essential. Do you have the time and/or staff to help prepare a potential pump patient and then follow/manage the new pump patient closely the first few weeks after pump initiation (Hirsch 2010)? Ineffective follow-up, likewise, can create problems for the HCP as well as for the new pump patient. Learn about the resources available to you—local Certified Diabetes Educators (CDEs), diabetes centers, and pump company clinical support staff (company-employed or per diem contracted CDEs) can be of great assistance.
References
Department of Health and Human Services (DHHS) Centers for Medicare & Medicaid Services: National Coverage Determination (NCD) for Infusion PUMPs (280.14) http://www.cms.gov/medicare-coverage-database/details/nca-details.aspx?NCAId=40&NcaName=Insulin+Infusion+Pump&CoverageSelection=National&KeyWord=insulin+pump&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA& Accessed 10 February 2013
Department of Health and Human Services (DHHS) Centers for Medicare & Medicaid Services: Decision Memo for INSULIN Infusion PUMP (CAG-00041N) http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=40&NcaName=Insulin+Infusion+Pump&CoverageSelection=National&KeyWord=insulin+pump&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAEAAA& Accessed 10 February 2013
Hirsch IB: Practical pearls in insulin pump therapy. Diabetes Technol Ther 12 (Suppl 1):S23–S27, 2010
Shalitin S, Lahav-Ritte T, Lebenthal Y, Devries L, Phillip M: Does the timing of insulin pump therapy initiation after type 1 diabetes onset have an impact on glycemic control? Diabetes Tech Ther 14:1–9, 2012
Skyler J, Ponder S, Kruger D, Matheson D, Parkin C: Is there a place for insulin pump therapy in your practice? Clin Diab 25:50–56, 2007
Chapter 4 Getting the Patient Ready
Goals and Objectives
It may seem like a simple concept to “get the patient ready” for pump therapy, but as the HCP responsible for prescribing the pump to the patient, it is also your responsibility to make sure the patient is prepared to achieve and maintain success with pump therapy.
Formal training of the patient to use a pump has three stages: prepump education, pump start-up, and pump therapy follow-up and management. Prepump education is usually spread over a few weeks, with a minimum of three visits of 1–3 h each. The usual pump start-up (see Chapter 5) consists of one 3- to 4-h session. Pump follow-up and management can range from a few weeks to several months.
When planning the prepump education, consider both the learning style of each patient as well as their general diabetes knowledge. Some pump patients complete just two to three 1-h preparation sessions with a verbal exchange of information, whereas others need a structured learning situation, such as several 1- to 3-h sessions or classes spread over 3–4 months, with written tests to gauge the information flow. The average patient will find the latter a bit much and may become so intimidated by the formality that they decide pump therapy is just not for them. A combination of individual and group sessions may work well because many patients benefit from group interaction. Success begets success, and clinicians are likely to design and implement what they have found works best for their patients.
A group class covering some of the pump education topics can also be time-efficient for the healthcare professional/team. Ideally, patients should have sessions with an endocrinologist and a CDE, who can be a registered dietitian (RD), registered nurse (RN), registered pharmacist (RPh), or exercise physiologist, and has experience with pump therapy. Consultation with a psychologist, who specializes in diabetes and understands pump therapy is also extremely useful.
Another consideration for pump readiness is to recommend that your potential pump patient attend a local pump support group. Most pump support groups are facilitated by a pump-savvy CDE who can manage the tone of the overall group and keep the focus on the topic(s) being discussed. The caveat to attending a pump support group is that, depending on the patients who are present, potential pump patients may become inappropriately excited hearing how “easy” pump therapy is. On the other hand, potential patients may become so dismayed by complaints that they decide pump therapy isn’t for them. In both cases, pump therapy reality lies somewhere between the supportive successful pump patient and the unhappy struggling pump patient. Many clinicians recommend potential pumpers attend at least two support group meetings before making the final decision to choose pump therapy.
There are education components that will guarantee successful pump therapy. Although the patient’s education begins as you present the “Steps for Helping the Patient Determine and Achieve Readiness” (Chapter 3), once a decision to proceed with pump therapy occurs, new educational objectives emerge:
• Establishing goals
• Learning carbohydrate counting (if this is new to the patient)
• Calculating insulin-to-carbohydrate ratio(s) (ICR) (if this is new to the patient)
• Calculating the correction (sensitivity) factor(s) (CF) (if this is new to the patient)
• Managing hyperglycemia and hypoglycemia
• Choosing and inserting infusion sets
• Coping with lifestyle issues, sick days, exercise, supplies, and travel
A patient reference published by the American Diabetes Association, Insulin Pumps and Continuous Glucose Monitoring (Kaufman 2012) can be of great assistance to your patients as they learn the details of pump therapy.
Review or establish appropriate blood glucose and A1C targets with the patient at this time (Tables 2 and 3) (ADA 2013). Emphasize that pump therapy does not guarantee an automatic improvement in control but may make achieving control easier while providing a more flexible lifestyle. The responsibility for the improvements patients make using this new tool rests in their hands. Patients who are not doing well on MDI therapy may embrace the greater lifestyle flexibility offered by insulin pump therapy and become willing to put forth the effort needed for success.
| TABLE 2. Glycemic Recommendations for Nonpregnant Adults with Diabetes* | |
| Preprandial capillary plasma glucose (mg/dl) | 70–130* |
| Peak postprandial capillary plasma glucose (mg/dl) | <180* |
| A1C (%) | <7* |
| Goals should be individualized based on: • duration of diabetes • age/life expectancy • comorbid conditions • known CVD or advanced microvascular complications • hypoglycemia unawareness • individual patient considerations | |
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*More- or less-stringent glycemic goals may be appropriate for individual patients.
Postprandial glucose may be targeted if A1C goals are not met despite
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