Putting Your Patients on the Pump. Karen M. Bolderman

I press this button, I might make a mistake.” The insulin start that follows a saline trial may serve as a review of the technical training of the pump initiation process. This may be beneficial to those patients who are not quick learners or who express nervousness or anxiety about their actual pump start.

      A saline trial should not be mandatory. MDI therapy must continue while wearing a saline pump; therefore, the patient does twice the work without enjoying the flexibility or freedom associated with pump therapy. And a patient who is excited about pump therapy is impatient to get started. A pump patient who is required by his or her clinician or CDE to wear the pump with saline first may resent the delay in the pump start and view it as a waste of time. The clinician and patient, or parents of the pediatric patient, should decide together if a saline start is truly appropriate. Saline requires a prescription, which the prescribing physician must provide to the patient.

Lifestyle Issues and Wearing the Pump

      Many prospective pump users hesitate or neglect to ask about lifestyle concerns; therefore, the healthcare professional must take the initiative and include this information in the pump education process.

      Daily Wear

      The pump can be worn by several different means, including a clip, a case (leather, vinyl, or plastic) with or without a built-in clip or belt loops, or inside clothing such as thigh or leg garments, boxer shorts, lounging pants, and slips with pump pouches or pockets. A cotton infant sock is another option: the pump fits into the sock easily and can be worn in the side or cup of a bra, under control-top pantyhose or other shapewear-type undergarments, or pinned inside clothing. Some patients wear the pump in the top of their foot sock with long infusion set tubing under their slacks/trousers and use a remote feature or cross their legs and use the touch bolus button to deliver bolus insulin as needed. Another option is to sew pockets into the seams of garments or use Velcro for removable pockets. There are companies that manufacture devices that even roll up the pump tubing (refer to Chapter 8, Forms and Resources). Ask the pump patient in training to think ahead about wearing the pump with various types of clothing and in different situations, such as getting dressed and using the bathroom (toilet). An insulin pump pod, or “tubeless” pump is attached directly to the skin and does not require use of a case or clip.

      Sleeping

      Every prospective pump user wonders what to do with the pump during sleep. The patient may want to try wearing the pump inside the pocket of pajamas, a nightshirt, a nightgown, or boxer shorts. Another option, depending on the length of the tubing, is placing the pump in a specific location, such as under the pillow or on a night table. The pump can also be clipped to a sheet or blanket or placed freely in the bed. Longer tubing provides greater flexibility for moving and turning. Reassure the pump patient that even if the tubing is knotted upon awakening, insulin delivery will not be disturbed. The infusion set/pod dressing or tape secures the infusion set safely to the site.

      Use of an electric blanket can affect the potency of insulin, especially if the pump is directly on the heating coils. Pump users need to consider this if their fasting blood glucose is erratic without explanation.

      Bathing/Showering

      Pumps are waterproof or water resistant—check with the pump manufacturer for specific guidelines. Even if the pump patient is not planning on wearing the pump while bathing or showering, pumps have been known to fall in the toilet. With a disconnect infusion set, the pump can be disconnected for up to 1 h and reconnected after bathing or showering. Remind the patient that insulin is very heat sensitive; soaking in a hot bath or whirlpool or using a sauna while wearing the pump is not recommended.

      Intimacy/Sexual Activity

      To wear the pump or not during sexual activity is the patient’s choice. If the patient wants to keep the pump connected, longer infusion set tubing may be recommended or preferred. The patient should be reminded to reconnect his or her infusion set and pump and the infusion site should always be checked to make certain the set base has remained intact. See Intimacy/Sexual Activity for additional information.

      Sports/Physical Exercise

      Advise the patient that an insulin pump can, and should be worn during exercise and physical activity, and even professional athletes keep their pumps attached while engaged in their sport of choice. Specific suggestions for wearing the pump and guidelines for adjusting insulin doses during exercise are provided in Exercise and Physical Activity.

      Medical Procedures, Sick Days/Illness, and Hospitalization

      The specific medical procedure (CAT scan, X-ray, etc.) will determine whether or not the pump should be worn. Patients may also be advised prior to the medical procedure or test if it is appropriate for the pump to be exposed to the medical test or procedure. Remind the patient that if the pump is to be disconnected longer than an hour, it may be necessary to make adjustments in insulin doses.

      Advise patients that, similar to MDI therapy, lengthy medical procedures and sick days and illness often require adjustments in insulin doses and the same guidelines will apply. A prospective pump patient may ask if they can wear their pump while ill—reassure the patient that illness does not require the pump to be disconnected, but in the case of severe illness or if the patient is incapable of operating their pump, s/he may require the assistance of another person and/or a temporary return to MDI therapy. A back-up, or “pre-pump” plan is essential.

      Refer to Managing Sick Days and Medical Procedures , for specifics on managing pump therapy during medical procedures, sick days, and hospitalization.

Patient Support System

      Pump therapy initiation can be an emotional process for the patient. It may have taken a patient several months or even years to make the decision to choose pump therapy. In addition to your support and encouragement, the patient’s personal support system is an important factor in successful pump therapy. Spouse/significant other and family encouragement will help the patient in his/her pump education and initiation process. The patient may choose to also involve friends and co-workers, and may invite them to co-attend pump support group meetings, or at the least, may inform them of this life-changing decision. Diabetes-focused consumer magazines and publications are other materials the patient may find helpful. Social media are another avenue of support, and the availability of information on the internet is astounding. There are many internet resources related to insulin pump therapy, and patients may find or be directed to various insulin pump sites and blogs. You can also provide reliable credible resources (see Chapter 8, Forms and Resources). Pump manufacturers offer support via internet, print, and telephone and can serve as a great resource to a new pump patient.

Ordering the Pump and Supplies

      Once you and the patient have decided to initiate pump therapy and the patient is close to “being ready” (refer to preceding chapters), the next step is to order the pump and supplies. Insurance companies and pump manufacturers vary in the pump order process. Pump companies have designated personnel who walk the patient through the order process. Depending on the company’s policies and procedures, as well as those of the patient’s insurance company, the process can take anywhere from a few days to a few weeks. A signed order or prescription for the pump and initial supplies (infusion sets or pods, cartridges/reservoirs, tape, skin prep) from the healthcare professional is required, and additional paperwork may be requested. This may include, but is not limited to: a letter of medical necessity, usually with “check-off boxes” related to the patient’s diabetes control status and/or complications; SMBG data maintained by the patient or available from you; and recent and past A1C results. Additionally, the pump order may also include instructions for the pump start and initial settings, including blood glucose targets, basal rate(s), insulin-to-carb ratio(s), correction factor(s), and duration of insulin action (“insulin on board”). A prescription for saline is required if a saline pump start is desirable, and a prescription for rapid-acting insulin, taking into account the additional amount needed for tubing, is a must.

      A logistic consideration is the designation of the pump delivery. Some