risks for the healthcare professional (HCP) as well. Preparing the patient for pump therapy requires an assessment of the patient’s “readiness” and diabetes knowledge and coordination of efforts on the part of the patient, pump manufacturer, and diabetes educators. The HCP’s initial learning curve, i.e., willingness to learn pump therapy, and the time investment for patient follow-up and management are crucial factors in assuring success with pump therapy.
• A learning curve. Pump therapy requires education, skills training, and initial intensive follow-up and management. A patient contemplating pump therapy must know beforehand how to count carbohydrate and match insulin doses with carbohydrate intake and basal needs. A patient must also know his/her correction (sensitivity) factor(s) and how and when to use a corrective insulin dose. The pump wearer must learn the technical “buttonology” of their specific pump and learn how to insert the battery(ies), fill (if appropriate) and insert the insulin cartridge/reservoir, change the infusion set and tubing (if applicable), and calculate appropriate insulin bolus doses. Intensive follow-up for the first few weeks after pump initiation is essential and includes detailed recordkeeping of glucose levels, carbohydrate intake, exercise, and insulin doses. For children, the learning curve also involves their parents and caregivers.
• Frequent SMBG. The pump wearer must perform a minimum of four glucose checks daily, with additional checks as needed between meals; during sleep hours; before, during, and after exercise; during illness and at times of stress; and when glucose levels become erratic or “unexplainable.” Bolus doses of insulin must be calculated to match the person’s food intake, anticipated activity, current glucose level, and insulin “on board” from a previous bolus dose(s).
• Possible weight gain. Insulin pumps offer precise dosage delivery to match the patient’s food intake. It can become easy for the pump wearer to bolus extra insulin for additional calories. People may begin to eat foods that may have been considered “forbidden” before using a pump and may over indulge in high-calorie foods of low nutrient value. Although glycemic control can be maintained with additional insulin doses for excessive caloric intake, weight gain can result.
• Hypoglycemia. If the basal rates are not set correctly or if the pump wearer miscalculates and overdoses a bolus delivery or doesn’t compensate for exercise or for the insulin “on board” from a previous bolus dose(s), hypoglycemia can result. Pattern management is very important.
• Unexpected hyperglycemia. If the patient miscalculates or improperly sets the basal rate(s) or bolus doses, hyperglycemia can occur unexpectedly. The rare pump failure or occasional site occlusion or site “blockage” due to overuse and resultant scar tissue can decrease or prevent basal/bolus delivery, resulting in hyperglycemia.
• Ketoacidosis. In addition to the potential improper setting of the basal rate(s), the omission of filling the tubing (if applicable), and omission or miscalculation of a bolus dose, the rare pump malfunction may also cause partial or total interruption in the basal delivery. Because the pump uses only rapid-acting insulin, there is no “background” insulin available for hyperglycemia and the prevention of ketonemia. However, studies from the past three decades revealed a decrease in diabetic ketoacidosis in pump wearers compared with patients using MDI therapies (Bruttomesso 2009).
• Skin irritation and infusion site infections. People with sensitive skin may develop redness, tenderness, itching, or rashes from the infusion set or pump self-adhesive tape. Those who perspire heavily or participate in water sports may have problems with getting the tape to stick to their skin. Removing the adhesive may also cause concern. Site infections can occur from poor insertion technique or leaving the infusion set or pump (if applicable) in place too long.
• Logistics/placement. Although the insulin pump weighs about 4 oz and is smaller than a smart phone, wearing it creates challenges. Despite offering flexibility in lifestyle, many people may find it unpleasant or intolerable to be connected 24 h a day to a small external device. Pumps that use tubing to connect to an infusion set require a clip, a case with a built-in clip, or a belt-loop case for attachment. Some people prefer to place their pump in a pocket, whereas others may choose to wear their pump discreetly under clothing. Tubeless or patch pumps cannot be moved into pockets. They can be placed under clothing, but when wearing or changing clothes that do not cover or “hide” them (such as sleeveless tops or low-waisted slacks), because the pump’s adhesive is applied to the skin, the pump is immovable until the infusion set and site are changed several days later. Intimacy/sexual activity, showering or bathing, exercise, and contact sports create additional challenges in how to wear the pump.
• Medical requirements. Some insurance companies may require that a potential pump patient provide SMBG records and/or a medical necessity form completed by the healthcare professional, as well as certain lab reports (such as recent A1C or C-peptide levels) before the patient is “approved” for the purchase of an insulin pump.
• Paying for it. In 2013, the average price of an insulin pump is between $6,000 and $8,000. Disposable supplies, including pump batteries, insulin cartridges/reservoirs, infusion sets, and skin preparation products can add up to an additional $1,500 or more per year. As of this writing, a recent introduction to the pump market offers a lower initial “setup” cost but requires disposable components that may cost slightly more than standard pump supplies, thus enabling the disposable components to be covered under a patient’s insurance for supplies rather than durable medical equipment. In general, increased insurance reimbursement for pump therapy has helped to increase its use (Scheiner 2009). Some insurance companies cover all or some of the expense, whereas others may provide for only the pump and not the supplies, or vice versa. Advise your patient to be thoroughly familiar with the costs before making a commitment to pursue pump therapy. Pump manufacturers are happy to work with a potential pump patient’s insurance company to investigate coverage and out-of-pocket costs.
References
American Diabetes Association: Continuous subcutaneous insulin infusion (Position Statement). Diabetes Care 27(Suppl. 1):S110, 2004
Bruttomesso D, Costa S, Baritussio A: Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy. Diabet Metab Res Rev 25:99–111, 2009
HSBC Global Research: Diabetes: proprietary survey on insulin pumps and continuous blood glucose monitoring. Healthcare U.S. Equipment & Supplies, 2005
Scheiner G, Sobel RJ, Smithe DE, Pick AJ, Kruger D, King J, Green K: Insulin pump therapy: guidelines for successful outcomes. The Diabetes Educator 35(Suppl. 2):29S–43S, 2009
U.S. Food and Drug Administration, General Hospital and Personal Use Medical Devices Panel: Insulin Infusion Pumps Panel Information, 2010
Chapter 2 Pump and Infusion Set Options and Selection
Karen M. Bolderman, RD, LDN, CDE
Susan L. Barlow, RD, CDE
Pump Features
Several manufacturers sell insulin pumps and infusion sets. A pump company may offer more than one model. Each pump has slightly different features. And there are many different types of infusion sets available for pumps that are connected to the patient with an infusion set (versus a “patch/pod/tubeless” pump).
What kind of pump—standard with tubing and infusion set or “patch”/pod? A pump that is totally “contained,” or one that has a disposable component to it? The latter style pump’s settings are programmed into the “hardware”
