensus statement published in the Journal of Diabetes Science and Technology.

“Patients with insulin pumps are being seen with increasing frequency in the hospital setting,” Bithika Thompson, MD, assistant professor of medicine in the division of endocrinology at the Mayo Clinic in Scottsdale, Arizona, told Endocrine Today. “Although this patient population represents a small percentage of those hospitalized with diabetes, it is a high-visibility population. There is a large potential for error on the part of the health care team if they lack familiarity with these devices.”

In May 2017, the Diabetes Technology Society convened a panel of U.S. endocrinology experts in Atlanta to discuss current and future use of insulin pump therapy in the inpatient setting. Thompson, along with Curtiss B. Cook, MD, and Mary Korytkowski, MD, served as moderators for three topics: current evidence for inpatient use of insulin pump therapy, recommended contraindications for inpatient use of pump therapy, and best practices to ensure safe transitions of pump therapy during an inpatient stay. Panelists also assessed findings from six retrospective reviews and two case reports on pump therapy in the inpatient setting.

Evidence for hospital use

There is little data comparing the use of pump therapy with conventional basal-bolus therapy in hospitalized patients, the panelists wrote; however, the committee agreed that patients successfully using the technology in the outpatient setting should be allowed to continue the use of pump therapy as an inpatient, provided the patient is deemed competent to do so.

“There is evidence that patients who are allowed to continue [pump therapy] in the hospital setting feel more involved in their care, and as a result, report higher levels of satisfaction with their care,” the panel wrote. “Panelists also pointed out that evaluation of pump use in the inpatient setting is a unique opportunity for the physician to examine current settings for basal rates, insulin-to-carbohydrate ratios and correction factors on a day-to-day basis in a structured setting.”

The panelists recommended the development of institutional protocols for inpatient use of pump therapy to ensure compliance with desirable behaviors, such as obtaining an endocrinology consult, documenting patient agreement forms and entering necessary orders. The panel cautioned that insulin pump use in the hospital can cause confusion among hospital staff who may be unfamiliar with the technology, increasing the risk for medication errors and glycemic events.

“Insulin pumps can be used safely in the hospital provided there are protocols in place to ensure this safety,” Thompson said. “Clinicians should be able to assess a patient to determine ability to safely continue use of the pump in the hospital and recognize when transition to alternate treatment would be advisable.”

Contraindications for use

Not all patients utilizing insulin pump therapy are good candidates to continue pump use in the inpatient setting, the panelists noted. Upon admission, providers should assess patients for their ability to safely continue pump therapy.

“Special consideration should be given to the reason for hospitalization (eg, monitoring, surgery, treatment), the acuity of the condition for which the patient is hospitalized, as well as the willingness and ability of the patient to operate the pump during the hospitalization,” the panel wrote.

Pump therapy should be discontinued in patients hospitalized with a critical illness, including diabetic ketoacidosis or hyperglycemic hyperosmolar state. In specific cases, such as before upcoming major surgery, practitioners may proactively consider transitioning a patient to basal-bolus insulin therapy, the panel wrote. Insulin management can also become difficult when high doses of glucocorticoid therapy are initiated, which can cause elevations in blood glucose.

“In many cases, insulin pumps should be removed for patient safety,” the panel wrote. “As the clinical course changes, this decision should be constantly reassessed to determine the need to remove the pump or the ability to restart the pump. Providers must work closely with patients to decide on the best course of action.”

Thompson added that large, multicenter studies of insulin pump use demonstrating safety and efficacy of continued use in the hospital are lacking, and that institution-specific reports of insulin pump use would be useful to gain a better understanding of inpatient use of this technology.

The guideline pertains to adult inpatients only and does not apply to perioperative or labor and delivery settings. – by Regina Schaffer

For more information:

Bithika Thompson, MD, can be reached at the Mayo Clinic, Division of Endocrinology, 13400 E. Shea Blvd., Scottsdale, AZ 85259; email: thompson.bithika@mayo.edu.

Disclosures: One author reports she has served on an advisory board for Novo Nordisk; another reports he has served as a consultant for Ascensia, EOFlow, Intarcia, Lifecare, Novo Nordisk, Onduo and Voluntis.