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Insulin Pump Start-Up Training

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Considerations for getting patients started on new insulin pumps.

Reviewed by: the ADCES Professional Practice Committee

Acknowledgements: Carla Cox, PhD, RD, CDE, CPT; Karen M. Bolderman, RD, LDN, CDE; Gary Scheiner, MS, CDE; Claire M. Blum, MS Ed, RN, CDE; Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE; Janet Mertz, MS, RD, LD, CDE. Revisions: January 2018: Diana Isaacs, PharmD, BCPS, BC-ADM, CDE, Diane Battaglia, RN, CDE, Carla Cox, PhD, RD, CDE, CPT. Revisions: March 2021: Carla Cox, PhD, RDN, CDCES, CPT

Insulin pump start-up education (“pump training”) takes 1-3 hours and should be done in an outpatient setting, such as the prescriber/specialist’s office. Pump manufacturers employ or contract with healthcare professionals (RDs, RNs and PharmDs) who are usually CDCES certified by the pump manufacturer as a certified pump trainer (CPT). CPTs provide pump training services, following the prescribing physician’s pump start orders.

The prescriber is responsible for providing/signing off on pump start orders to the diabetes care and education specialist or designated pump trainer assigned to provide the pump start-up training.

These include:

  • Starting basal rate(s).
  • Insulin-to-carbohydrate ratio(s) (ICR).
  • Target blood glucose level(s). 10,11
  • Correction (or sensitivity) factor(s) and instructions for use.
  • Duration of insulin action (“insulin on board” or “active insulin time”).
  • Self-monitoring of blood glucose (SMBG) instructions or utilization of a CGM device.
  • Communication guidelines, i.e., who, when and where the patient contacts for reporting glucose results, asking for diabetes management assistance (specialist/prescriber) and asking for technical assistance (pump manufacturer/CDCES)
  • Understand how to upload the device and provide data to the provider/CDCES.
  • Determine who is available 24/7 to cover medical management questions that may arise.4

The specialist should carefully set the pump startup date, assuring that the individual’s first few weeks of pump therapy are planned during “normal routine” days, avoiding situations or conditions that may adversely affect blood glucose levels or interfere with the establishment of basal rates.9

Start-up orders should be provided to the individual several days in advance and should include:

  • 24-48 hour pre-pump adjustments in insulin injection therapy.
  • Glucose history either through meter or CGM data upload.
  • A list of supplies to bring to the pump start-up appointment.
  • Specific information regarding appointment time and location.9

The pump wearer must also learn the technical components of their pump, including how to:

  • Insert or charge the battery.
  • Fill and insert the insulin cartridge/reservoir.
  • Insert and change the infusion set and tubing (if applicable).
  • Input information for the pump to calculate appropriate insulin dosages.
  • Program basal rate changes.
  • Review the pump history. With advances in sensor-integrated insulin pumps, a thorough understanding of the automated systems and the potential to revert to manual mode is needed. Most manufacturers require that training on their pump is conducted by a healthcare provider certified by the manufacturer as a pump trainer (“CPT”). A pump start is best conducted at a time in the day and on the day(s) of the week when the managing healthcare professional is available for medical management following the pump initiation.

Specific instructions for follow-up and management during the first few weeks after pump start-up should include: Frequent SMBG, i.e. minimum of four to five times per day, i.e. 3:00 a.m., fasting, before each meal, 2 hours after meals and bedtime.

All SMBG readings should be entered into the pump. Generally, CGM glucose data should also be entered into the system, however there is one system at this writing that auto inserts the glucose reading and incorporates the data into the delivery system without input from the user.

  • Limiting alcohol and high-fat foods.
  • Inputting all carbohydrate values.
  • Recording any additional insulin or carbohydrate intake outside of the dosing within the insulin pump (correctional factors for blocked cannula, carbohydrates for hypoglycemia) that would not otherwise be noted in the pump download.
  • Recording any unexpected or unusual events that could affect blood glucose levels, e.g., stress or illness, unusual exercise routine as well as the onset of menses.
  • Instructions to upload or e-mail the information to the diabetes care and education specialist as agreed upon, generally initially daily.
  • Reminders to call the pump manufacturer’s support service with questions or problems related to the technical functions of the pump if the diabetes care and education specialist is not available.

Follow Up

A follow-up visit should occur within one week after start-up. This allows for the opportunity to review and observe an infusion set or pod site change, remove pump syringe/cartridge, filling and insertion. The individual should be in contact with the prescriber or CDCES/CPT within2-4 weeks after the pump start-up for a review of insulin pump download data including glucose, dosing, compliance with infusion site changes, alarms and any overriding of the automated system. Review of infusion set sights and options should also occur.

Non-programmable insulin patch pumps are also available. These systems have a fixed basal rate (different rates available) along with an option for bolus delivery. The dosing is not integrated into the pump but is at the discrepancy of the wearer. Data from these pumps is not downloadable at this time.

 

View more pump training documents

References:

1. Bergenstal R, Tamorlane W, Ahmann A et al. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010:363:311-320. 2. Bally L, Hood T and Hovorka R. Closed-loop for type 1 diabetes-an introduction and appraisal for the generalist. BMC Medicine. 2-17:15:14. Accessed 8/26/2017/ 3. Heinemann L, Fleming G, Petrie J et al. Insulin Pump Risks and Benefits: A Clinical Appraisal of Pump Safety Standards, Adverse Event Reporting, and Research Needs A Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015;38:716–722. 4. Grunberger G, Abelseth J, Bailey T, et al. (2014) Consensus Statement by the American Association of Clinical Endocrinologists/American College of Endocrinology Insulin Pump Management Task Force. Endocrine Practice: 2014:20(5) 463-489. 5. Decision Memo for Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092R) available: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=109&. Accessed 9/6/2017 6. Beck J, Greenwood D, Blanton L et al. 2017 National Standards for Diabetes Self-Management Education and Support. https://doi.org/10.2337/dci17-0025. Accessed 9/9/2017. 7. Walsh J, Roberts R. Pumping Insulin: Everything for Success on an Insulin Pump and CGM. 6th Edition. Torrey Pines Press, 2016 8. McCrea, D. A Primer on Insulin Pump Therapy for Health Care Providers. Nurs Clin N Am 52 (2017) 553–564. 9. Bolderman K. “Pump Start-Up” in Putting Your Patients on the Pump. Alexandria VA: American Diabetes Association 2013. 10. Standards of Medical Care in Diabetes--2017. Diabetes Care. 2017;40 Suppl 1:S48-57. 11. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17 Suppl 2:1-53. 12. Clayton-Jeter H. Contributing Factors to Insulin Pump Errors in Children, Adolescents and Adults Available: http://www.fda.gov/forhealthprofessionals/articlesofinterest/ucm295562.htm. Accessed February 13, 2014. 13. Aldasouqi S and Reed A. Pitfalls of insulin pump clocks: technical glitches that may potentially affect medical care in patient with diabetes. J Diabetes Sci Technol 2014;8(6):1215-1220. 14. Evert AB, Insulin pump therapy troubleshooting for optimal performance. Empower. 2015;7(4):23-24 15. Guilhem I, Leguerrier AM, Lecordier F, et al. Technical risks with subcutaneous insulin infusion. Diabetes Metab. 2006;32(3):279-284. 16. Maahs D, Horton L and Chase H. The use of insulin pumps in youth with type 1 diabetes. Diabetes Technol Ther 2010;12(suppl1):S59-65. 17. Cornish A, Chase HP. Navigating airport security with an insulin pump and/or sensor. Diabetes Technol Ther. 2012;14(11):984-985. 18. American Diabetes Association. Fact Sheet – Air Travel and Diabetes Available: http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/publicaccommodations/air-traveland-diabetes/what-can-i-bring-with-me.html?referrer=https://www.google.com/. Accessed 9/10/2017 19. Diabetes care in the school and day care setting. Diabetes Care. 2014;37 Suppl 1:S91-96. 20. McCrea D. Management of the hospitalized diabetes patient with an insulin pump. Crit Care Nurs Clin North Am. 2013;25(1):111-121. 21. Boyle ME, Seifert KM, Beer KA, et al. Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. J Diabetes Sci Technol. 2012;6(1):184- 190. 22. Buchko BL, Artz B, Dayhoff S, et al. Improving care of patients with insulin pumps during hospitalization: translating the evidence. J Nurs Care Qual. 2012;27(4):333-340. 23. Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges and Opportunities. Diabetes Technol Ther. 2016;18(Suppl2):S2-3-S2-13. 24. https://www.diabeteseducator.org/practice/practice-documents/practice-papers © Copyright © 2021 Association of Diabetes Care & Education Specialists. All rights reserved Reproduction or republication strictly prohibited without prior written permission 13 25. Bergenstal RM1, Tamborlane WV, Ahmann A, et al STAR 3 Study Group. Sensor-augmented pump therapy for A1C reduction (START 3) Study: results from the 6 month continuation phase. Diabetes Care. 2011;34(11):2403-5. 26. Abraham MB1,2, Nicholas JA1,3, Smith GJ3 et al; PLGM Study Group. Reduction in Hypoglycemia With the Predictive Low-Glucose Management System: A Long-Term Randomized Controlled Trial in Adolescents With Type 1 Diabetes. Diabetes Care. 2017;Nov 30. pii: dc171604. doi: 10.2337/dc17- 1604. [Epub ahead of print] 27. Forlenza G, Raghinaru D, Cameron F, et al. Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents. Pediatric Diabetes. 2017;1-9. 28. Breton M, Chernavvsky D, Forlenza G et al. Closed-loop control during intense prolonged outdoor exercise in adolescents with type 1 diabetes: the artificial pancreas ski study. Diabetes Care. 2017:40(12):1644-50. 12. 29. Tauschmann M, Thabit H, Bally L, et al. Closed-loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre 12-week randomised trial. Lancet. 2018:13:92. 30. OpenAPS.Outcomes. Downloaded 3/2/2021. 31. Standards of Medical Care in Diabetes-2021Diabetes Care. 2021;44 Suppl 1:S89 32. Danne T, Nimri R, Battelino R et al. International consensus of use of continuous glucose monitoring. Diabetes Care. 2017:40(12):1631-1640. 33. Chase P and Messner L. Understanding insulin pumps, continuous glucose monitors and the artificial pancreas (3rd ed). 2016. Children’s Diabetes Foundation at Denver, Colorado. 34. Wallia A, Umpierrez G, Rushakoff R et al. Consensus statement on inpatient use of continuous glucose monitoring. J. Diabetes Sci Technol. 2017:11(5);1036-1041. 35. Shapiro A. FDA approval of nonadjunctive use of continuous glucose monitors for insulin dosing: A potential risky decision. JAMA. 2017:318(16);1541-1542. 36. Rinker J, Dickinson J, Litchmanb M et al. Diabetes Educator. 2018:44(3):260-268.


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ADCES and danatech curate product specifics and periodically review them for accuracy and relevance. As a result, the information may or may not be the most recent. We recommend visiting the manufacturer's website for the latest details if you have any questions.