Thursday, January 30, 2014

Personal Reflections on Journal Article- Optimizing Insulin Pump Therapy: A Quality Improvement Project

I spent part of my lunch break reading an article from the November/December issue of the Diabetes Educator. The title is  Optimizing Insulin Pump Therapy: A Quality Improvement Project.

From the abstract:

Purpose The purpose of the study was to assess insulin pump use and provide ongoing education.

Methods A quality improvement project using a pump assessment questionnaire was implemented at an endocrinology office in the southeastern United States. The questionnaire was designed to evaluate all aspects of insulin pump therapy, including pump operations, infusion set failure, management of acute complications, and usage of advanced device features. Eighty-nine patients (80% with type 1 diabetes and 20% with type 2 diabetes) completed the questionnaire at the endocrinology practice. A certified diabetes educator reviewed the questions with each patient, identifying deficiencies and training opportunities.

Results The most common areas of deficiency identified after implementation of the assessment form included the following: expired or no basal insulin prescription in the event of pump failure or removal, no mupirocin (Bactroban®, GlaxoSmithKline, Research Triangle Park, North Carolina) prescription for suspected site infections, lack of insulin syringe if pump stopped working, failure to check urine ketones, no antiemetic prescription for sick day intervention, using manual bolus instead of bolus calculator, and lack of in-date glucagon kit.

Conclusions Use of a pump assessment questionnaire allows for focused discussion concerning patient behaviors related to pump operations, troubleshooting, and self-management. Incorporating use of a pump assessment questionnaire into routine practice may result in improved patient education and avoidance of adverse events specific to insulin pump therapy.

Essentially, the authors of this paper gave questionnaires to patients in an endocrinology office who used insulin pumps.  Those who were included in this study were exclusively Medtronic users with a minimum of one year of experience using their pump. The survey used closed-ended questions to facilitate conversations between the PWD and their health care team. The office has 2 endocrinologists, and an FNP who deals with most of their pumpers. It's unclear from the paper as to whether or not annual visits to assess pump use were a given for this practice or not, but it seems the office will start using these questionnaires annually.

The authors achieved their goal of identifying weaknesses within their practice. Through use of their surveys, they were able to determine which topics each patient needed to cover in order to increase the effectiveness of pump therapy. I'd be interested in a follow-up paper to determine if spot retraining helped with overall control.

My personal reflection on this post is that I can identify with many of the shortcomings elucidated in this paper. The one that worries me the most, but I continually forget to mention with my doctor is a lack of a backup plan if something were to go wrong with my pump. I have not had a prescription for a basal insulin in over 10 years. Only once has anything gone wrong, but when it did I was testing and injecting Humalog like nobody's business. For a day and a half. It was pretty crappy. I should really do something about that.

Along the lines of preparedness, I haven't owned Glucagon probably since diagnosis. Thankfully, I've never needed it. But I suppose the point of emergency preparedness is to, you know, be prepared for emergencies that hopefully never happen. The article also stresses that we pumpers should have a prescription for mupirocin in our bag of tricks in the event of a site infection. It's not a bad idea, but the few infected sites I've ever gotten were easily worked out with Neosporin.

Other than those things, I feel pretty good.. Of the identified shortcomings, most of them deal with being prepared and not having prescriptions for glucagon, mupirocin, and antiemetic drugs. With the exception of basal insulin, I am decently prepared.

The key to using an insulin pump is using it effectively. Perhaps more endocrinology practices should use similar questionnaires to identify weaknesses in pump use. Personally, I haven't had pump training in... well... pretty much since Medtronic introduced the Paradigm with the Bolus Wizard. I think I got mine in 2007 or so. I'm sure there are some gaps in my pump education.

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