Insulin Pump Continuation in the Hospital Shaylyn Vogler, PharmD PGY1 Pharmacy Resident

Objectives Provide guidance for pharmacists on the procedure for initiating continuous subcutaneous insulin infusion (CSII) pump therapy Briefly discuss the roles of various healthcare team members in the CSII pump continuation protocol

Initiating the PowerPlan for Insulin Pumps Only providers can: Initiate continuation or resumption of continuous subcutaneous insulin infusion (CSII) pump Determine if patient is suitable for managing CSII pump therapy Contraindications to using patient’s own CSII pump Pump settings irretrievable from pump Inability to demonstrate competency for pump use Altered level of consciousness Inability/ refusal to participate Necessary pump supplies unavailable Risk of suicide Diabetic Ketoacidosis Hyperglycemic Hyperosmolar State Critically ill or hemodynamically unstable CSII pump not working properly

Insulin Pump PowerPlan 1. Search “insulin pump” 2. Be sure to select PowerPlan icon 3. Click the evidence link icon to print “Patient Agreement Form”

Insulin Pump Patient Agreement Must be completed by provider

Insulin Pump PowerPlan 4. Select appropriate insulin product using Patient’s Insulin Pump Settings form

Insulin Pump PowerPlan 5. Decide whether Provider or Pharmacist will complete Insulin Pump Settings in PowerForm

Initiating Insulin Pump Therapy After initiating PowerPlan, task will fire for nursing to fill out this form with the patient or surrogate Form is then scanned into Pyxis Connect Should expect questions!

Initiating Insulin Pump Therapy After initiating PowerPlan, task will fire for pharmacy (if physician selected for pharmacist to complete PowerForm) Pump settings must be entered within 24 hours

Insulin Pump PowerForm Simple Dosing PowerForm Insulin selection Basal rate (up to 4) Meal bolus, select one: Insulin to carb ratio, or Fixed insulin Insulin sensitivity factor (ISF)/Correction bolus Blood glucose target ranges Documentation of where insulin pump settings were obtained Advance Dosing PowerForm Insulin selection Basal rate (up to 24) Meal bolus, select one: Insulin to carb ratio Fixed insulin, or Units per servings of carbohydrates Insulin sensitivity factor (ISF)/Correction bolus Blood glucose target ranges Documentation of where insulin pump settings were obtained

Insulin Pump PowerForm Choose the correct type of insulin, based on the PowerPlan order Select appropriate therapeutic interchanges for all non- formulary insulins PowerPlan: PowerForm:

Refilling Insulin Pumps Pharmacy dispenses insulin to refill pumps Nurse must sign for insulin and document waste Signed delivery form scanned into Pyxis Connect Unused portions of U-200 or U-500 must be returned to pharmacy by the same pharmacy staff who delivered it Be sure to choose correct insulin (“for pump refill”)

Scanning Insulin Nurse will scan the label barcode, not the vial or pen

Modifying Insulin Pump Settings Process different than other modify order processes An order to Modify Insulin Pump Settings must be entered: The Insulin Pump Settings PowerForm will appear with last charted values populating the fields Modify insulin pump settings and sign the PowerForm

Monitoring Bedside blood glucose AC and HS at minimum As needed for signs and symptoms of high or low blood sugar Nursing will assess patient’s ability to manage pump at least once every shift using either Insulin Pump Patient Checklist Insulin Pump Surrogate Checklist

Elevated Blood Glucose If BG is >250 mg/dL on 2 or more consecutive occasions: Administer correction bolus via insulin syringe (pump infusion set may be nonviable) Patient’s blood glucose to be tested 4 hours after dose and call made to physician if BG still >250 mg/dL

Viewing Current Insulin Dosing Basal Rates: found on Results Review page under glucose data or on the Insulin Pump Settings PowerForm Bolus Doses: not entered into Cerner; charted on paper Insulin Pump Diary/Flowsheet, which may be found at bedside or in physical chart (see next slide) MAR Summary View: Will show insulin pump refills (does not contain dosing information)

Insulin Pump Diary/Flowsheet

Discontinuation of Pump Pump to be discontinued if: Patient or surrogate fails to qualify for initiation or continuation CSII pump is discontinued or interrupted for >1 hour

Questions?

Shaylyn Vogler, PharmD PGY1 Pharmacy Resident Thank you! Shaylyn Vogler, PharmD PGY1 Pharmacy Resident