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Perioperative Management of Patients with Insulin Pumps Faith Pollock APRN, ACNS-BC, BC-ADM, CDE Abbott Northwestern Hospital September 26, 2015
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Perioperative Management of Patients with Insulin PumpsFaith Pollock APRN, ACNS-BC, BC-ADM, CDEAbbott Northwestern HospitalSeptember 26, 2015
DisclosureThere are no conflicts of interest or relevant financial interests in making this presentation and have indicated that my presentation does not include discussion of an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose.
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Objective
Describe how a team effort promotes optimal care and safety for patients with insulin pumps.
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Applause for Team Work
Patient
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Team Members
• Faith Pollock, Diabetes Clinical Nurse Specialist
• Dr. Bill Dickey, Hospitalist, Medical Director
• Dr. Nicoletta Manciu, Anesthesiologist
• Dr. John Knorp, Anesthesiologist
• Chris Pocta, Manager Patient Care OR/pre-op and post-op
• Donna Johnson, Supervisor Patient Care OR/pre-op and post-op
• Matt Kresl, Manager Pharmacy
• Barb Bly, Quality/Patient Safety
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What is an Insulin Pump?Computerized device that delivers insulin
• Self-managed by the patient• Reservoir filled with rapid acting insulin• Insulin infused SQ through a thin plastic cannula via an infusion set
- Infusion set worn usually in abdomen, upper thigh, hip/buttock
• Provides a continuous basal rate of insulin - Necessary to maintain a normal metabolic state when not eating
• Provides bolus doses of insulin - Programmed and managed by the patient in addition to the basal rate- Prandial dose: to cover the carbohydrate content eaten - Correction dose: to treat hyperglycemia or blood glucose levels over a predetermined
target
Continuous Subcutaneous Insulin Infusion (CSII)
What Prompted this Team?• Lack of systematic approach for perioperative
management of patients using CSII for glucose management- Found via a root cause analysis
• Risks were high for these patients- Severe hypoglycemia- Severe hyperglycemia leading to DKA
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Goal of the Team
Prevent severe hypo and hyperglycemia8
GAPS• Patients on CSII not identified before surgery• Insulin pump settings and type of insulin rarely
documented preoperatively• No pre-op plan taking into account how long the
patient will be unable to manage their CSII• No standards for the duration of surgery for
which CSII may be used to manage glucoses• Inadequate training of RNs to manage IV insulin
infusions for alternative insulin therapy
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Perioperative CSII Management
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Processes (1)
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Processes (2)
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Processes (3)
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Processes (4)
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Hospitalist Training• Concepts of CSII• Strategies for the perioperative management of
patients on CSII• Demonstrate how to interrogate the most common
insulin pump- Provided demo pumps for hands on - Pocket cards for reference
• Alternative insulin therapies if insulin pump therapy discontinued
• Template for note in Excellian
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Perioperative Nurse Training• Processes• EXPECTATION that they call CNS or hospitalist
- In pre-op- Recovery
• Overview of management guidelines• Insulin infusion protocol
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What has happened so far?5.5 patients seen per month• Diabetes CNS 87%• Hospitalist 13%• 5% not seen in preop2/3 of surgeries were 2 hours or less50% of patients continued CSII basal rate• 30% at usual basal rates• 70% at reduced basal rates50% of patients were recommended alternative insulin regimen• 20% CSII held during surgery, resumed post-op• 44% CSII held and insulin infusion initiated• 13% CSII continued during surgery, insulin infusion post-op• 19% CSII held during surgery, insulin infusion post-op
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Snapshot of 30 patients
Glucoses (mg/dL)Less than 40 Less than 70 70-180 181-300 Greater than 300
Pre-op % 0 0 53 40 7
Intra-op % 0 4 49 43 4
Post-op % 0 3 43 53 0
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Frequency that glucoses NOT tested Q1H during surgery was 20%
BEST OF ALL…
Patient Satisfaction Perioperative Team Work
PATIENT
References• Abbott Northwestern Hospital (2014). Perioperative
continuous subcutaneous insulin infusion (CSII) management guidelines. Retrieved from http://akn.allina.com/patientcare/PoliciesProceduresMore/diabetescare/index.
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