Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 26:

Diabetes Technologies

Donna Tomky, MSN, CDE1

1Tomky is a board certified adult nurse practitioner and certified diabetes educator working at ABQ Health Partners, Department of Endocrinology and Diabetes, Albuquerque, NM.

Technology offers many solutions to improve diabetes care in delivering more precise dosing of insulin and measuring glucose. Nurses are challenged to keep up with the latest technological advances available to individuals with diabetes. This chapter addresses what nurses need to know for safe and effective care of patients with diabetes wearing currently available continuous subcutaneous insulin infusion (CSII) pumps and continuous glucose monitoring (CGM) systems. Few health-care providers (HCP) will have practical knowledge of the operation of all the devices available in the rapidly changing field of diabetes technologies. HCPs will need to rely on the individual with diabetes, their caregivers, and diabetes technology experts and the manufactures for up-to-date operational information for each device.

Insulin pumps have been in use for >35 years for insulin replacement therapy. Estimated use in patients with type 1 diabetes (T1D) is near 20–30% and <1% in insulin-treated type 2 diabetes (T2D).1 According to Tucker, “When used correctly, insulin pumps can provide more convenient insulin delivery for patients and may improve blood glucose control.”CGM systems have been in use just over 10 years. CGM devices are designed to augment self–blood glucose monitoring for individuals with diabetes. CGM devices measure interstitial glucose. Nurses need to understand basic information about these devices to safely and effectively care for patients in all health-care settings.

OVERVIEW OF CSII PUMPS (INSULIN PUMP THERAPY)

Insulin pumps are portable devices continuously infusing rapid- or short-acting (regular) insulin into the subcutaneous tissue through a pumping mechanism. Current insulin pumps are not an artificial pancreas or implanted device. Hybrid closed loop systems that have the threshold suspend feature are considered the first step and further advances in technology are leading us closer to a truly artificial pancreas. Most insulin pumps today are designed to deliver precise preprogrammed doses of insulin for continuous flow of background (basal) insulin while allowing the wearer to give a surge (bolus) of insulin on demand for covering food or correcting elevated glucoses. Insulin pump therapy (IPT) requires the wearer to actively manage their diabetes by employing critical skills and knowledge for safe and effectiveness use.1 One of the most important ongoing self-care behaviors is frequent capillary blood glucose (CBG) monitoring (>4 times/day) for direct feedback about how well the insulin pump is working.

Insulin Pump Technology

An insulin pump is a small battery-operated mechanical device used to control the delivery of subcutaneous insulin. There are two different pump designs. The original and most commonly used pump design looks like a small pager that contains a reservoir of short- or rapid-acting insulin that is attached to a plastic tubing. At the opposite end of the tubing is a detachable 27- or 29-gauge needle or soft Teflon catheter, called an infusion set. Insulin flows from the reservoir, through the tubing into the infusion set tethered to the insulin pump. The needle or soft catheter (referred to as a cannula) resides in the subcutaneous skin and is the outlet for the insulin infusion.

The other pump design is a patch or pod that houses both the electronics and insulin with a Teflon catheter that is controlled remotely by a handheld device. The pod device is not tethered to the pumping device by tubing. The catheter of either device is inserted into the subcutaneous tissue and stays in place with self-adhesive tape or a bio-occlusive dressing. The pump wearer changes the infusion site every 24–72 h using aseptic technique. All pumps contain miniature computers that provide an array of basal and bolus functions.

Every year the American Diabetes Association’s magazine Diabetes Forecast publishes a consumer guide in which all the current technologies are listed. This is an excellent resource for anyone interested in reviewing the features of the latest technologies. The Diabetes Forecast Consumer Guide is available online3 at http://www.diabetesforecast.org/landing-pages/lp-consumer-guide.html.

Pumps are starting to integrate CGM sensors to give real-time interstitial glucose results to evaluate trends and alert the patient of glucose levels that are falling dangerously low or are rising too high. Advances in technology are rapidly occurring. Recent approval of the MiniMed 670G integrated system predicts when a person’s blood glucose is dropping and prevents the low from occurring and also corrects for a rising blood glucose. The insulin pump increases and decreases the basal insulin based on the rate and fall of the glucose. It is considered a hybrid closed loop system because the individual still needs to signal when they plan to eat and estimate the appropriate amount of bolus insulin.3–5

The individual or family member must be in command and have the training, skills, and appropriate self-care behaviors to wear the pump safely and effectively. Current and future research aims to eventually develop a fully closed loop system.

Basic Pump Functions

Insulin dependency or deficiency requires full insulin replacement. Normally, the pancreas secretes physiologic amounts of insulin continuously with rising and falling glucose levels. Insulin pumps are designed to closely mimic the person’s body without diabetes by delivering insulin at 1/100th of a unit increments. Insulin is required to use nutriments to fuel the body. During the fasting state, insulin is released at a slow and steady state (basal), with larger amounts (bolus) released during the fed state (Fig. 26.1).

Figure 26.1—Normal insulin secretion

Figure 26.1—Normal insulin secretion.

The benefits of CSII therapy are derived from the pharmacological advantage of using rapid-acting insulin that is delivered as a continuous infusion with incremental bolus administration at meals Rapid-acting insulin is associated with the least amount of variation in day-to-day absorption. Only rapid- or fast-acting insulin (insulin lispro, aspart, glulisine, or regular insulin) is used in the pump. Intermediate- and long-acting insulins never are used in the pump. Insulin is delivered by either the basal rate or a bolus.

Only an insulin pump can deliver precise amounts of basal insulin (metabolic or background insulin) for the body’s continuous fasting or basic insulin requirements. The basal delivery mode is preprogrammed with a continuous infusion of insulin for 24 h/day. Usually, the basal rate approximates 50% of the total daily insulin needs. If basal rates are set appropriately, the patient can fast and does not need to eat to maintain fairly level blood glucose levels. Meals can be skipped, delayed, or altered without loss of glycemic control. Depending on glucose patterns that are analyzed over several days, basal infusion can be programmed to coincide with the diurnal variation of insulin sensitivity and the requirements at different times of day. Basal rates can be overridden for a selected period of time by setting higher or lower temporary rates for exercise, illness, or special needs such as steroid bursts. Pumps are equipped to allow multiple basal rate patterns to accommodate change in the patient’s routine—for example, a profile for usual workday versus weekend activities.

The other important pump feature is delivery of bolus insulin. Bolus insulin is activated by the patient with a push of a button and is given just before eating food or as needed to correct high blood glucose (Fig. 26.2). The bolus can be given all at once to cover food (carbohydrate intake) or over time to mimic the insulin release for a more slowly digested meal.

Figure 26.2—Pump insulin delivery

Figure 26.2—Pump insulin delivery.

Insulin pump embedded software is programmed with individualized basal rates, insulin-to-carbohydrate ratios, correction factors, target blood glucose, and active insulin rates designed for instant insulin calculations for manual boluses by the pump wearer.

Insulin Pump Management

Pump therapy requires a professional staff knowledgeable about the unique and special requirements of insulin pump wearers. Ideally, IPT should be prescribed and managed by a knowledgeable and experienced diabetes health-care team with insulin pump expertise.1 At a minimum, the team should consist of an endocrinologist, diabetologist, or diabetes nurse practitioner or physician assistant, and a diabetes educator familiar with IPT. Before initiating pump therapy, an individual must be able to master aseptic infusion site changes and basic pump programming and be able to demonstrate safe and consistent self-management behaviors of frequent glucose monitoring, taking all insulin injections, and accurately assessing food by a common method of carbohydrate counting.6 Individuals who utilize an insulin pump for management must be taught specific skills related to wearing a pump, addressing problem solving for hyperglycemia and hypoglycemia, and sick-day management.

Assessment of Safe and Effective IPT

Effective IPT depends on appropriate candidate selection and preparation for initiating and ongoing management of pump therapy.7 It generally is accepted that highly motivated insulin-requiring patients with well-established diabetes self-care behaviors, including problem-solving skills and frequent self-monitoring of blood glucose, are most successful at IPT. Expert consensus considers candidate selection, training, and ongoing support critical for safe and effective use of insulin pump.1,6 Periodic retraining of the patient and family or caregiver is important to maximize the safety and use of the pump. Table 26.1 gives clinical indications for IPT.

Table 26.1—Clinical Indications for Insulin Pump Therapy

Clinical Indications

• Suboptimal glycemic control despite optimized multiple daily injection therapy

• Wide glycemic excursions

• Dawn phenomenon with elevated fasting blood glucose levels

• Frequent severe hypoglycemia and/or hypoglycemic unawareness

• Pregnant or planning conception

—Inconsistent daily schedule not well managed with injections

—Insulin sensitivity and requirement of low doses of insulin

• Gastroparesis

—Early neuropathy or nephropathy

—Renal transplantation

Lifestyle Indications

• Erratic schedule

• Varied work shifts

• Frequent travel

• Desire for flexibility

• Inconvenience of multiple daily injections (MDI)

Desired Attributes

• Has sound rationale for pursuing and realistic expectations of insulin pump therapy

• Has capacity to learn the technical and cognitive components of the pump

• Has appropriate problem-solving skills for troubleshooting hyper- and hypoglycemic events and sick days

• Demonstrates independent diabetes management and knowledge of the basics of diabetes education, including all topics listed in the National Standards for Diabetes Self-Management Education and Support8

• Performs blood glucose monitoring accurately and frequently, up to 6–10 times daily

• Complies with recommendations for safe insulin pump use

• Pays attention to details regarding the insulin regimen and the needed adjustments

• Anticipates insulin needs as situations change

• Performs the technical components of insulin pump use or has necessary support if visually, cognitively, or physically impaired

• Does not have serious disease that could impair technical performance

• Demonstrates emotional stability and adequate emotional support from family or significant others

• Can obtain adequate financial resources to cover the initial and ongoing costs of CSII therapy (approximately $7,000 for setup and $1,500–$3,000 for yearly supplies)6

Source: Adapted from American Association of Clinical Endocrinologists,1 American Association of Diabetes Educators.6

Important Skills for Safe, Successful IPT

The patient or family member must be able to fill a reservoir, insert and change the pump catheter every 2 to 3 days, competently program the pump, assess nutritional values of meals or snacks, monitor blood glucose levels frequently (>4x/day), check ketone levels when appropriate, and collaborate with the health-care team to achieve goals of diabetes therapy.6 If the patient is incapable of performing these skills, then resuming insulin injection therapy may be a more safe and appropriate option for insulin replacement therapy.1

IPT has not been fully evaluated in patients with T2D nor shown to be more effective than multiple daily injections in this population. A limited number of clinical studies show that IPT can safely improve glycemic control and β-cell function in a relatively short period. Pump therapy may be particularly useful in treating patients with T2D not satisfactorily controlled with multiple daily injection therapy while using less insulin.9,10 Usually, higher insulin doses are required for individuals with T2D versus T1D because both insulin deficiency and insulin resistance are common.

Characteristics of Pump Therapy for T1D and T2D

Consider the following characteristics when using pump therapy to treat patients with T1D versus patients with T2D:

• Patients with T2D usually need a higher basal rate.

• Regular U500 insulin is sometimes used in pumps for patients with extreme insulin resistance; although this is off-label use, some practitioners do use this. (The importance to nurses is to know the difference as U500 insulin is five times the concentration of U100 and doses are not interchangeable.)11

• Meal-related boluses are larger for patients with T2D.

• The time between reservoir refills is shorter for patients with T2D.

• Battery life may be shorter for patients with T2D.

• Pump therapy may improve endogenous insulin secretion and resistance for patients with T2D.

• Patient acceptance and satisfaction are similar in T1D and T2D.12

Benefits of Pump Therapy

Research has shown that using pump therapy to maintain normal or near-normal blood glucose levels can improve health and reduce the long-term complications of diabetes, although the same can be said of multiple daily injections.13

• Possible improvements in blood glucose include the following:

—Pumps do not use long-acting insulin, but instead only use rapid- or short-acting insulin.

—Pump wearers may experience fewer and less severe hypoglycemic events.

—Insulin dosing can be precise, to within 1/100th of a unit.

—Insulin absorption is more predictable from a continuous insulin depot.

—Dawn phenomenon effects are easier to manage with the basal rate and can be set to accommodate the rise in insulin requirements overnight.

—Basal rates can be quickly changed to accommodate growth spurtsin children or increased insulin needs during pregnancy.

• Possible improvements in the safety profile include the following:

—Reducing the basal rate during periods of low physiological requirements can minimize nocturnal or daytime hypoglycemia.

—Using a temporary basal rate that meets short-term physiological needs can accommodate the patient when sick or during exercise or periods of high physical activity.

• Possible improvement in lifestyle flexibility and patient satisfaction include the following:

—Meals and food can be customized to fit the individual’s schedule and preference in timing, size of meal, and type of food.

—Carbohydrate counting using an insulin-to-carbohydrate ratio can be used to match appropriate amounts of (bolus) insulin to the food consumed.

—Weight loss may be more easily achieved in motivated patients, although initial improved glycemia may promote weight gain.

—Pumps can deliver insulin to coincide with travel or work schedules.

Limitations of Pump Therapy

The risks or drawbacks of pump therapy must be fully understood by the wearer and the health-care team, including the following:

• Pumps are not for everyone, and patients must maintain a high degree of motivation before and throughout pump therapy.

• Patients must be willing to maintain habitual and frequent self-monitoring of blood glucose and/or wear CGM sensor.

• The learning curve is steep, and some patients struggle with the concepts and problem-solving skills required for IPT.

• Being connected to a pump is a visual reminder of having diabetes.

• Technical or mechanical failure is possible with a pump and, if not corrected in a timely manner, can quickly lead to diabetic ketoacidosis (DKA) in individuals with T1D.

• Skin irritations and infections are possible at the infusion sites.

• Weight gain is possible with improved glycemic control and increased ease of dosing for additional calories.

• Some patient populations, such as children or the visually impaired, likely will require assistance from a caregiver.

Additionally, many physicians and health-care providers are unfamiliar with pump therapy and may not provide the necessary training and support.

The cost of insulin pumps usually is more than $8,000, and supplies (not including blood glucose monitoring items) cost $2,500–6,000 per year. Insulin pumps with integrated glucose sensors are more than $10,000. Insurance companies typically cover only 50–80% of pump expenses, and coverage varies from state to state and plan to plan. Reimbursement for diabetes education to support the patient also varies.14

Contraindications to Pump Therapy

Following are contraindications to pump therapy:

• Some individuals have unrealistic expectations that pump therapy will cure their diabetes and automatically control it.

• Severe depression or other serious mental health disorders may distract patients from paying attention to details that are critical to successful pump therapy.

• A history of poor self-care behaviors and health-care practices, such as failure to perform self-monitoring of blood glucose, keep appointments, weigh and estimate portions of food to appropriately match food with insulin, and apply problem-solving skills, will signal less than optimal self-care behaviors. It also may increase the risk for DKA in people with T1D.

• Financial resources are needed to initiate and maintain optimal pump therapy practices.

CONSIDERATIONS FOR PROBLEM SOLVING

Hyperglycemia

Because the insulin pump only uses short- or rapid-acting insulin, even a partial interruption of insulin flow can result in hyperglycemia in patients with absence of endogenous insulin. Complete interruption can result in ketosis or ketoacidosis within a few short hours. High blood glucose can occur for various reasons, including infection, illness, stress, menstrual cycle, battery failure, infusion set or catheter occlusion, leaking connection, inadequate or missed meal bolus, or poorly absorbing insulin from the site. Immediate replacement of subcutaneous or intravenous insulin is required. The patient must act quickly by injecting rapid-acting insulin to correct high blood glucose and by restarting IPT or implementing a correction bolus of rapid-acting insulin and long-acting basal insulin (glargine, detemir, degludec, or NPH).

Troubleshooting Hyperglycemia in Insulin Pump Therapy

The following list includes possible causes for unexplained hyperglylcemia.

• Red, tender, and swollen catheter site (the insulin is not being absorbed correctly and leads to high blood glucose levels, which indicates that the site needs to be changed)

• Leakage, breakage, or kinking of tubing

• Battery failure

• Empty reservoir or cartridge

• Improper positioning of reservoir, piston rod, or cartridge

• Improper basal rate or other pump programming

• Air in tubing

• Illness

• Menstrual cycle fluctuations or growth spurts in children and adolescents

• Omitted bolus or improper amount given

• Ineffective insulin (expired date, exposure to heat or cold)

• Crimped cannula or needle not penetrating skin or blocking insulin flow

• Change in usual routine

• Lipohypertrophy or micro scarring reduces efficacy and predictable insulin absorption

• Suspect site not absorbing, if no other apparent reason for high blood glucose

CAUTION: Any of these problems can occur even though the infusion site or set was recently changed.

When assessing a patient on pump therapy, the health-care provider should address the following:

• Correct known problems immediately.

• Advise the patient to change infusion sites with each new reservoir or cartridge, infusion set, and catheter or pod.

• Check urine or blood for ketones.

• Check serum for bicarbonate to determine the severity of DKA.

• Advise the patient to take supplemental rapid-acting insulin with a conventional insulin syringe or pen if hyperglycemia persists despite having given correction insulin by pump.

• Provide nursing support for symptoms of nausea, dehydration, or infection.

Hypoglycemia

Hypoglycemia is the main side effect of insulin, regardless of delivery method. IPT does not seem to have a higher rate of hypoglycemia than multiple daily injections. In fact, pump therapy has been shown to reduce severe hypoglycemia because of pumping small amounts of insulin, particularly in children.1,15

People with severe hypoglycemia are in danger of losing consciousness. Not everyone gets warning signs of low blood glucose (i.e., hypoglycemia unawareness); therefore, reinforcing frequent blood glucose monitoring to pump wearers, especially before driving or when operating equipment, is essential. CGM or frequent blood glucose monitoring are the only dependable ways to verify glucose levels at any time. There are now insulin pumps integrated with CGM that have threshold suspend. There are also CGM with share features that allow others to be alerted if the individual is having a low blood glucose. Significant others, including family members, friends, or coworkers, need education and training on how to administer glucagon intramuscularly or subcutaneously, in the event that the pump wearer experiences a severe hypoglycemic event. Administration of intramuscular glucagon will work faster than subcutaneous glucagon.

Practical Point

When using any technology, whether CSII or a CGM system, if the symptoms do not match the glucose reading on the CGM, verify with a capillary blood glucose reading.

Safety Concerns

Insulin dosages vary from person to person and can be altered significantly by changes in diet, exercise, stress levels, and many other variables. Performing frequent blood glucose testing or wearing CGM is necessary to safely use a pump. Blood glucose levels can be maintained near the normal range after individualized basal rate and bolus requirements have been determined based on blood glucose results. A basic rule is to always check CBG before giving insulin even if the patient wears CGM. Of special note, CGM devices require frequent calibration with CBG testing to remain accurate.

Costs and Coverage of Insulin Pumps

Pump wearers must have financial resources (health insurance or money) to afford IPT. Startup and ongoing costs are several thousands of dollars a year. Most commercial health insurances cover IPT with varying out of pocket costs to the patient. Medicare covers the cost of pumps and ongoing supplies for patients requiring insulin who either meet the fasting C-peptide testing requirement or are β-cell autoantibody positive.16 Once a patient meets Medicare requirements, no further testing is required. Medicare, however, currently requires pump patients to be assessed by their diabetes provider every 3 months for ongoing assessment, support, and coverage of supplies.

MANAGING INSULIN PUMP THERAPY DURING TESTS, PROCEDURES, AND HOSPITALIZATIONS

The insulin pump may be continued in the hospital if the staff is competent in IPT or if the patient and family are able to safely operate the insulin pump. If the patient is not alert and oriented to person, place, and time, or otherwise is incapable of self-management during the hospital stay, then remaining on the insulin pump would not be safe.17 In that instance, basal pump insulin should be replaced with long-acting insulin, such as glargine, detemir, or degludec. Basal insulin dosage is calculated by converting the total daily basal insulin for a once (or sometimes twice) daily dose of glargine or detemir.18,19 Basal insulin needs to be given 2 h before removing the pump.20 The insulin pump should be discontinued with possible replacement basal insulin during X-rays, magnetic resonance imaging, and other procedures that might affect a pump’s reliability of insulin delivery. If a person is going to be off the insulin pump for <1 h, then the patient can give a bolus to replace the anticipated hour of missed basal (e.g., basal rate at 1.2 U/h), then give a 1.2-unit bolus to replace anticipated missed basal insulin and immediately remove the pump. If, however, the patient anticipates being off the insulin pump for >1 h, then compensatory basal insulin should be administered. For short surgical procedures, the pump can be left on, infusing the basal rate. Site placement of the pump during surgery must be coordinated with the surgical team. Every institution should establish a policy for use of the insulin pump depending on the staff’s expertise within the facility.

CGM

A CGM system consists of three basic parts: a receiver, transmitter, and sensor. The wireless monitor, often called the receiver, is a handheld monitor or smartphone application that can display glucose results on a screen. A receiver can be a stand-alone device or can be integrated into the display screen of an insulin pump. The transmitter is a simple device about the size of a quarter that hooks to the sensor and streams glucose information over radio waves to the monitor. The disposable sensor is inserted into the subcutaneous tissue with the transmitter mounted on top for continuous sensing of the interstitial glucose and can be worn for ≤1 week (length of time is specific to each device). The sensor uses the same glucose oxidase enzyme to measure interstitial fluid glucose levels as a test strip.

The user must calibrate the device with CBG readings at least 2–4 times daily. CGM does not replace glucose monitoring altogether. Interstitial glucose measurement typically lags behind capillary glucose by 5–15 min so the wearer must incorporate capillary glucose monitoring.20 Technology is rapidly changing and by the time this book is published there may be systems available that require no calibrations. The primary function of CGM is to alert the wearer of dangerously high or low glucose levels depending on individualized targets. It also gives visual trends of glucose patterns retrospectively and, if used effectively, can help the wearer and the health-care professional review glucose patterns to augment diabetes management.

Another great feature of CGM for the wearer as well as the nurse is the device’s glucose trend arrows. The CBG often only reveals what the glucose is at that moment in time, whereas CGM indicates what direction the glucose is heading (whether the glucose level is trending high or low and how quickly this is occurring). Because CGM lags behind the CBG, the U.S. Food and Drug Administration has approved current devices with the caveat that the wearer checks a capillary blood glucose before giving insulin for food or initiating treatment for hypoglycemia or hyperglycemia. Continuous glucose sensors generally are not used in the hospital setting. Experts, however, consider CGM safe and effective to use if the patient is capable of safe diabetes self-management during a hospitalization or outpatient procedure.

CGM typically is used by individuals with hypoglycemia unawareness in T1D; however, CGM also can be used to monitor the current “diabetes status” of patients with both T1D and T2D to provide treatment guidance. Glucose data can be downloaded to the computer to review trends and make therapeutic decisions. Studies show this treatment reduced A1C levels by 0.4% to ≥1.0%. CGM systems cost between $1,000 and $1,500 and need to be replaced every 6–12 months. The sensors should be replaced about 6–7 days and cost ~$70–100 apiece.21 Use of CGM usually is dictated by insurance reimbursement with most commercial plans leading the way. The Centers for Medical Services (Medicare) is beginning to change its coverage policies for CGM now that the Dexcom G5 has been approved for making diabetes treatment decisions without the need for a confirmatory capillary glucose. However, this does not alter the need for calibration of the device.22

Clinical Pearls for Nurses

Critical factors for successful IPT require appropriate patient selection; and intense and ongoing diabetes self-management education, training, skill building, and support by a knowledgeable diabetes care team. Regardless of the patient’s past experience and expertise, a nurse must know the essential assessment indicators that demonstrate the patient is safely and effectively using their pump. If directed to halt IPT, the nurse should not remove the patient’s pump without orders to implement a similar basal and bolus insulin regimen with injections or intravenous drip.

Longtime insulin pump users need a periodic review of pump skills, including the use of advanced features, such as temporary basal rates and extended or combination bolus selections. In the case of pump failure, each patient should have an individual backup plan to replace pump insulin doses with injected insulin. Every person using a pump needs to have an emergency supply of long-acting insulin for this purpose. The plan should be written and kept in a secure place. Likewise, each patient needs to keep a copy of the current pump settings for reprogramming a new or replacement pump. The nurse also can document the pump settings in the electronic medical record at each outpatient visit. Each insulin pump company has a customer service phone number, usually printed on the back of the pump. Patients can request assistance with troubleshooting pump malfunctions, report infusion set problems, or discuss insurance coverage issues.

The insulin pump is a medical device and, as such, needs to be protected from damage. Because it contains insulin, the pump should not be exposed to extreme heat or cold as this can destroy insulin’s chemical composition. Not all pumps are waterproof and those that are have limitations, such as submersion depth and time limits.

Nurses must understand the basics of accurate and safe use of CGM to support their patients using advanced diabetes technologies. Here, too, the patient needs to know the process for contacting the company to ask for assistance or to report malfunctions and obtain replacements.

SUMMARY

In general practice, nurses, unless they are diabetes pump specialists, likely are not trained in operating insulin pumps or continuous glucose sensors. They, however, should be able to access resources for the patient in any health-care setting to assist with pump management. Nurses should recognize that most patients on insulin pumps are knowledgeable and that the patient’s expertise should be acknowledged. Patients should be allowed to continue pump therapy if they are able to safely and effectively manage their pump while hospitalized or undergoing an outpatient procedure. It is of paramount importance that each health-care institution or setting has a policy on IPT. Interruption of IPT can disrupt the patient’s glucose control and lead to rapid deterioration in metabolic status. Continuing pump therapy during hospitalization helps the patient to maintain target glucose levels and reduce risk factors for infection and increased length of stay. Diabetes technology research is forging ahead with integrating IPT and continuous glucose monitoring to “close the loop,” which soon may provide an artificial pancreas, further reducing the burden for individuals living with diabetes.

REFERENCES

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3. Diabetes Forecast Consumer Guide. Available from www.diabetes.org/diabetes-forecast/resource-guide.jsp. Accessed 11 February 2017

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10. Reznik Y, et al. Opt2mise study group, efficacy and safety of insulin pump therapy in type 2 diabetes: the Opt2mise study. Poster 102-LB presented at ADA Scientific Sessions 2014, San Francisco, CA

11. U.S. Food and Drug Administration. Mixups between Insulin U-100 and U-500 (April 2008). FDA Patient Safety News 2008;79

12. Peyrot M, Rubin R, Chen X, Frias JP. Associations between improved glucose control and patient-reported outcomes after initiation of insulin pump therapy in patients with type 2 diabetes mellitus. Diabetes Technol Ther2011;13:471–476

13. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long- term complications in insulin dependent diabetes mellitus. N Engl J Med 1993;329:977–985

14. Kanakis SJ, Watts C, Leichter SB. The business of insulin pumps in diabetes care: clinical and economic considerations. Clin Diabetes 2002;20:214–216

15. Litton J. Insulin pump therapy in toddlers and preschool children with type 1 diabetes mellitus. J Pediatr 2002;141:490–495

16. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Infusion pumps: C-peptide levels as a criterion for use. 2005. Available from www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3705.pdf. Accessed 11 February 2017

17. Cook C, Boyle M, Cisar N, Miller-Cage V, Bourgeois P, Roust L, Smith S, Zimmerman R. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting. Diabetes Educ 2005;31:849–857

18. Bode B, Steed D, Schleusener D, Strange P. Switch to multiple daily injections with insulin glargine and insulin lispro from continuous subcutaneous insulin infusion with insulin lispro: a randomized, open-label study using a continuous glucose. Endocr Pract 2005;11:157–164

19. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/getting-started.html. Accessed 19 February 2017

20. Liebl A, Henrichs H, Heinemann L, et al. Continuous glucose monitoring: evidence and consensus statement for clinical use. J Diabetes Sci Technol 2013;7:500–519

21. Huang E, O’Grady M, Basu A, et al. The cost-effectiveness of continuous glucose monitoring in type 1 diabetes. Diabetes Care 2010;33:1269–1274

22. https://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMS1682R.pdf. Accessed 19 February 2017