Insulin Pump Management in the Inpatient Setting
By: Gina Miller
Insulin pumps are being prescribed more and more frequently for diabetics. As the popularity of these devices increases, it means the chances of encountering a patient with an insulin pump increases. Frequently, patients are requesting to continue to use their own pumps rather than receive injections and sliding scale insulin when admitted. What are the requirements from a regulatory point of view for management of an inpatient with an insulin pump? CMS regulations which guide medication management (482.25), nursing care (482.23), and documentation (482.24) will apply. Let’s explore…
As with any medication, the same regulatory requirements apply to insulin administered by a pump. The hospital has a responsibility to safely manage medications brought into the hospital by practitioners, family members, or patients. This includes insulin pumps. Organizations must have policies and procedures to guide nursing care for patients using insulin pumps. Additionally, there must be evidence of staff education and training regarding the policies that apply to this population. There is no requirement that staff know how to operate the pump independently, but they must know the content of, and requirements set forth by the policy. For example, the policy should outline the requirements for the assessment and care of the site, documentation, monitoring, and actions should the device malfunction. Policy should also define when a patient’s own pump may be used, and in what situations it may not be used. A hospital could sustain a citation if staff who care for a patient with an insulin pump are unable to substantiate that the policy around the management of insulin pumps was followed.
The provider should be notified of the presence of the pump, and settings need to be verified so the provider is aware of the type and name of insulin used, and basal and bolus dosages being administered. There must be a provider order allowing the patient to continue to use and self-manage their insulin pump. An order stating to use the patient’s personal insulin pump home settings is not sufficient. The order must include the requirements set forth by your medication order policy. The type of insulin, base rate, incremental units (sliding scale) to cover meals or hyperglycemia, and frequency of monitoring glucose should be defined by the provider order for the pump. The organization’s policy which defines the requirements for a complete medication order also applies to licensed providers who order insulin pumps. Organizations may want to clearly define in policy the contents of a complete order for an insulin pump (e.g., the dose, basal rate, bolus rate, timing, etc).
If the organization allows patients to self-manage their own devices, there must be a written process in place to assess the patient for competencies to safely self-manage their medications including the insulin pump. For example, barriers to learning should be assessed. This would include any clinical or environmental factors that could be a barrier to self-management. Consider if the patient will receive narcotic analgesics for management of pain or undergo surgery; this could be a barrier to their ability to manage the pump. The assessment must be documented in the patient’s record prior to allowing the patient to self-manage the pump. The results of the assessment including any barriers identified and the patient’s response to the education provided must be documented. Education should include the same elements as if you are educating around any medication – the name, type and purpose, how to administer, any potential side effects, and symptoms to report. If a family member (in the case of a pediatric patient) is going to manage the pump, the assessment and education of the family member should be clearly demonstrated in the record. If the patient brings their own insulin from home, the organization must follow their policy for identification and storage of home medication. Additionally, if the patient’s own glucose testing device is used – either intermittent or continuous, a policy approved by leadership is required that includes a way to verify the testing device functions appropriately and is calibrated. The policy could require that the manufacturer’s instructions be available to staff, however the organization may define the process to verify proper functioning.
Documentation in the medical record must include requirements defined by Federal and State law, accepted standards of practice, and medical staff approved hospital policy. The organization is allowed to define the requirements for documentation, but surveyors will assess for compliance to the policy. If the organization’s policy for medication administration requires the dose, route,and time be documented for all medications, then the surveyor will assess compliance to that standard even if the patient administers the medication. An organization would be wise to assure that the documentation requirements for insulin pumps are well-defined by policy.
It is important to remember that an insulin pump is a medication delivery system and therefore is required to be managed the same as all medications in the hospital. Clearly defined expectations and staff education will assure the safe, effective management when the hospital permits patients to continue to use their own devices during hospitalization.
Centers for Medicare and Medicaid Services, (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from cms.gov
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