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Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital Setting (Adult and Pediatric) (2.3.19)

Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital Setting (Adult and Pediatric) (2.3.19) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.19


UW HEALTH CLINICAL POLICY 1
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose
Monitor Use in the Hospital Setting (Adult and Pediatric)
Policy Number: 2.3.19
Category: UW Health
Type: Inpatient
Effective Date: March 24, 2017

I. PURPOSE

To ensure safe care of patients who continue the use of their own subcutaneous insulin pumps and/or
continuous glucose monitoring systems during hospitalization. This policy will also describe criteria for pump
use, documentation requirements, and special considerations for those patients undergoing procedures
and/or surgery that may affect safety.

II. EQUIPMENT AND DEFINITIONS

A. Subcutaneous Insulin Pump
An insulin pump is a computerized device powered by an external battery. The pump has a
reservoir that is filled with rapid-acting insulin in most cases. In rare cases patients use U-100
Regular insulin or U-500 insulin (refer to Pharmacy Operating Procedure: U-500 Insulin 500 units/1
mL: Storage, Order Entry, Preparation, and Dispensing for associated policy requirements). The
insulin infuses subcutaneously through a thin plastic catheter called an infusion set. The pump is
worn 24 hours a day and continuously delivers pre-programmed amounts of insulin. Bolus doses of
insulin are given to cover carbohydrate intake and to correct hyperglycemia.
B. Pump Supplies
Insulin pump supplies such as the infusion set, reservoir, insertion device, and batteries should be
supplied by the patient. If necessary, call the patient’s family to bring supplies to the hospital.
C. Infusion Site
Typical subcutaneous insulin administration sites include the abdomen, the upper thigh, or the
hip/buttock. Site rotation is important and is typically done every 2-3 days.
D. Basal Rate
Hourly continuous infusion rates of insulin necessary to maintain a normal metabolic state when not
eating. Multiple basal rates can be programmed throughout a 24 hour period.
E. Bolus Doses
Insulin doses given based on food intake, glucose values, and possibly modified with changes in
activity.
F. Correction Dose
A bolus dose delivered when needed to treat hyperglycemia or blood glucose levels over a pre-
determined target glucose.
G. Insulin to Carbohydrate Ratio (ICR or I:C)
Calculation of the number of units needed to cover a specific number of carbohydrates. For
example, if one unit of insulin covers 10 grams of carbohydrates, 3.6 units would cover 36 grams of
carbohydrates. This information may be programmed into pumps.
H. Insulin Sensitivity Factor (ISF)
The number of units required to lower the blood glucose a certain number of points. For example, if
one (1) unit of insulin lowers a blood glucose by 50 points, and the patient is 200 points above their
target blood glucose range, four (4) units of insulin would be necessary to correct the glucose to the
target range. This information may be programmed into pumps.
I. Continuous Glucose Monitoring (CGM)
Continuous Glucose Monitoring Systems are devices that continuously monitor and record interstitial fluid
glucose levels. Patients and families may refer to this as “sensor therapy.” CGM systems use a tiny sensor
inserted under the skin to check glucose levels in the interstitial space. The sensor stays in place for several
days to a week and then must be replaced. A non-disposable transmitter is connected to the sensor and
sends information about glucose levels via radio waves from the sensor to a pager-like wireless monitor.
Continuous glucose monitoring is not currently recommended as a replacement for point of care testing.

III. POLICY ELEMENTS

A. Criteria for Insulin Pump Use (and Reasons to Discontinue)
i. The patient (or designated primary support managing pump for the patient) must be



UW HEALTH CLINICAL POLICY 2
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital
Setting (Adult and Pediatric)
Policy Number: 2.3.19

capable of managing the pump safely within the hospital setting. Competence must be
assessed and documented (see IV.A.).
ii. The patient must be oriented. If the patient’s level of consciousness is impaired for any
reason such as fatigue or effects of sedating medications (i.e., narcotics), this should
influence a clinician’s judgment about appropriateness of pump use (see III.A.4. Reasons
to discontinue pump use).
iii. The patient must have the physical dexterity and visual ability to use pump. If patient has
physical or visual impairments, patient (or primary support managing pump for patient)
must be able to verbalize or demonstrate strategies they use to overcome these barriers
(such as magnifiers, etc.).
iv. Completion of Agreement to Use a Patient’s Own Medication Delivery Device (Appendix
B).
v. Reasons to discontinue pump use include but are not limited to:
a. Patient or primary support incapable of or deemed unsafe to independently
manage pump.
b. Patient cannot provide his/her own pump supplies (see II. Equipment).
c. Patient is suicidal or at risk for suicide.
d. Persistent hypoglycemia or hyperglycemia that is not corrected by infusion rate
adjustments made by patient in collaboration with prescribing physician and/or
Diabetes Management Service or Endocrine Service.
e. Patient has admitting diagnosis of diabetic ketoacidosis or hyperosmolar
hyperglycemic state (DKA/HHS) or develops one of these conditions during
hospitalization. The subcutaneous insulin pump should be discontinued after an
alternative insulin source such as an intravenous insulin infusion is initiated.
f. Mechanical failure of patient’s pump.
B. Criteria for Continuous Glucose Monitor Use
i. The patient (or designated primary support managing CGM system for patient) must be
capable of doing so independently.
ii. Reasons to discontinue CGM use include but are not limited to:
a. Patient or primary suport unable to manage CGM system independently
including calibration.
b. Patient or primary support cannot provide own supplies.
c. Patient or primary support unwilling to allow blood glucose monitoring using
hospital glucose meter. (CGM has not been approved to guide therapy in the
hospital setting, and therefore, point of care glucose monitoring is required.)
d. Patient is critically ill.
e. CGM placement location interferes with treatment and/or positioning for surgery
or procedures.
C. Orders
i. One of the following order sets must be completed when a determination is made that a
patient may continue use of his/her own insulin pump during hospitalization: Diabetes
Management With Pump – Adult – Supplemental (3139) or Diabetes Management with
Pump – Pediatric – Supplemental (2187) Orders. Orders and/or administration instruction
notes such as “administer insulin per home regimen” are NOT acceptable.
ii. Orders will include but are not limited to: self-administration order, type of insulin used in
the pump, basal rates with associated administration times, insulin/carbohydrate ratios or
set doses for meal coverage, sensitivity/ correction factor(s) for hyperglycemia,
timing/frequency of blood glucose testing, target blood glucose, and any other directions
for use.
iii. If the patient no longer meets criteria for insulin pump use, orders must be given for
basal/bolus/correction insulin management using subcutaneous injections or a continuous
intravenous insulin infusion.
iv. Orders will be necessary when a patient’s pump is removed for diagnostic tests or surgery
(see section III.E. Considerations for Radiology Procedures and Perioperative Settings).
v. All patients on insulin pumps must have hypoglycemia treatment orders. Refer to
Hypoglycemia Treatment Algorithm and Nursing Patient Care Policy 13.24, Hypoglycemia,
Care of the Hospitalized Patient.



UW HEALTH CLINICAL POLICY 3
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital
Setting (Adult and Pediatric)
Policy Number: 2.3.19

vi. It is strongly recommended that the Diabetes Management Service or Endocrine
Fellow/Faculty be consulted to assist with the care and management of patients who
remain on their insulin pump while hospitalized.
D. Blood Glucose Testing and Insulin Management
i. The patient is responsible for the care and maintenance of the insulin pump and/or CGM
and for providing the supplies needed to operate the equipment (see II. Equipment). The
pharmacy department will dispense formulary insulin for the pump as needed.
ii. Use of the patient’s own insulin for filling/re-filling an insulin pump is permitted only when
done in accordance with Hospital Administrative Policy 8.17, Administration of
Medications.
iii. Hospital glucose meters will be used according to Nursing Patient Care Policy 11.26,
Nova Stat Strip Blood Glucose Meter, to check patient’s blood glucoses. Glucose results
will be discussed with the patient (or primary support managing pump/CGM for patient).
Based on the glucose results, the patient (or primary support managing pump/CGM for
patient) will adjust the insulin pump settings to dose insulin accordingly.
iv. Patients may use their own lancets/lancet device for fingerstick capillary blood testing if
desired.
v. If glucose is greater than or equal to 250 mg/dL and the cause is unknown, the patient (or
primary support managing pump for patient) should administer a correction dose of
insulin. If the blood glucose is not decreasing within 1-2 hours after this correction dose,
pump trouble-shooting should be performed by the patient (or primary support managing
pump for patient). This could include but is not limited to checking to see if the insulin
reservoir is empty, if the infusion site is occluded or leaking, or if the infusion tubing is
kinked. The toll-free phone number on the back of the pump can be called as needed for a
resource. An alternative insulin source may be needed if hyperglycemia persists and/or if
the cause of the hyperglycemia is not known.
vi. If glucose is less than or equal to 70 mg/dL, follow orders for treatment and refer to Policy 13.24.
The pump should not be removed without orders for alternative insulin dosing once hypoglycemia
is resolved.
E. Documentation
i. If a patient uses an insulin pump, then insulin orders must be included in the patient’s
clinical record and specifically included in the patient’s Medication Administration Record
(MAR) to facilitate reconciliation of insulin pump programming every 24 hours.
ii. The Agreement to Use a Patient’s Own Medication Delivery Device (Appendix B in
Related section on U-Connect) must be completed within the first 24 hours of admission
or prior to a patient resuming use of their own pump during the hospitalization.
iii. A 24-hour total of insulin administered via the patient’s insulin pump must be documented
daily. This total is often called the “Total Daily Dose” and includes basal and bolus doses.
This information should be retrieved by the patient from the “Utilities” or “History” menu or
“Home/My records” section depending on the brand of the pump. (See Appendix A in
Related section on U-Connect for screen shots of Health Link documentation tools.)
iv. The patient’s nurse must document all bolus doses given by the patient for meal coverage
and/or for correction of hyperglycemia. (See Appendix A for screen shots of Health Link
documentation tools.)
v. The nurse must assess and document the site condition of the insulin pump infusion site
twice daily and more often during episodes of hyperglycemia, or for patients who have a
history of skin infections, allergic reactions, and/or when there are concerns about infusion
catheter patency or dislodgement. Specifically note any signs of inflammation or irritation
including redness, swelling, warmth, tenderness, and drainage.
vi. When a patient (or primary support) changes his/her insulin pump infusion site (usually
every 2-3 days), the nurse must document the date, time, and location of the new site in
the appropriate Lines/Drains/Airways (LDA) Doc Flowsheet.
vii. See IV.A.2 regarding documentation of competency to use an insulin pump.
F. Considerations for Radiology Procedures and Perioperative Settings
i. To protect the pump and/or CGM from being deprogrammed or damaged by exposure to
ionizing or magnetic fields, it must be disconnected and taken outside of the room for ANY
of the following procedures (patient can temporarily suspend the pump’s operation and



UW HEALTH CLINICAL POLICY 4
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital
Setting (Adult and Pediatric)
Policy Number: 2.3.19

disconnect at insertion site):
a. X-rays
b. Magnetic resonance imaging (MRI)
c. Computerized tomography (CT)
d. Positron emission tomography (PET) scan
e. Any test, procedure, or surgery that would use radiation or magnetic fields
ii. For a procedure during which the pump must be removed, the following must be done
(unless other strategies for delivering insulin have been enacted):
a. Keep the insulin pump in place and infusing en route to the procedure;
b. Patient (or primary support managing pump for patient) should disconnect the
pump just prior to the procedure to minimize the time off the pump. Place the
pump where it will not be exposed to ionizing radiation or magnetic fields.
c. Reconnect the insulin pump and resume pump therapy AS SOON AS POSSIBLE
following departure from the room where the procedure was completed. If more
than one (1) hour has passed since the pump was removed, assess blood
glucose level. Patient may be able to correct the glucose level by using the
pump. If not, an alternative delivery method will need to be ordered such as a
continuous intravenous insulin infusion. An interruption in insulin delivery for
more than two (2) hours can lead to severe hyperglycemia and DKA.
d. The timing of pump removal/insulin infusion suspension will need to be
individualized for patients getting PET scans who may need insulin suspended
longer than one (1) hour prior to procedure.
iii. For a surgery during which the pump must be removed due to length of the surgery
(usually two [2] hours or greater) or due to the anticipated use of radiation or magnetic
fields, or electrocautery, the following must be done:
a. The patient (or primary support managing pump for patient) should remove the
insulin pump before being transported to surgery.
b. The pump should be secured if possible or according to UW Health Clinical
Policy 2.1.22, Patient Belongings and Valuables.
c. While the patient is in surgery, the physicians or Anesthesia department will
manage the patient’s blood glucose.
d. The patient must meet criteria as noted in III.A. to resume pump use after
surgery. If the patient does not meet criteria, an alternative mode of delivery will
be needed until the patient’s pump can be resumed.
iv. In surgical cases lasting less than two (2) hours and not involving radiation or magnetic
fields, patients may be able to continue pump usage during surgery. The appropriateness
of this option should be determined by the diabetes specialist(s), surgeon and/or
anesthesiologist, and patient prior to surgery.
v. If the patient will be disconnected from the pump longer than one (1) hour, orders will be
needed for another mode of insulin delivery before the insulin pump is removed. The
patient should not be without insulin coverage. An interruption in insulin delivery for more
than two (2) hours can lead to severe hyperglycemia and DKA.

IV. PROCEDURE

A. Assessment of Competence
i. Requirements for self-administration must be met as outlined in Policy 8.17.
ii. Staff nurses, pharmacists, Learning Center nurses, Diabetes Clinical Nurse Specialists,
Diabetes Management Service staff, and Endocrine Fellows may all participate in the
competency assessment and documentation process.
iii. A competency assessment should include the following:
a. Knowledge of infusion site care.
b. Knowledge of pump set-up and programming (as evidenced by patient or primary
support managing the pump for the patient verbalizing or demonstrating infusion
set/reservoir changes and by demonstrating review of pump settings such as
infusion rates).
c. Knowledge of trouble-shooting measures including how to contact the pump



UW HEALTH CLINICAL POLICY 5
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital
Setting (Adult and Pediatric)
Policy Number: 2.3.19

manufacturer (toll-free help access number is on the back of the pump).
d. Most but not all patients who use a pump count carbohydrates. Therefore,
competence should be assessed but not required for a patient to stay on his/her
pump while hospitalized.
B. Document assessment findings in Health Link in Patient Education activity (Choose Title: Diabetes,
Therapeutic Regimen Management, Ineffective, Topic: Insulin Pump (Patient’s Own) as shown in
policy addendum).
C. Competence should be re-assessed if patient’s cognitive status changes or if staff caring for the
patient suspect the patient’s level of competence has changed since initial assessment.
D. Notify the primary team and/or Diabetes Management Service staff or Endocrine Fellow/Faculty if
the patient’s ability to perform self-management is compromised.

V. COORDINATION

Author: CNS, Diabetes
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Diabetes Resource Nurses
Approval committees: Inpatient Diabetes Quality Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: February 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
UW Health Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

A. Appendix A: Health Link Documentation (see Related section on U-Connect)
B. Appendix B: Agreement to Use a Patient’s Own Medication Delivery Device (see Related section on U-
Connect)
C. UW Health Clinical Policy 2.1.22, Patient Belongings and Valuables
D. Hospital Administrative Policy 8.17, Administration of Medications
E. Hospital Administrative Policy 8.33, High Alert Medication Administration
F. Nursing Patient Care Policy 10.26, Use of a Patient’s Own Medication Delivery Device
G. Nursing Patient Care Policy 11.26, Nova Stat Strip Blood Glucose Meter
H. Nursing Patient Care Policy 13.24, Hypoglycemia, Care of the Hospitalized Patient (including addendum
document: Adult Hypoglycemia Treatment Algorithm)
I. Pharmacy Operating Procedure, U-500 Insulin 500 units/1 mL: Storage, Order Entry, Preparation, and
Dispensing
J. Association, A. D. (2017). Standards of medical care in diabetes—2017. Diabetes Care, 40(Supplement 1),
S14-S80. doi: 10.2337/dc14-S014 I
K. Boyle, M. E., Seifert, K. M., Beer, K. A., Apsey, H. A., Nassar, A. A., Littman, S. D., Cook, C. B., & et al.
(2012). Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the
perioperative period. Journal of Diabetes Science and Technology, 6(1), 184-190.
L. Grunberger, G., Bailey, T. S., Cohen, A. J., Flood, T. M., Handelsman, Y., Hellman, R., & et al. (2010).
Statement by the American Association of Clinical Endocrinologists Consensus Panel on insulin pump
management. Endocrine Practice: Official Journal of the American College of Endocrinology and the
American Association of Clinical Endocrinologists, 16(5), 746-762.



UW HEALTH CLINICAL POLICY 6
Policy Title: Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital
Setting (Adult and Pediatric)
Policy Number: 2.3.19

M. Institute for Safe Medicine Practices (ISMP) (2016, October 20). Guidelines for the safe management of
patients with an external subcutaneous insulin pump during hospitalization. Acute care ISMP Medication
Safety Alert, 21(21), 3-7. Retrieved from
https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1151
N. Lansang, M. C., Modic, M. B., Sauvey, R., Lock, P., Ross, D., Combs, P., & Kennedy, L. (2013). Approach
to the adult hospitalized patient on an insulin pump. Journal of Hospital Medicine, 8(12), 721-727.
doi:10.1002/jhm.2109 VII
O. Mackey, P. A., Thompson, B. M., Boyle, M. E., Apsey, H. A., Seifert, K. M., Schlinkert, R. T., . . . Cook, C. B.
(2015). Update on a quality initiative to standardize perioperative care for continuous subcutaneous insulin
infusion therapy. J Diabetes Sci Technol, 9(6), 1299-1306. doi:10.1177/1932296815592027
P. McCrea, D. (2013). Management of the hospitalized diabetes patient with an insulin pump. Crit Care Nurs
Clin North Am, 25(1), 111-121. doi:10.1016/j.ccell.2012.11.010

VIII. REVIEW DETAILS

Version: Original
Next Revision Due: March 24, 2020
Formerly Known as: Nursing Patient Care departmental policy #10.25