Demonstrates emotional stability. The pump patient must routinely attend education sessions and attend to tasks that require routine. A patient with untreated depression, eating disorders, manipulative behavior, or other psychoses is usually ill-suited for pump therapy. Carefully assess the pump candidate’s psychological status, or refer the patient to a mental health professional. Suggest treatment options for behaviors that may interfere with pump therapy.
Young or old, age in itself is not necessarily a contraindication to successful pump therapy. Children as young as newborns and people in their 70s have had success with pump therapy.
The patient’s education level is not a deciding factor in pump therapy. However, diabetes knowledge and an understanding of the relationship between insulin and food, stress, and exercise are key factors in assuring successful pump therapy.
Contraindications: Red Flags
Why the Patient Isn’t Ready for Pump Therapy
Although pump therapy does not increase the risk of mortality among its users, the frequency of adverse events increases with:
• Poor candidate selection
• Infrequent SMBG
• Insufficient or inadequate supervision and monitoring by the diabetes healthcare professional or team
• Inexperienced pump therapy practitioners
Indications that the Patient Is Not an Appropriate Candidate
There can be numerous reasons why a patient may not be an appropriate candidate for pump therapy. However, this doesn’t mean the patient may not ever be ready for an insulin pump. Behavioral changes, diabetes knowledge, and maturity in dealing with diabetes challenges come with time and education. Be aware that any of the concerns below can be corrected, thus improving the patient’s readiness to take on pump therapy:
• Complains of performing frequent blood glucose checks: thinks that pump therapy reduces or omits the need to perform SMBG
• Is “tired of meal planning,” counting carbohydrate, and calculating mealtime insulin doses: believes that the pump automatically calculates necessary bolus doses without any user input
• Does not want to carry any “diabetes supplies,” e.g., back-up injection device, insulin, hypoglycemia treatment (and when using pump therapy, spare infusion sets)
• Doesn’t understand the causes, prevention, and treatment of hypoglycemia
• Is not aware of glucagon and doesn’t have a plan for its use (i.e., a family member or significant other trained in the administration of glucagon)
• Doesn’t understand the causes, prevention, and treatment of hyperglycemia
• Is not aware of ketone strips, does not have ketone strips, or does not know when/how to check for ketones
• Lives alone and does not have a readily accessible support team (family, friends, coworkers, access to emergency services)
• Has evidence of a psychiatric disorder, including severe or recurrent depression, severe eating disorder, or a history of attempted suicide
• Lacks insurance or means to pay for an insulin pump and pump supplies
Steps for Helping the Patient Determine and Achieve Readiness
You may be able to identify good candidates for insulin pump therapy, but patients still need to decide whether pump therapy is for them. Here is an education plan for helping the patient make this decision.
1. Give the patient a general overview of what pump therapy entails. Discuss the advantages and challenges, as well as realistic goals and expectations for pump therapy.
2. Review the prospective pump user’s medical history and evaluate his or her diabetes knowledge. Consider using written pre- and post-tests.
3. Demonstrate how an insulin pump works (bolus delivery). Explain basic pump therapy terms, including basal rate, bolus dose, infusion set, infusion sites, dressing, and insulin cartridge/reservoir. Show available models, and encourage the patient to learn the features offered by each brand of pump. Explain that he or she can disconnect the pump for bathing, intimacy, and intensive sports.
4. Have the patient handle a pump. Some patients mistakenly believe the pump is worn only during the day and removed at bedtime. Others believe an insulin pump is surgically implanted or permanently attached. Most people are surprised to learn how small a pump is and how it is worn.
5. Show the differences between a pump that uses tubing that connects to an infusion site and a pump that is worn without tubing and is directly connected to the body.
6. Show the available infusion sets. Explain that tubing (if applicable) is available in various lengths to accommodate where the pump is worn. Explain how a pump with tubing can be worn in and under clothing, such as in a pocket, sock, or bra. Show pump accessories, such as clips, leather cases, fanny bag–type cases, clothing with built-in pump pouches or pockets, and Velcro-attached removable pockets or small (infant-sized) socks. Show appropriate sites for wearing a “patch” pump that does not require tubing.
7. Demonstrate the insertion and removal of an infusion set. Demonstrate an infusion set inserter device, if appropriate. Allow the patient to practice a self-insertion. There is a commercially available injection pad, or “rubber belly,” that attaches to the patient’s abdomen, thigh, or upper arm with an adjustable strap. Does the patient want to wear an infusion set for a few days to get accustomed to the feel of it? If possible, offer the option of wearing a demo pump with saline for a few days to determine how the patient likes that particular pump and pump therapy in general (see Optional Saline Trial). When parents are considering pump therapy for their child, this experience sometimes results in postponing pump therapy; the parents recognize the learning curve and time commitment a pump requires, or they discover that their child is not quite ready. Because saline is a prescription item, the prescribing physician will need to provide a “saline-start” order and a prescription for saline. Pump manufacturer personnel—either a Certified Pump Trainer or clinical staff—will provide brief training on the pump. Some patients wear two or three brands of pumps before making a final decision.
8. Provide a list of the various pump manufacturers with names and telephone numbers of the local sales representative, corporate office telephone numbers, and website information. Encourage the patient to access pump company websites (monitored by the pump company) and contact the manufacturers’ sales representatives, who will offer “sales calls” to patients and/or provide additional information, such as literature and a DVD. Pump company “online pump school” website instructions may also be available. Does your protocol place the responsibility of contacting pump manufacturer sales representatives on you? Is there a local pump support group meeting that the patient can attend to meet pump users and other potential pump patients? Encourage the patient to speak with other pump wearers and potential pumpers via face-to-face conversations or the use of social media.
Are YOU Ready?
Additionally, the HCP who initiates pump therapy should also consider his/her ability to effectively start and maintain a patient on an insulin pump. Although there are benefits to the patients for insulin pump therapy, there is also the potential for confusion and inadequate training (Skyler 2007), which can create additional work and anxiety for the HCP. An effective
