Purpose for the Program
Continuous subcutaneous insulin infusion (CSII) pump therapy is associated with better quality of life and in some studies better glucose control than standard multidose insulin injections. A person with diabetes who uses an insulin pump for blood glucose management considers the insulin pump as a lifeline. Disconnecting from the insulin pump raises concern and triggers unnecessary anxiety. Most of our patients were told to discontinue their pumps on admission to the labor and delivery unit. Sometimes a physician would write an order to allow a patient to continue using the pump, which was problematic because no supervision of insulin delivery or assessment of the patient's ability to manage the pump was taking place by nursing staff or physicians. The obstetricians were not familiar with the intricacies of dose adjustments and the need for quick, abrupt changes in dosage during the postpartum period.
To partner with the director of our Diabetes and Obesity Institute and initiate a pump pilot program with tools and guidelines unique to the obstetric setting. The most important component of this patient-centric journey was use of an insulin pump agreement. Because these patients make daily insulin dose adjustments independently, it was critical to empower both the pump-using patient and nurse to form a partnership concerning insulin dosage during hospitalization. The agreement addressed the following key points:
- Showing the nurse bolus doses, basal rates, and changes.
- Frequency of infusion set and infusion site changes.
- Reporting symptoms of hypoglycemia and pump problems.
- Situations when the pump may need to be discontinued.
Implementation, Outcomes, and Evaluation
Standardized orders for insulin pump therapy management in the intrapartum and immediate postpartum periods were developed, along with a medication administration record that allowed for documentation of basal rates and boluses. All pump patients have an endocrine consult to assess ability to manage self-care and determine postpartum dosage changes. Mandatory education sessions for all nurses, midlevel healthcare providers, and physician staff were provided by our diabetes nurse clinicians. The sessions addressed technical aspects of CSII pump therapy and the patient's emotional connection to the pump. The nurse clinicians were notified when a patient using an insulin pump was admitted and assisted nurses and healthcare providers with any process issues. Data collection and outcomes evaluation are ongoing with changes being made as relevant.
Implications for Nursing Practice
Nursing has been essential in the formation of a multidisciplinary team that partnered with other disciplines to provide safe, effective, and patient-centered care.